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Home My WebLink About0017 CLAMSHELL POINT LANE - Health 17 CLAMSHELL.POINT i COTUITo -7 LOCATION �t � � SIWAGE PERMIT NO. '00000 VILLAGE ld, I N S T A LLER'S NAME i ADDRESS f � s pro 0� GUILDER OR OWNER .00 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED Z�1�6,2 79 r � c�i Fss...... ..- .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................O F.........................................----.------.....------------..................... Appliratiou for Digpuiial Workii Tottotrurtiurt ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at -� totCionslifut Pa;� L3. Ub CQ ................_ ................................ --......---.......--------.... ........---••-••---•-----•--------------------.....----------------------------------------------- Location-Address or Lot No. ----------------Pry. 3. t�- ---..... Owner Address Installer Address + �� d Type of Building Size Lot.._._r. .z ... ........Sq. feet U Dwelling—No. of Bedrooms.............. .Expansion Attic. ( ) Garbage Grinder ( ) Other—T e of Building ........... No. of persons............................ Showers — Cafeteria P4 Other fixtures ---------------------------•-•-- . W Design Flow........... .........................gallons per person per day. Total daily flow............3. 0...................gallons. WSeptic Tank—Liquid capacity10.04--gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.......................Width.....v._.-.-....... Total Length..... ....�-..... Total leaching area.................... ft. Seepage Pit No.........)........... Diameter.......Ia ...... Depth below inlet........1-.......... Total leaching area.-Q.`GQ. .......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. l................minutes per inch Depth of Test Pit................--.. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....---................ •-•-------------------------------•-------•----•-••----...........-------------•--------•----------........................................................ 0 Description of Soil........................................................................................................................................................................ x c., W .......................................................=-•-------...------------....------•--•-•-----------------•---------------------------•--•---•---------------------•-------•------..........----•- UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•-------•------••---------------------------------------................----.....-----------------------•----------•-------------------------------------------.........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIYLE 5 of the State Sanitar/iis Code— e undersigned rther agrees not to place the system in operation until a Certificate of Compliance has b eo r ealth. Signed---• - ----------• .......I.................................... --•------•-• ................ Da t e Application Approved B � Date Applieati�,n Disapproved for the following reasons---------------•--•---------••-------------------------------------------------------------.. .........---.._ .......................... •----------------------------------------------- •--------------------------------------------------------------------------------------------------------------------- Date Pe y^ r::ut No......................................................... Issued_....................................................... J - Date No................_....... �� " FRs.. ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ....................O F.......................................................-.................................. Appliratiou for Disposal Works Tunstrortion rrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 0 f -4 Iq ---.... ........................... ........... .......:. Lt-N--.-•------------•----•--................••-- -. ....... .T.... Adde or o ---......_, jjon ..... kA B- Owner Address ....................................................................................... ..... --•-................................ ......................•-----•-----•--- Installer Address d Type of Building Size Lot.....K"v mo--------Sq. feet Dwelling—No. of Bedrooms................._.......•.........._....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures --------------------------------------------------------_------ -•------•-------------------•••----•••--•-•......._---•--•-•-.......------- Design Flow...........�J�.........................gallons per person per day. Total dail flow...........__ Wg P P P Y Y T.;:j!'� dons. WSeptic Tank—Liquid'capacityl.Q Aa_._gallons Length_............. Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I........... Diameter.......)a........ Depth below inlet......`-........... Total leaching area.,?,C)C,.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.............................•--- .......................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.__.__............_. Depth to ground water•-__-____-___-__._---__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth,to ground water........................ pd ----------------- •----- •----------------------------------------- -.... -..... •....... ---..------ -... -...--------••-----..----•--•------------ ._._.. ODescription of Soil....................................................................................................................••••---•-•-••-••----•--.....----------------------•- V ._......-••••-•----••-----•......----•.....................•--••--------------......----------------•-.......--•••-•.........--••----••---------•----•••••-•-•--•-•--•------•----••-•-•--......---•--•_.. W --••--•----•--------- .................................................................................................................................................................................. UNature of Repairs or Alterations—Answer when applicable....................................................................--------------------------- --•-----------••-•---------•------------•-••---•-••-•-•--•--•••••-•-•-••:-••-••---•--•---•-••-••....•-•...••-•-•-••-•--------------•••-------•----•-•••-••-••---•--....---•-••-•••-••-•••--••••........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTiE 5 of the State Sanitary Code—The undersigned urt-ier agrees not to place the system in operation until a Certificate of Compliance has been jissu�e�d'byyythe:boa�rc,o iealth. c4g • -- - --- ------------------------------------------------ -- .. �P / ................•-.Date•------••---.. Application Approved By.._... .........._ - Date Application Disapproved for the following reasons--------------•-•-•--••-•--•----•-••--••--•--•-----------------...---------...--••...----•--•••--...__..--------- ......._---•..........................••••••••-•-------••--••---•-•---•--------••••--•...._._...----...•............-----••------•-•-•••----•------••--•..........._...---•--•---•--=-----•-•---•-•-•--- Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF�HEALTH � ..........................................OF......-•.............ads......!i ...................................• C�rriif irab of Tompliaurr THIS IS�RTI Y, t t. Individual Sewage Disposal System constructed ( ..)..or Repaired ( ) by.............r. _.. /..q.._._._...__/"_`_.._ .. ...._.. ...... ___..__ , ..__.____.___ _.................__._�_.a_._�__._....... ..............._.................. at•--------------•----•--------------•---••---•-----•--------------------------•---•---------------------------------•------------------------•-•--•------•------------------------------------------- has been installed in accordance witli the provisions of TIT Li&A of ate Sanitary Code as described in the application for Disposal Works Construction Permit No................................ .... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE -/Z `�f Z Inspector_ .!-�................................•---•---------------•-•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD_ O HEALTH to No......................... FEE........................ Disposal rk rtrwtion prmit Permissior> iereby granted............... � '.... -------•---....•---..._.. •------•-•-•--...-•----------•--••--•............................................ to Construct epai )°,an In ivid., 1 Sege pisposa ystem atNo............................................................................... Street as shown on the application for Disposal Works Construction Pexm't No...... .................. Pat ., __.__.s............................ .. r ...._ ,4....._ -. .-•-•-•------------------•-.. �.Z �� Board o health DATE-•--• -------- --•-•-----------------••-- ---....----•--•----•-----.......... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i -- -- -- /0/;2 ' �It,wl_� t✓o�nll..�( - 3 Fst:yt�oM ► ,0XN LAO GAmuAGE 6Qi Qr�c:2 8 tit Lam! t=Lx>v 1 to k 3 . .3?p G p.D. . . .. ��• ��A .. • ` . wo,E-�T-tc Tk 33a,. ISC M • �A5 6.P.D. V� lq0 ,5F ' AMF-A z. moo �� _ • • �. . . . • � ; : : : � - ` � ' _I�� ' t�jp �$F � 2.S • 2;-jrj Q.P.D. . . _ � .. i ,. . ; •� - TdTAL -1PE6IG1.• 8$ G.P. it D. ... .._- .TOTAL Pt::,Oc,E> -dTjC>Q tzhrE ttq 4 filCHA ; '�� ' " ;i �,, ' ; ! .: F� Per .�.� FA tea__: 2 Or qL 4v' 2 r Tor Treat, �; . ._ ! FG 95 , . ,�,�, ,., . - 4- Z -max 7. --t Sync to �;. PIT . .CEIZTlP%ED PLC) P'L./�1J E . . . LcvGATI O" COTU•)T EZ-8t : • . . . �o Swat. - : : ` ( 5 GGaT1t=�( Ts4A-r THE P1-AtII.1 RL-pcQ Et.Ic E Wr-ZMot.1 Gca4APt. YS W tT1-i TNT: �IDE.LtN� : :k.DT A1.JD SCTmAcv- S'GQUtCENccuTS OF TNG ! . ?cww of w;2,;,.�7Aa4,6 AI4t> Is f49T- LOGATEb• WITt-ttt.l TK•t= j=l.Oob PLAW. i •UIS.T�2-g.-81 �• . . � � Bh.XTG1Z <a"eE tic. t2CGl,;m- ZED "140 5ueva iO ` os-rEevtt_Lc "('t-1 15 �7 i.A►-1 t'S 1J OT L'a►S CD OW A N IwsrCtjMEwr �,uc:•icY , ,c►{c:. �Fc, r�, s'-tcwt-a ANPt_t cA.a.1T ...- � r,AA L-0-C -LiWa5 1 PAVL WOMAS PftGINbF BARNSTABLE LC3': A'i IG: Ll 1 SEWAGE # VJI:LAGE e l ASSESSOR'S-MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /V0 0 LEACHING FACILITY: (type) (size) CA l A�/ NO.OF BEDROOMS BUILDER O 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 r~ "a �A �eeh AA A C)I BA I) s Afow . 9 1993 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292 35 00 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1�" CERTIFICATION -- a �F ,•'� Property Address: 17 CLAMSHELL POINT, IV P. COTUIT Name of Owner OWEN NEEDHAM � �3 O Address of Owner: SAME J 9 Date of Inspection: 10/27/99 yy O'eQ49,y `9`9 a Name of Inspector:(Please Print)JOHN GRACI �EAT'�(F 1 am a DEP approved system inspector pursuant to Secdon 15.340 o/Tide 5(310 CMR 15.000) C� Company Name: n/a Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT I 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 inspection.The Inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpectlon Is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further E I ion By the Local Approving Authority performing at the time of the inspection.My inspection does Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:10/27/99 The System Inspector shal submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.THE SYSTEM NEEDS TO BE PUMPED NOW AND MAINTAINED EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.THE LEACH PIT HAD 6"OF LEACHING LEFT AT THE TIME OF THE INSPECTION.LEACH PIT HAD SOME SOLID CARRYOVER.RECOMMEND RAISING COVERS TO MAINTAIN SYSTEM. revised 9/2/98 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: I]& 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n1a The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced Wa The system required pumping more than four 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 obstruction is removed revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27199 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER nla revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems In addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system Is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping Information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates duringthat period.Large volumes of water have not been Introduced Into the system recent) or as art of this Inspection. P 9 Ys Y P P X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. �( The site was Inspected for signs of breakout, X All system components,excluding the Sol!Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined In the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) 11 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9098 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10127199 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN now: MIA Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):-W Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): NQ Last date of occupancy: n& COM MERCIALIINDUSTRIAL Type of establishment: nla Design now: IVA gpd(Based on 15.203) Basis of design now: n/a Grease trap present:(yes or no):-W Industrial Waste Holding Tank present:(yes or no): MQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nla Last date of occupancy: n& OTHER: (Describe) n& > Last date of occupancy: n/a GENERAL INFORMATION PUMPING RECORDS and source of information: NONE System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nla. gallons Reason for pumping: n& TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 15 YEARS OLD_ Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 BUILDING SEWER: (Locate on site plan) Depth below grade: iC Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc:) IVA SEPTIC TANK: X (locate on site plan) Depth below grade: 8_ Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ D& J Dimensions: L B'6"H 5'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: 3r Scum thickness: Distance from top of scum to top of outlet tee or baffle:-C Distance from bottom of scum to bottom of outlet tee or baffle: in How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING NOW AND EVERY ONE YEAR. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n/A Dimensions: n/a Scum thickness: n/A Distance from top of scum to top of outlet tee or baffle:j/a Distance from bottom of scum to bottom of outlet tee or baffle n/A Date of last pumping: nla Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,evidence of leakage, etc.) n1a revised 9/2198 Page 7 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n(a Dimensions: n/a Capacity: n(a gallons Design flow: n1a gallons/day Alarm present: NO Alarm level:jita- Alarm in working order:Yes_No—: NQ Date of previous pumping: n(a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:Wa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.) PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n1a Type: leaching pits,number: 6'X4'LEACH PIT leaching chambers,number: -n& leaching galleries,number: _WA leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n/A Alternative system: n& Name of Technology: -n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTLI ALL SOUND AND FUNTIONING PROP R Y THE PIT HAD 1'OF LEACHING LEFT AT THE TIME OF THE INSPECTION_SHOULn CESSPOOLS: _ (locate on site plan) Number and configuration: n1A Depth-top of liquid to inlet invert: n/A Depth of solids layer: n1a Depth of scum layer. n1a Dimensions of cesspool: n& Materials of construction: nta Indication of groundwater: n/A inflow(cesspool must be pumped as part of Inspection)n1A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1a PRIVY: _ (locate on site plan) Materials of construction:n1A Dimensions:n1a Depth of solids: n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10127/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Ili Q 0 6 C O �A a� AC30DA 3 R 17� � 33 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 CLAMSHELL POINT RD.COTUIT Owner: OWEN NEEDHAM Date of Inspection:10/27/99 NRCS Report name: n/a Soil Type: Wa Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data the High Groundwater Elevation. Must be completed)Describe how you established , ( ' ) USGS MAPS AND CHART revised 9/2198 Page 11 of 11