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Home My WebLink About0259 CLAMSHELL COVE ROAD - Health 25�Clamshe Cove Road i COt fi 1. i ,A ,005,. `026 I , I � � i i' I '�-•,r 's h s ` l' lull il:illl VrI� ° Qv -� I DilI i c ! I �Iili�l rNk ®r, i 1 "n i f J I!I% IJ 117 In ry f .I� Ili r: � i I (! Ar iI� � i (II ►I ! �! 'I�i I � 1' i f ! jr t f i At }.I �\ \c i i 1 � s S s, r i i a x �I ! I ! j-, i 1 n z 1 { j I I I ► 's I 1 I � i II e I J I1 ' t „a- o � — I , jj J I tt ?-n`i I ii I I r V F IA I ry _j i r I� �o.7i ` no LJ "d I I ' q x� J • I v i i t lJ J_ aan l� t , � „ Il .� lili li I . .`'i t.¢�•C Vio w'4 JIZ N�I`!I ZIZ � x < V q p9 C d x. Li 2L 1 p ,d z 1 f� r l�� 4 � I , i i I a � all I e f I f Ey w 4 . . �.: :.. � a_o,•� � ., 1 sue• I ; lei I x un 30 15 04:03p p.1 H/P 1005�°�� Commonwealth of Massachusetts Title 5 Official Inspection Form o► Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 259 Clamshell Cove Road N = Property Address Adrienne Tanashian Owner Owners Name -s>' information is :__: required for every Cotuit MA 02635 6-24-15 page. CityrTown State Zip Code Date of Inspection 01 C� Inspection results must be submitted on this foam. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ``�uUulnmgr�� j on the'computer, \��.o`�tN .. MA only l0� ' use onl the tab 1. Inspector I ��•�� -- S,p9��' key to move your =o. - '••yG cursor-do not James D.Sears _a DAMES use the return Name of Inspector B v key. i y Ca ewideEnterprises.LLC o o.` J- 1/- 11 Company Name '%,, �F-.?T ;��:G%� .�� 1 153 Commercial Street Company Address _Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails I ❑ Needs Further Evaluation by the Local Approving Authority 6-28-15 I)Kpedor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15irrs•i 3/13 Title 5 Official Inspection Forms SubsurfaceSewaGe Disposal System•Page 1 of 17 Y Jun 3015 04:03p p.2 Commonwealth of Ma ssachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 259 Clamshell Cove Road Property Address ! Adrienne Tanashian Owner Owner's Name infuriation is required for every Cotuit MA 02635 6-24-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank-D Box and three flows. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether meta)or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y (] N ❑ ND(Explain below): 15ins•T13 Title 5 Official Inspection Form:Subsurface Sewage Dispoaal System•Page 2 of 17 i Jun 30 15 04:04p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l 259 Clamshell Cove Road Property Address j Adrienne Tanashian Owner Owner's Name required foon r Cotuit NIA 02635 6-24-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if , pumps/alarms are repaired. B) System Conditionally Passes (cont.): i ❑ Observation of sewage backup or break out or high static water level in the distribution box due , to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): i ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NC?(Explain below): I� ❑ obstruction is removed ❑ Y ❑ N ❑ NO :below (Explain ) ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i 1 C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water Q Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3f13 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 3 of'17 I i i Jun 3015 04:04p p.4 ! i Commonwealth of Massachusetts Title 5 Official Inspection Form "I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 259 Clamshell Cove Road i Property Address i Adrienne Tanashian Owner owners Name informationis required for every Cotait MA 02635 6-24-15 � page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: I **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form_ j 3. Other. i I i D System Failure Criteria Applicable to All Systems: Y Pp Y You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool: Liquid depth in is less than 6" below invert or available volume is less than Y day flow ,L F/I C111,u67 Ons-3M3 Us 5 Official Inspection Fan.Subsurface Sewage Disposal System-Page 4 of 17 i I I Jun 30 15 04;04p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Clamshell Cove Road Property Address Adrienne Tanashian Owner Owner's Name information is Cotuit MA 02635 6-24-15 f required for every, page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ' Yes No Required pumping more than 4 times in the last year NOT due to clogged or i El obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ' ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. i [] ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. I ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 20009pd- 10.000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the foffo-,Ming, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Offidal Inspedon Form:Suhsurfew Sewage Disposal System•Page 5 of 17 I I Jun 30 1504:05p p.6 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 259 Clamshell Cove Road Property Address Adrienne Tanashian Owner Owner's Name Information required for every Cotuit MA 02635 6-24-15 page. Citylrown state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as NIA) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information_ For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)PIC CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 151ns•3113 rife 5 Official lnspedion Fors Subsurface Sewage Disposal System•Pape 6 of 17 Jun 30 1504:05p p.7 Commonwealth of Massachusetts ggcg�-W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 259 Clamshell Cove Road ` Property Address Adrienne Tanashian Owner Owner's Name information is required for every Cotuit MA 02635 6-24-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: I The system is a 1500 Gal. Tank D Box and three flows I Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No it Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report_) I Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2013-80;000Gal g ( y g f gpd))' 2014-190,000Gars Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CNIR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: r51ns•3113 TAIe 5 Qfhdal hWedion Form:Subsurface Sewage Dispos315ystem-Page 7 of 17 Jun 30 15 04:05p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1 259 Clamshell Cove Road j Property Address ! Adrienne Tanashian Owner Owners Name information is required for every Cotuit MA 02635 6-24-15 page. CityfTown State Zip Code Dale of Inspection j D. System Information (cont.) I Last date of occupancy/use: pate Other(describe below): j I General Information ! Pumping Records: Source of information: 6-11 /12-13/5-15 Was system pumped as part of the inspection? [] ye ® No j If yes,volume pumped: gallons j How was quantity pumped determined? Reason for pumping: I Type of System: ¢ ® Septic tank, distribution box, soil absorption system { ❑ Single cesspool C] Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract i❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3L13 Tills 5 Official inspection Form:Subeurlaoe Scw"c Diapoeal System•Poe 8 of 17 L Jun 30 15 04:06p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 259 Clamshell Cove Road Property Address Adrienne Tanashian Owner Owner's Name information is required for every Cotuit MA 02635 6-24-15 page. City/Town State Zip Code Date of Inspection i D. System Information (cone:.) i Approximate age of all components, date installed(i#known) and source of information: i I 1996 Permit # 95-1802 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet t Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 28" feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast. H-20 Sludge depth: — 15ins-3113 Title 5 Official Wmaion Form:Subsurface Sewage Disposal System•Patio 9 of 17 Jun 30 15 04:06p p.10 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Clarnshell Cove Road U>%y Property Address p I Adrienne Tanashian Owner Owner's Name information s Cotuit AAA 02635 6-24-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness a" Distance from top of scum to top of outlet tee or baffle 8" i Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Asbuilt-Tape i Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank at working level. Tank at 28"below grade. Inlet cove at 6", outlet cover at 10". Note: Both covers are 34"cement. In and out let tees. No sign of leak age or over loadind. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Offidal Inspec 4on Form:Subsurface Sewage Disposal System-Page 10 of 17 Jun 30 15 04:06p p.11 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Clamshell Cove Road Property Address Adrienne Tanashian Owner Owner's Name i information is required for every Cotuit MA 02635 6-24-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc_): i i i i . } Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: -- Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official hs pection fortrt Subsurface Sewage Disposal System-Page 11 of 17 I Jun 3015 04:07p p.12 i i Commonwealth of Massachusetts i r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Clamshell Cove Road i Property Address Adrienne Tanashian Owner Owner's Name information is required for every .Cctuit MA 02635 6-24-15 page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): ! Depth of liquid level above outlet invert — Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 96"x'f 6"-22" below grade wlcover at 14. Box is clean and solid. No sign of over loading or solid carry over_ i i r r II i i Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes [] No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): If or alarms pumps are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): if SAS not located, explain why: Mrs•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 17 Jun 30 15 04:07p p.13 I 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Clamshell Cove Road Property Address , Adrienne Tanashian Owner Owner's Name information required for every Cotuit MA 02635 6-24-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: i ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology. Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three flows. Flows are 33" below grade. Flows are clean and wet. No sign of over loading. i i Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 ORdal Inspection Forth:Subsurface Sawage Disposal System-Pape 13 of 17 1 i Jun 30 15 04:07p p.14 I I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 259 Clarnshell Cove Road Property Address Adrienne Tanashian Owner Owner's Name information is required for every Cotuit MA 02635 6-24-15 page.. City[Town State Zip Code Date of Inspection D. System Information (corn.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Privy(locate on site plan): I F Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I (Sins•Yi 3 Title 5 Official In3pecUan Form:Subsurface SewapP_Disposal System•Pa{le 14 of 17 l Jun 30 1504:08p p.15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 259 Clamshell Cove Road Property Address Adrienne Tanashian I Owner Owner's Name informatequiredfo is Catuit _ MA 02635 6-24-15 i required for every _ page_ Cityrrown State Zip Code Date cf Inspection D. System information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building_ Check one of the boxes below: hand-sketch in the area below 1-1 I drawina ntt:;chari cPnarataly f � It _ r —�_____� B - 3 = a -G ; 103 - =s3, F__ 0 -y_ 5 1 15•.6•3n3 TNe 5 0ffipai trupettim Form:subswiaw sewege Otsposal system•Page 15 of 17 I . L i Jun 3015 04:08p p.16 i I Commonwealth of Massachusetts f Title 5 Official Inspection Form ! IF- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 259 Clamshell Cove Road I Property Address Adrienne Tanashian I Owner Owner's Name i information is required for every Cotuit MA 02635 6-24-15 page_ Citylrown State Zip Code Date of Inspection D. System Information (cost.) j Site Exam: i [] Check Slope ❑ Surface water Q Check cellar ❑ Shallow wells 10, I Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) Q Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Auger T.H.10*no G.W.. Bottom of flow's at 4'below grade Bottom of flow's at 6'above T.H.Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. L9ns•3113 Title 5 Baal Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 i Jun 301504:08p p.17 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 259 Clamshell Cove Road Property Address Adrienne Tanashian Owner Owner's Name information is required for every Cotuit MA 02635 6-24-15 _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, 8, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I f t5ins-3/13 -rite 5 Official Inspection Form:Subsurface Soarage Disposal system'-Page 17 of 17 No. D FEE THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS �ppliration for Disposal *Vstera Cfuustrurttuu jhrrait Application is hereby made for a Permit to Construct( or Repair( ) an On-site Sewage Disposal System at: Location Address or Lot No. a T--� Owner's Name,Address and Tel.No. Z,S� ��q"'rSr�c't c, Co✓�TZn Corv� T Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. !�Vzr r;r 1L �i✓G/�✓Cri�7L/.v C_ Type of Building: 2 b Dwelling No. of Bedrooms / Garbage Grinder(� Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow r 0 gallons per day. Calculated daily flow -7 3 v gallons. Plan Date Number of sheets Revision Date Title PRE/Posey c�T7< fJ �c.,� �c'oR j��SY--�a�or G��sraw /jui�Ob�2j Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has issued by this Boaqflf Health. Signed Date 1,Q '3 Application Approved by %C �=- Date f/ —f 91 Application Disapproved for the following reasons Permit No. 1 �11��_ Date Issued ! Z NO. )�1�DI �FEEg THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS 1japlication for (fonstrurtion Frrmit Application is hereby made for a Permit to Construct (L-<Or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. / a Owner's Name,Address and Tel.No. C<? y`L-1 l �- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (-zo-Tf&2,r_ ter✓ //✓L7-G3YL/ti C. Rv. /,J-Y 713 S Pf-,J/L,/f Type of Building: `3 a e c Dwelling No. of Bedrooms Garb Grinder. g Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures \ ` ,Design Flow /U gallons per day. Calculated daily flow 3 V gallons. Plan Date. �U»'�U ` f Number of sheets Revision Date Title� "�r✓!emu S1 c�-O �T7 C j>c- j'/6,.. ,co r2 l�c -S'�-�C�.r- c� S rz,�-, �'o�cAc�Z f Description of Soil Nature of Repairs or Alterations(Answer when applicable) T Date last inspected: 1 _.. Agreement:�� The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa, df Health. Signed rae�2�- '/ s �--. Dated Application Approved by �� Date Application Disapproved for the following reasons Permit No. ` �n Dom_ Date Issued THE COMMONWEALTH OF MASSACHUSETTS , MASSACHUSETTS � er�tftr�c#� Df hum Itttxtre THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( ) or rep aired/replaced( ) on by JV4AV A l do- for � °° AfAVY at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ 'g dated Use of thisysystem is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on DATE 1/'r" o '°"° Inspectot& �, 1 Y q THE COMMONWEALTH OF MASSACHUSETTS No. 1_^J nO`a, ;_ W_e u �Q�Y, MASSACHUSETTS FEE _ ,Disposal ,Sgs#Pm (fons#rurtion IlPrmt# Permission is hereby granted to to construct or re air a( )an On-site Sew e§4tem located at �nd as described in the above Application for Disposal System Construction Permit. The applicant r 4gnizes his/her duty to comply with Title 5 and the following local provisions or special conditio All construction In a competed ithin three years of the date below. �o DATE Approved by D . FORM 1255 Rev.3/95 A.M.S LKIN CO.-8 STON,MA rjz�< L�0� NO. : ADARES"�: 9 CL �,sti�CC T� f 014NERS NAME: be e- SEWAGE PERMIT NO. : �75/,M NEW: REFAIR: DATE ISSUED:/Q~9l"1"5rDATE INSTALLED 1-3®,�' INSTALLERS NAME: L A w/,�ef5r D0/► c)i/^,n/ INSTALLATION1 OF: 1500 L 7A/Uk—' 3 /=ZOO WATER TABLE: FINAL INSPECTION DRAWING OF INSTALLATION ON REVERSE SIDE: w� � � ��t` � � �.�� # Y + � � � i � � T c, TOWN OF B(,RNST OLE LOCATION SEWAGE # VILLAGE ' ` t ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � I TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR SOIL TEST ELEV. _ /O/ 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST ��ppNN CLEAN SAND SOIL TEST DONE BY COVERS WITNESSED BY a' SCHEDULE 40 PVC PIPE �, LOAM AND SEED OBSERVATION HOLE 1 ELEv.- 97 0 OBSERVATION HOLE 2 ELEV.- 9 '7. 7 MIN. PITCH 1/8' PER FT. \ 2' . AYER OF PERCOLATION RATE Z MIN./INCH AT 7I1 INCHES PERCOLATION RATE 2 MIN./INCH AT 78 INCHES 1/e' TO 1/2' DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MO TT. 07M 4' CAST IRON PIPE WASTED STONE ENT NOT REQUIRED 7 OP- qNr C (OR EQUAL MINIMUM " - U PITCH 1 4 PER FT. ,, z - - -___-• --�—-_ 1 CU. FT. OF - �- CONCRETE ,7 (�rK7 Fi.� �',X -7 --- - i FLOW LINE _ - ----___1 ANCHOR y-`� --- _ _ ELEV. _ MIN. t9- v r rp_ rt+ _ 0 0 0 0 0 0 � . 7- � e`�/3 �-� ?'a r LEVEL cn o C3 o 0 o r� 12' -} _� J�. 7 S 1 1 / o ELEV. o ELEV. = f g' ELFV �+ !j L pgwr✓ (oy� S� DISTRIBUTION 3 F fi#�o,or tlsd4f /�.�. , s,�,,., /� S�l�+0 B L BOX ?Y z� ,.� A (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED 1314m S4a Sys/i 1500 GALLON IF MORE THAN ONE OUTLET -_ 1, or ' �' TRENCH FORMA r10N (TO BE PLACED ON FIRM BASE) SOIL ABSORPTION WELL �� N0 WATER ENCOUNTERED AT ��a ELEV. _ / �1� WATER ENCOUNTERED AT 13� SEPTIC TANK In ZONE ELEV. 3/a- TO 1 STONE SYSTEM (SAS) INDEX ADJUST_____ i LEGEND: DESIGN CALCULATIONS T BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABir- ELEV. = EXISTING SPOT ELEVATION 00,�0 NUMBER OF BEDROOMS SEWAGE DISPOSAL S Y 5 i E M PROFILE OBSERVED WATER TABLE ( / / ) ELEV. = _-___. EXISTING CONTOUR ----00---- GARBAGE DISPOSAL UNIT NOT TO SCALE FINAL SPOT ELEVATION TOTAL ESTIMATED FLOW FINAL CONTOUR (-l!L-GAL /BR./DAY X s BR.) 33G GAL/DAY SOIL TEST LOCATION REQUIRED SEPTIC TANK CAPACITY GAL UTIUTY POLE -4 ACTUAL S17E OF SEPTIC TANK vo GAL., TOWN ATER SOIL CLASSIFICATION CATCH WB SIN W �O DESIGNPERCOLATION RATE MIN./IN. �y GAS LINE G - EFFLUENT LOADING RATE ?y GAL/DAY/SF. 1 LEACHING � �.,, `f�L- SQ FT. r " LEACHING CAPACITY (AREA X RATE) 9 GAL./DAY 1-, -;P1 L' T RESERVE LEACHING CAPACITY 3 � GAL/DAY 2-3, NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. i �v TITLE 5 AND THE TOWN OF c F RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO ` /��S` WITHIN 6' OF FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF T�f �� 1�✓�o ss� \`� WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN �G Too .a 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4 ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL f�yCt�nsG�i r BE MORTARED IN PLACE. I \~ NO DETERMINA I ION HAS BEEN MADE AS TO COMPLIANCE WITH j 1 \ t OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 6 UTILITIES SHOWN ARE APPRO)OMATE ONLY, EXCAVATION CONTRACTOR IS TO CALi_ 'DIG-SAFE' AT 1-800-322-48" AT LEAST 72 HOURS � 10 PRIOR TO COMMENCING WORK ON SITE. 17 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVAINM AS WELL AS \ SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. 8. PARCEL IS IN FLOOD ZONE c UU \ G 9. LOT IS SHOWN ON ASSESSORS MAP AS PARCEL �� -: \ <<� fit'C+ \ V�4" I SHOW '�r Nam A,f' PROVEu : GARL! OF HEALTH 4r - � DATE AGENT j OWL PROPOSED PROPOSED SEPTIC DESIGN FOR i Vol l % {� r PROJECT LOCATION �•' C) 1 J I 56 Q �- s ,> c ,.►• �-- a r� r 1 "3�— { �Y S WEE--'SER ENGINEERING 235 GREAT WESTERN ROAD 508— P. 0. BOX , 398-3922 SOJTH DENNIS, MASS. 02660 [DATE ILO G LOCATION MAP '1Oe N0 //,3s' SHEET / OF I 01995 SWEETSER