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HomeMy WebLinkAbout0096 CONTENT LANE - Health 96 Content Lane Cotuit P A 040 031 Commonwealth of Massachusetts 070— 03 / -. Title 5 Official Inspection Form :.. r Subsurface Sewage Disposal System Form om- Not for Voluntary Assessments F� l Property Address t S �oGo i d Owner Owner's Name information is required for every /010 -moo� O�U I � __ � � pC., / page. City/I own State Zip Code Date of-Irisp ction Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Ins ector inform ion Cl filling out forms p G /�3 93 on the computer, use only the tab a r key to move your Name of Inspector ��V/ O cursor-do not use the return - T key. Company Name �O &d J Company Address yak City/Town [��s x^ ///�rA/7(7n�/ State Zip Code ii0E7 r �JI a V D -_ O (/(��O id Telephon tuber License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that tA�srn: es 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Ll Inspecto 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc•rev.7/2612018 ?IJe 5 of dal inspection=o—.suosurac a sewage Disposal Sys'—•?age 1 of 18 Commonwealth of Massachusetts ? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C004 Property Address Owner Owner's Name information is 0, required for every - O I � /�- J page. City/Town State Zip Code Date of I specti n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6. 1) System P es: I 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: 2) 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 metal 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): t5insp.doc-rev.7/26/2018 'itle 5 C?5aai inspecacr.rom:suosurace sewage Disposai system-Page 2 of 18 L Commonwealth of Massachusetts j�_p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Property Address Owner �OCG 1 Owner's Name �O ' information is required for every oa,'3s page. City/Town State Zip Code Date of Insp ction C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 - 'i ifle 5 Officiai;nspecncn Roan:Subsurface Sewage Disposal System•Page 3 of t8 i_ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address � Owner Owner's Name information is CA.41 required for every / - as 63s ca //ifla d page. CityfTown State Zip Code Date of In ection C. Inspection Summary (cost.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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: **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. c. Other: 4) System Failure Criteria Applicable to All Systems: 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 logged 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 t5insp.00c-rev.7262018 Title 5 Of9aai Inspection Form:subsurface sewage oispcsal System•Page 4 of 18 L Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z� Property Address, O Proco/91 Q Owner Owner's Name information is / od 6 3S a a required for every _ page. Cityfrown State Zip Code Date of Ins ection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to Ail Systems: (cont.) Yes No i Static liquid level in e distribution box above outlet invert due to an overloaded F 1 E th or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: EJ 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 water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. t� 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.] ID he system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. LJ The system fails. 1 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. 5) 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 following, in addition to the questions in Section C.4. 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 —i 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 ;5insp.doc•rev.?262018 -da nspeaion=om:subsu,�ace Sewage Disoosal System•Page 5 of 18 i i Commonwealth of Massachusetts ` Inspection Form Title 5 Official Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address o !0 Owner Owner's Name /M information is C�a�3 A IY a O required for every page. City[Town State Zip Code Date of In pecti n C. Inspection Summary (cont.) . If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes ❑ umping 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 N/A) 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 IIIYYY 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)[310 CMR 15.302(5)] Title 5 Official inspeCuor=on:suDsL rtace sewage Disposal System•?age 6 of 1a t5insp•doc•rev.M612018 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� q co . / w_4✓�*- I �N Property Address n Owner Owner's Name information is �O I Q�-css p�fl required for every page. CitylTown State Zip Code Date of Inspe 'on D. System Information .1. Residential Flow Conditions: 3 Number of bedrooms (design): 'Dumber of bedrooms (actual): ? 30 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): c� Description: / Isco 6.46, -- ESd Soo Cz Number of current residents.- Does residence have a garbage grinder? ❑ Yes 29- INo Does residence have a water treatment unit? ❑ Yes 1 o If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection [I Yes No information in this report.) Laundry system inspected? ❑ YesPdo'— Seasonal use? ❑ Yes Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Yes �No� Last date of occupancy: Date 5insp.doc•rev.7 26/20�8 Tide 5 cftdai.nspecaon=crn.Sucsu'ace Sewage Diapcsai System•Page 7 of 78 I_ f Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Property Address Owner 10 co ,0 7neName information is Q /� required for every 1 d D page. n State Zip Code Date of In pecti D. System Information (Cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment.- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as par of the inspection? ❑ Yes No If yes, volume pumped: - galionS How was quantity pumped determined? Reason for pumping: — v t5insp.000•rev.7/26201-8 Title 5 Offidal inscection=omn:Subsurface sewaoe oisposai system•Page 8 of 18 Commonwealth of Massachusetts -. Title 5 Official Inspection Form kSubsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /OCo i O Owner Owners Name 1 information is Co /'� Ogg /(( required for every page. City[Town State Zip Code Date of In ectio D. System Information (cont.) 4. Type of S m: 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) ❑ 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components. date inst lied (if k o n) and source of information: ram Z Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): C;16 Depth below grade: feet Material of construction: ❑ cast iron 0 PVC ❑ other(explain): ! D Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/612018 ' ?age 9 of 18 We 5 C�`g2i nspecticn Form.sucsur=e sewage Disposal system• Commonwealth of Massachusetts Title 5 Official Inspection Form ° i Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments s ents Property Address Owner Owner's Name 1�C0 information is O , d, Hfj*on — D. c required for every page. City/Town State Zip Code Date of Insp System Information (cont.) 6. Septic Tank (locate on site plan): l/ Depth below grade: feet Material construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal lis t age'.g years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ov / Sludge depth.- Distance from top of sludge to bottom of outlet tee or baffle Scum thickness l� 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 - How were dimensions determined? - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �il✓`l t vj CO 01^Qvr�e�/ �0 olt I—eln l✓l t5insp.doc-rev.7/2 6120 1 8 line 5 vmoai inspecoon=orm:scosurrace Sewage Disposai system-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'W�ww Property Address /'o60 1 p Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins# ction D. System Information (cont.) 7. 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 Comments (on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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: r • Capacity: gallons Design Flow: gallons per day t5insp.doe•rev.712 612 01 8 �itie 5-Moa!irspamon Fort:Seosu-face Sewage 0lsposal •?aye t t of t8 System Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ao co /0 Owner Owner's Name information is required for every page. Cit /Town State Zip Code Date of Insp tion D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): P-eV Depth of liquid level above outlet invert I 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.): ?;7e g�ifiG2i:nsc ecuon co, S,5,jace Sewage Disposal System•?age 12 of 18 t5insp.doc•rev.7/282018 f Commonwealth of Massachusetts p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C-0 0 Property Address Aocolal Owner Owner's Name r Oinformation is d 1 required for every page. Cdy/town State Zip Code Date of Insp ction D. System Information (cont.) 10. Pump Chamber(locate on site plan): 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 pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ` lI(7t^ &,(o,17 leaching pits number.- 7 leaching chambers number: ❑ leaching galleries number: ❑. leaching trenches number, length.- 7 leaching fields number, dimensions: 7 overflow cesspool number: innovative/alternative system Type/name of technology: --- 'me 5 Q"oai:nspecuon=0=,SuD_,rtace Sewage Disposal System•?age t3 of 18 t5inap.doc•rev.7/26/2018 I I Commonwealth of Massachusetts Title 5 Official Inspection Form . i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners Name information is ,� 'f required for every ao page. City/Town State Zip Code Date of Instectiorl D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): , !/ t9�vf✓1 9 l� Coe/ . N tj • Idu 46 /(4 f 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tsinsp.coc-rev.7/26/2018 ?ine 5 Oftca,Inspection Form:sucsudace Sewage Disposai system•Page 14 of 18 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address rOCO (O Owner Owners Name information is 0441 63s CZ /Y ao required for every l� - page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 'roe 5 Offlaai;nsoacuon=orm.scosurace sewage Disposal system•?age is of t8 tsinsp.doc-rev.1/26/2018 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address to Co to Owner Owner's Name information is required for every 6 Y page. Cityl I own State Zip Code Date of Insp ction D. System Information (cost.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or ben arks. Locate all wells within 100 feet. Locate where public water supply enters =in ck one of the boxes below: the area below ❑ drawing attached separately €5i¢ C d✓ i i Rtso� i ��- I I t5insp.doo•rev.7126/2018 Title 5 fipai InSG=-ion=cm:Subscrface Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 (fo 1,4 Property Address Owner Owner's Name information is AIA required for every — C404W/'(— page. City/Town State Zip Code Date of Ins ction D. System Information (cons.) 15. Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate ail 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 propertyiobservation hole within 150 feet of SAS) Checked wit' 'jcal Board of Health explain:- f �s v/0 G r Checked with local excavators; installers - (attach documentation) ' Accessed USGS database- explain.- You must des crib ow y u established the high ground water elevation- / 5Z S-4 y'Q P1,f 7(c- 114 POO I,- Ub �W7TVH. Before filing this Inspection Report. please see Report Completeness Checklist on next page. 5insp.doc•rev.7/262018 _ -;'je 5 07taal,nspecon=on:Suosudace Sewage Disposal Systen•?age 17 of 18 r Commonwealth of Massachusetts w: ,l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P; (,— h Property Address /'O c o to Owner Owners Name information is required for every page. City/Town State Zip Code Date of Inspe ion E. Report Completeness Checklist Complete ll applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. rtification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary. 1, 2, 3, or 5 completed as appropriate 4 afure Criteria) and 6 (Checklist)completed D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included w t5inspAoc-rev.7126l2018 ':ue 9 ofloai inspection ro-n sunurtace Sewage otsposai System•?age 18 of 18 I � - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y, w d DEPARTMENT OF ENVIRONMENTAL PROTECTION "0 MAP PARCEL* LOT � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 96 Content Lane Cotuit MA 02635 Owner's Name: John Cook Owner's Address: Same Date of Inspection: November 1,2003 Name(if Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. 1 12003 Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 TOWN OF BARNSTABLE Teleph)ne Number: 508-428-1779 HEALTH DEFT. CERTIFICATION STATEMENT I certif; that I have personally inspected the sewage disposal system at this address and that the information reported below k 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: X Passes ^Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: � Date: I UO The sys tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)u ithin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or;treater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.T ie original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authorii y. Notes a id Comments: System in good condition.Observed no standing water in chambers, recommended pumph-g tank. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. T tis inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 'ispection Form 6/15/2000 page I Page 2 3f l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 Content Lane,Cotuit Owner: John Cook Date of Inspection:November 1,2003 Inspeci ion Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sylem Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3 10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comm-mts: B. SyAem 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. Answei yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain "he septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun•1,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existinf tank is replaced with a complying septic tank as approved by the Board of Health. *A met i1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicati rig that the tank is less than 20 years old is available. ND ex€lain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstruc:ed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approv,.1 of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND exr lain: the system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass in:pection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND exX lain: Page 3 if 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prope►ty Address: 96 Content Lane,Cotuit Owner: John Cook Date o-'Inspection: November 1,2003 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 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,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 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 *'"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and she 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. 3. Dther: Page 4 A 11 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 Content Lane,Cotuit Owner: John Cook Date of Inspection: November 1,2003 D. SyAem Failure Criteria applicable to all systems: You mi ist indicate"yes"or"no"to each of the following for all inspections: Yes No X_ Backup of sewage into facility or system component due to 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 %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 _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma No_ (YesMo)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 doff ect the failure. E. La rge Systems: To be c onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You mi st indicate either"yes"or"no"to each of the following: (The fo lowing criteria apply to large systems in addition to the criteria above) yes nt I 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 II 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 signific<nt 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. A I Page 5 of 11 �3FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propel ty Address: 96 Content Lane,Cotuit Owner; John Cook Date o 'Inspection: November 1,2003 Check f the following have been done. You must indicate"yes"or"no"as to each of the following: Yes P to _X_ __ 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? _X_ __ 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? _X_ __ Were as built plans of the system obtained and examined?(if they were not available note as N/A) _X_ __ Was the facility or dwelling inspected for signs of sewage back up? _X_ __ Was the site inspected for signs of break out? _X_ __ Were all system components,excluding the SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the conditi(in of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper mainte►Lance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n o _X_ __ Existing information.For example, a plan at the Board of Health. X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distanct is unacceptable)(310 CMR 15.302(3)(b)] cl Page AiI i)FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. Propel ty Address: 96 Content Lane,Cotuit Owner: John Cook Date o;'Inspection: November 1,2003 FLOW CONDITIONS RESIII ENTIAL Numbe-of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIG V flow based on 310 CMR 15.203(for example: 110,gpd x#of bedrooms):330 Numbe•of current residents: 1 Does re sidence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundr✓system inspected(yes or no): Season.it use: (yes or no):No Water j peter readings,if available(last 2 years usage(gpd)): 2002—34,000/2003—16,000=68 gpd. Sump I ump(yes or no): No Last da:e of occupancy: Currently Occupied COMA IERCIALANDUSTRIAL Type o'establishment: Design flow(based on 310 CMR 15.203): -gpd Basis o["design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sa litaty waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last da:e of occupancy/use: OTHE R.(describe): GENERAL INFORMATION Pumping Records: None Source of information: - Was sy;tem pumped as part of the inspection(yes or no): No If yes,1•olume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE 3F SYSTEM —X Se)tic tank,distribution box,soil absorption system _Sin gle cesspool _Ov:rflow cesspool _Pri fy —Sh;red system(yes or no)(if yes,attach previous inspection records, if any) _Inn)vative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtaine.l from system owner) —TiI lit tank `Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 10/18/99 Were sewage odors detected when arriving at the site(yes or no): No Page 7 :)f 11 13FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propei ty Address: 96 Content Lane,Cotuit Owner: John Cook Date o 'Inspection: November 1,2003 BUILT 4NG SEWER: X (locate on site plan) Depth 1,elow grade: V Materh Is of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 24' Commt nts(on condition of joints,venting,evidence of leakage,etc.): SEPTI'-TANK: X (locate on site plan) Depth below grade: 18" Mated,I of construction:—X—concrete_metal_fiberglass_polyethylene _oth,x(explain) If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certific;ite) Dimen,ions: 10.5' long x 5.8' wide-1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How v ere dimensions determined: STICK WITH HINGE FLAP. Commt nts(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relat,:d to outlet invert,evidence of leakage,etc.): Recommended Damaine.liquid level at bottom of outlet pine.Tees intact. GREA.iE TRAP: No (locate on site plan) Depth I elow grade: Materii I of construction:_concrete_metal_fiberglass_polyethylene_other (explah t): Dimew ions: Scum tl sickness: Distanc from top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Commt nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate d to outlet invert,evidence of leakage,etc.): Page 8 A 11 13FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Content Lane,Cotuit Owner:John Cook Date o I'Inspection: November 1,2003 TIGHY or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth I Below grade: Materi,1 of construction: concrete metal fiberglass polyethylene other(explain): Dimen:ions: Capacil y: gallons Design Flow: gallons/day Alarm;)resent(yes or no): Alarm eve]: Alarm in working order(yes or no): Date of last pumping: Comm(nts(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comm(nts(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.): Box set level. PUMP CHAMBER: No (locate on site plan) Pumps n working order(yes or no): Alarms in working order(yes or no): Comm(nts(note condition of pump chamber,condition of pumps and appurtenances,etc.): m Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Content Lane,Cotuit Owner: John Cook Date of Inspection: November 1,2003 SOIL f►BSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Two 500 gal.chambers. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: o��erflow cesspool,number: innovative/alternative system Type/name of technology: Comm(nts(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Observed no standing water in chambers. CESSPOOLS: X (cesspool must be pumped as part of inspection) (locate on site plan) Numbe•and configuration: Depth- top of liquid to inlet invert: Depth(f solids layer: Depth(f scum layer: Dimew ions of cesspool: Materk Is of construction: Indicati)n of groundwater inflow(yes or no): Comm(nts(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIV1k: No (locate on site plan) Materiels of construction: Dimew ions: Depth of solids: Comm(its(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Content Lane,Cotuit Owner: John Cook Date of Inspection: November 1,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchrr arks. Locate all wells within 100 feet. Locate where public water supply enters the building. Wly ya lob 0 • Page 1 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Content Lane,Cotuit Owner: John Cook Date oi'Inspection: November 1,2003 SITE YXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 10 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: O-)served site(abutting property/observation hole within 150 feet of SAS) C iecked with local Board of Health-explain: C iecked with local excavators,installers-(attach documentation) _X_A ccessed USGS database-explain: USGS topo map and town GIS You mi ist describe how you established the high ground water elevation: el.30. USGS topo map shows property at el.60 and town groundwater contour map shows groundwater at ` TOWN OF BARNSTABLE LOCATION �� �f &/�&rb L SEWAGE # VILLAGE 0—r6c l' ASSESSOR'S MAP & LOT / INSTALLER'S NAME&PHONE NO. M,A` 0725— SEPTIC TANK CAPACITY LEACHING FACILITY: (type) size) - NO.OF BEDROOMS BUILDER OR OWNER S PERMTTDATE: COMPLIANCE DATE:4a- //?1 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 ACk Z�4THk L 66W C 14 No. THE COMMONWEALTH OF MASSACHUSETTS FEE 6�C) F95 / BOAR OF HEALTH 1 It7 - OF &wVY1h— APPLICATION FOR/DISPOSAL SYSTEM CONSTRUCTION PERMIT , Application for a Permit to Construct ( ") Repair ( ) Upgrade ( ) Abandon ( ) - 2/complete System ❑Individual Components L'cation Owners Name OCt_,1 C)51 _C'.c7� Map/Parcel# Address Lot# 1 Tcl phone# L1_ Installer's Name 11 Designer's Name Address Address 413-ILI'Z Telephone# Telephone# Type of Building: Lot Size3 2 CC2 Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) �7 gpd Calculated design flow gpd Design flow provided 2JE pd Plan:-,Date 5`0��! �i� Number of sheets _� Revision Date Title ir'tn.' ( � YL q.z ,OA A-k-j! !1 k c 3-rA,- Descriptio of Soil(s)(�`_��'7"lC cu,,, t i Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS a 13 I The undersigned agrees • stall th above described Individual Sewa Dispos System in accordance with the provisions of TITLE 5 and further g no lace stem in operation u a Certi of Co lance has been issued by a Board of Health. Signed ate Inspections s ''~�~ FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 W_ .7 No: IGa .� THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH QF • N APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION VERMIT - ~ Application for a Permit to Construct (Repair ( ) Upgrade,( L,Abandon ( ) - N❑/Complete System ❑Individual"Co,mponents L canon Owner's Name ,„ •'.00trn CQ� 'C5'5'� ap/Parcel# Address Lot# • - Tel phone# 1 �9 lwl illcr's Name ! Designer's Name Address ' " .^xa -^� ^ryAddress L, t L r Telephone# Telephone# x Type of Building Lot Size3' OC3 Sq.feet 4. Dwelling No:'of Bedroorris..,t . a : _' tiGarbage Grknder ( ,) 6 ,• Other—Type of Building 'No.of persons � Showers (`"); Cafeteria ( ) - Other fixtures Desi n Flow min}ere required) °� d Calculated design flow d Desi n flow provide 2gpd • g ( q )�--gp g gp g P Plan:`Date 25- , Number of sheets Revision Date E Title ' Descripti0 of Soil(s)�(J"r•�2''l OCtnu., t2"—3Z`t (�CVA&4 Se.u<d,�t2""t3Z" (YL¢.c�s�c, �► Soil Evaluator Form No. Name of Soil Sa vuc kL Date of Evaluation 1 DESCRIPTION OF REPAIRS OR ALiL TERATIONS i The undersigned agrees stall th above described Individual a Sew a Disposal System in accordance with the provisions of f TITLE 5 and further g no lace stem in operation a Certi a of Co liance has been issupd by Pe Board of Health. Signed ate Inspections ,e FORM 1 — APPLICATION FOR DSCP DEP `APPROVED FORM 5/96 No: THE COMMONWEALTH OF MASSACHUSETTS FEE t'6® • d BOARD OF H E A LT H CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Compotsent(s). ❑Complete System The and igned,n 1Abdertify that the Sewa Dis osal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: at ` has been i stalled in accordant with the provisions of 310 CNfR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer 11A A Ct C) Designer: Inspector Alf A to The issuance of this certificate shall not be construed as a guarantee that the system will function as esign/ed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. l9 I THE COMMONWEALTH OF MASSACHUSETTS e� FEE I BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at !76 Cz A L 0 Ceti , as described in the application for Disposal System Construction Permit No. ��^ '(O,dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN rM PUBLISHERS- BOSTON i TOWN OF BARNSTABLE LOCATION l SEWAGE # VII.LAGE I�'`,�:����:_;� ASSESSOR'S MAP & LOT "' 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)�_;�=-�'-' �/_=/-✓'%a/.!i��r!' (size) �� NO.OF BEDROOMS BUMDER OR OWNERz, i 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, YU1 r� F 1 Town of Barnstable Department of Health,Safety,and Environmental Services Public Health Division Date 'S ' 4 367 Main Street,I lyannis MA 02601 eanriareer.a, d MAsa � _ °r�'o ►� Date Scheduled_ 31 1A4— C' Time Fee Pd. k(DO-0 O Soil Suitability Assessment for Sewage Disposal Performed By: ��'��'� J6f H eIBC Witnessed By: \/61'l_r J— a -Q "C/' LOCATION & GENERAL INFORMATION Location Address Owner's Name Ai 6 - .i-- � ���� - �� `r��� t c Address n Assessor's Map/Parcel: ('1\a f 0i+0 P� 03) �� l4 Engineer's Name " 1 NEW CONSTRUCTION ✓ REPAIR Telephone N 1-11. 1— Land Use Slopes(%) Surface Stones Distances from: Open Water Body R Possible Wet Area R Drinking Water Well R Drainage Way R Property Line R Other R SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) (2 Z 0 Parent material(geologic) r7�r✓"s Depth to Bedrock Depth to Groundwater: Standing Water in dole: Weeping from Pit Face Estimated Seasonal high Groundwater DETERMINATIONYOkSEASON'AL HIGH WATER:TABLI•; Method Used: death Ohserved Onndine in ohs.hole: in. Depth to soil mottles:_ _ in. Depth to weeping from side of ohs.hole: in. Groundwater Adjustment n. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST tiete3 �. Time /o Observation Hole# Z Time at 9" �p N Depth of Perc C> Time at 6" Start Pre-soak Time© � d 3 Time(9"-V) End Pre-soak /o "15� Rate Min./Inch L Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public licalth Division Observation Hole Data To Be Completed on Back—� Cnnv: Anniirint DEEP OBSERVATION HOLE LOG Hole# I Dep(h from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Uoulderes. Consislen. u y. y2 L/ � ;..:r 10 y1p. DEEP OBSERVATION HOLE LOG : Hole# z Depth from Soil I lorizon Soil'rexture Soil Color Soil 'Other Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones,Doulderes. Gravell r M..Pw1L✓ DEEP OBSERVATION MOLE LOG : :' Hole#. t)epth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency." Gravel) I I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil I lorizon Soil Tcxlure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Ilouldcres. Consistency—% Flood Insurance Rate Maw .Above 500 year flood hcundmy No_ Ycs t/ Within 500 year boundary No t/ Yes , Within 100'year flood boundary No Yes , Depth of Naturally Occurring Pervious Material 4 Poer nt lens,fibu sa.vt of naturally occurring pervious material exist in,all areas observed throughout the area proposed for the soil absorption system? Y e f If not,what is the depth of naturally occurring pervious material? Certification 1 certify that on -3 —41 9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent wid'i the required training,expertise and experience described in 310 CMR.15.017. Signature . Date -7-V-F�