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HomeMy WebLinkAbout0116 CONTENT LANE - Health ,.. 116 Content Lane Cotuit P A = 040 029 7 a Commonwealth of Massachusetts Title 5 Official Inspection Form h 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address W�5 Taylor Cobb Owner Owner's Name information is � required for every Cotuit ✓ Ma. 02635 7/2/2018 -� page. City/Town State Zip Code Date of Inspection hw� 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 filling out forms A. General Information Ul# (31 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification 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 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 ❑ Needs Further Evaluation by th, Local Approving Authority 7/2/2018 Inspector'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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form jo Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The dwelling located at 116 Content Lane Cotuit is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 precast leaching chambers. The system was found to be in proper working condition at the time of inspection. 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 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): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form 1' �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -�° 116 Content Lane V Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town 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: ** 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. 3. Other: D) 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 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 cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 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 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 2000gpd- 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 following, 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 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts ry ip Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. Cityrrown 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 ❑ ED 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 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 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)] 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 gpd t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts +� = ,p Title 5 Official Inspection Form fSubsurface Sewage Disposal System Form -Not for Voluntary Assessments f" 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2016= 323 gpd 2017= 381 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane v Property Address Taylor Cobb Owner Owners Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 ^�� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system repaired 01/2007 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 Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks , vented through roof Septic Tank(locate on site plan): Depth below grade: 2.5 feet k 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: 1000 gallons Sludge depth: 911 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements 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 needs to be cleaned soon and again every 2 years for proper maintenanc3. Water level was even with outlet invert, tank was structurally sound and not leaking. Outlet tee intact. Inlet and outlet covers are on risers. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 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.): 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): Distribution box was video inspected and found in good condition, no rot, water level was even with outlet invert. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts n Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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 facility was video inspected and found with 9" of standing water with a stain line 1" higher. 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.doc-rev.6/16, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments kqi, 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 . 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ drawing attached separately MCI �� � o U7 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ 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) ❑ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Content Lane Property Address Taylor Cobb Owner Owner's Name information is required for every Cotuit Ma. 02635 7/2/2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 s Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. Cityrrown State Zip Code Date of Inspection 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B & B Excavation,lnc. � Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 113640 Telephone Number License Number B. Certification 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 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 ❑ Needs Further Evaluation by the Local Approving Authority 6/10/13 Inspector's Si, ature 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. t5ins•11/10 Title 5 Official Inspect F :Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 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 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (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): 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town 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: **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. 3. Other: D) 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 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 cesspool is less than 6" below invert or available volume is less than 1/ day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 116 Content Lane 1y Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town 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 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 asses system if the well water analysis, performed y p y , p ed 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 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 following, 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 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 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•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town 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 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 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. El ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is re Cotuit MA 02635 6/7/13 wired for every 4 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1y 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit. MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: new leaching in 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'3"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 2'10"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: 1000 Sludge depth: 2 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 2' Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up but pumping is recommended Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is Cotuit MA 02635 6/7/13 required for every page. City/Town 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.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to be in good condition. No signs of carry over or back-up. 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 116 Content Lane M Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): At time of inspection leaching appeared to be in good working condition.Water level 14" below invert. No sign of hydraulic failure. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 'Commonwealth of Massachusetts a 7itio.3 Official Inspection Form Subsurface:Sewage:Disposal System Form -Not for Voluntary Assessments 11`6 Content Lane Property Address -Bruceand Janet.Andrews Owner Owner's Name information is required for every Cotuit MA. . 02635 6/7/13 page. GitylFown State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ drawing attached separately YA Art e) C, L� . f AZ, 17 ` A'3 50 131 7 ` t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >50' 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: 2006 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 116 Content Lane Property Address Bruce and Janet Andrews Owner Owner's Name information is required for every Cotuit MA 02635 6/7/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMPLETE THIS SECTION ON DELIVERY SENDER: COMPLETE THIS SECTION E'Complete items 1,2,and 3.Also complete A. Signature's item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse r ❑Addressee so that we can return the card to:you., �, ` c � eivetl by(Printed Name) C. Da of elivery ■ Attach this card to the back of the mailpiece; l or on the front if space permits. / ol 1. Article Addressed to: "C."' "k t,i °? %,D. Is delivery address different from item 1 ❑ es w . , J 9.1 If YES,enter delivery address below: ❑ No Ms Blair?Well eloved - 116 Content Lah" � 1G Cotuil 1VIti 026�5 I Service Type ❑Certified Mail ❑Express Mail ❑ Registered ❑Return Receipt for Merchandise - ❑ Insured Mail ❑C.O.D. 1 4.•Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 'Q,''7,0 0 5 116 0'�0 0 0 d 01`91 2 6 6 3(Transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-154D UNITED STAai TE P TAIC �,.. OtM10-8Lode 'aid • Sender: Please print your name, address, and ZIP+4 in this box• I I I I PUBLIC HEALTH DWISION TOWN OF BARNSTABLE M 200 MAIN STREET II HYANNIS, MASSACHUSSETS 02601 I I IayC„>t'„}",�, r_C,3i",}",r, �711tlttlf�l��ll��Itiftl��i�!l��Itlf�lflftl�ll�,l,l��tlf,lflld 1 m p -0 .. ru ita :�� � U ' Er jin Postage $ . 3 �pNN15 M� o p Certified Fee 6) aReturn Receipt Fee � ��Pastmark O (Endorsement Required) a • 7 0 Here r-3 ResMcted De"very Fee -0 (Endorsement Required) Total Postage&Fees O Sent To O �y tfeSt, ------ "-y!wY------------------------ -----------�........... Apt.No.;/ ��or PO Box No. Z;P+4 - = o� 3 5- :rr rr Certified Mail Provides: esrana f' Sd e A mailing receipt ( N)zooz oun ooee uuo o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is notavailable for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or`Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. Town of Barnstable OF tHE Tp� y�P� tio� Regulatory Services. Thomas F. Geiler,Director BARNSfABLE �A " ,eg Public He ion alth. Divis TED MP'�a - Thomas.McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304. January 10 2007 Ms.Blair Wellbeloved 116 Content Lane. Cotuit, MA 02635. - ORDER TO COMPLY WITH STATE-ENVIRONMENTAL CODE, Title 5. The septic system owned by you located at 116 Content Lane, Cotuit,.MA was last inspected November 201h 2006 by Robert a..Paolini,.a certified septic.inspector for the State of Massachusetts: The inspection of your septic system showed that your system"Fails"under.the guidelines.of 1995 TITLE.5.(310 CMR 15.00)due to the following: System is in.hydraulic failure You have 2.years.from the date of the system failure to.bring the system into.compliance. _ If there are any questions about this.reminder,please feel free to.contact the.Barnstable. Health Department. BARNSTABLE TH DEPARTMENT Thomas ..,McKean, R.S., C.H.O. Agent of the Board of Health f DATE 11 /20/06 PROPERTY ADDRESS 116 Content Lane Cotuit MA 02635 On the above date, the septic system at the address above was —/ Inspected. �6 This system consists of the following: -o Pox Based on inspection, I certify the following conditions: 0 k w U' mac' L'41 SIGNATURE _ Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . r. Address: P. 0. Box 66 ,e Centerville. Mass 02632 ; Phone: 508-775-3338 or 508-775-6412 V CY% JOSEPH P. ,MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775.6412 \ COMMONWEALTH OF MASS ACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS R d DEPARTMENT OF ENVIRONMENTAL PROTECTION I t TITLE 5 OFFICIAL INSPECTION FORM—NOT.FOR.VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: .. 1 1 6 Content' Lane Co ui.t MA 02635 Owner's Name: Blair Wellbeloved Owner's Address: Same Date of Inspection: 1 1 /2 0/0 6 Name of Inspector: (please print) Robert A P .o.l`ini Company Name: �. l.Pacom9a z .S:o.n Inc. Mailing Address: Cen t e2v.c e, qzz. Ue63Z Telephone Number: 5 0 8-7 7.5_-�3 3 3 8 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 the inspection.The inspection was performed based on my training and experience in.the proper function and maintenance of on s.,ite sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15:340 of Title 5(310 CMR M000). .The system: Passes - -Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector'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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of,l I OFFICIAL INSPECTION:FORM-:NOT FOR VOLUNTARY ASSESSMENT$ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 1 6 Content Lane Cotuit MA .02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 6 Inspection Summary: Check A,B,C,D or.1✓/ALWAI S complete all of Section.D A. System Passes: I have not found any information which indioates'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: B. System Conditionally Passes: One or.more system components as described in the"Conditional Pass".section need to b.e.replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. I W The septic tank is metal and.over 20 years old*or the septic tank(whether in 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. ND explain: 2 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 obstruction is removed distribution box is leveler or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3,of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 6 Content Lane Cotuit MA '. 02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 6 . ,C.nFurther Evaluation is Required by the Board of Health: Conditions exist which.require further evaluation by the Board of Health n.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. IM The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has aseptic 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 5Q 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 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. 3. Other: 3 Page 4.of 11 OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE-'SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: 1 1 6 Content' Lane Cotuit MA 0263.5 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 6 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following,-for all inspections: Yes Ng Backup of sewage into facility or system component due:to overloaded or clogged SAS or cesspool 7 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 cesspool is less than 6"below invert or available volume is less than''A.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. 7 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 l of a.public well. —7 Any portion of a cesspool or privy is within.50 feet of a private water supply well. 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 mast be attached to this form.] �5(Yes/No)The system fails.I have determined that one or more. f.the above failure:-criteria exist as described in 310 CMR 15303,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 101000 gpd to 15,000 gpd• 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) 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 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 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. 4 Page 5,of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: 1 1 6 Content Lane Cotuit. MA• 02635 Owner: Blair Wellbeloved " Date of Inspection: 1 1 /2 0/0 6 Check if the following have been done.You must indicate"•yes"or"no"`as to each.of the following: J_ No _ Pumping information was provided by the owner,occupant,or Board of Health JWere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? J 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? / J _ Were the septic tank manholes uncovered,opened,and the interior.of the tank inspected for the condition e b of thaffles 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: Yes no _ 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(3)(b)] 5 r Page 6 of 1 l OFFICIAL I-NSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM ^ PART C SYSTEM INFORMATION Property Address: 1 1 6 Convent Lane Cotuit MA 02635 Owner: Blair Wellbeloved Date of Inspection: 11 2 0/0 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):IA (10_:�;:3 j0 pJ Number of current residents'. 'S Does residence have a garbage grinder(yes or no):1`Lb Is laundry on a separate sewage system Eyes or no):a`[if yes separate inspection required) Laundry system inspected(yes or no):r 5 _ Seasonal use:(yes or no): 01,3 `7 G.P,� Water meter readings, if available(last 2 years usage(gpd)): 3T�Inv N006 _ . z-L j t C�,.PD Sump pump(yes or no):— Last date of occupancy: O-4 COMMERCIALLINbUSTRIAL Type of establishment: 1 L Design flow(baked on 310 CMR 15.203): gpd Basis of design,flow(seats/persons/sgft,etc.):. Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water-meter readings,if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records 9 Source of information: Was system pumped as�a,rt, �of the inspection(yes or no):_ If yes,volume pumped al ons- How as quanti pumped determined? 6. t)r-e p Reason for pumping: a rye�pjJ ��. g TYPE OF SYSTEM 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate aye of all compotnenti,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):l 6 Page 7of]I OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 1 1 6 Content .Lane Cotuit MA 02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 6 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC Y, other(explain): Distance from private water supply well ar'suction liner 10 comments(on condition of joints,venting,evidence of leakage,etc.). t ' 1av� itiovg�2 � SEPTIC TANK:—(locate on site plan) r� Depth below grade: Material of construction: A concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_.(attach.a copy of certificate) , �� r Dimensions: X Pfl X & Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Nx Scum thickness:-0 Distance from top of scum to top of outlet tee or baffle:N^ _ Distance from bottom of scum to bo om of outlet tee or baffle:How-were dimensions determined: RV ffl,p.QJ Oft Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): 1 _ d'. . GREASE TRAP:.0 alocate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relayed to outlet in rt,evidence of 1 akage,etc.): 7 Page 8.of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 6 Content Lane Cotuit MA 02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 o l n F TIGHT or HOLDING:TANK:nc)(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explaih):. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float swi hes,etc.): i x► n l,r�Ax�,e.. dai y I�Ld r'P 1� DISTRIBUTION BOX:�(if present must be opened)(locate on site plan) �. Depth of liquid level above outlet invert: (1125 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.): PUMP CHAMBER: (locate on site plan) ,.. Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition f pump ch mb condition f pumps and appurtenances, etc.): �o01�v C��Qi � � �{�PiP11 8 • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION(continued) Property Address: 1 1 6 Conte-nt Lane Cotuit MA. 02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 6 SOIL ABSORPTION SYSTEM_.(SAS): (locate on site plan,excavation not required) If SAS not ocat d explain why: Type leaching pits,number leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 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.): -� ILQ4 "Chu o 4. v O0-L� CESSPOOLS:ro (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 or no): CX Comments(note condition of oil,signs of hylaulic failure,level of ponding,condition of vegetation,etc.): e4o PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of oil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL;SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)° Property Address: 1 1 6 Content Lane Cotuit MA 02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 6 i SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent refererice'landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building: a r� Z�;. 0 10.. Page 11.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION,(continued) Property Address: - 1 1 6 Content Lane Cotuit MA 02635 Owner: Blair Wellbeloved Date of Inspection: 1 1 /2 0/0 h SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 60 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e.s Observed site(abutting property/observation hole within 150 feet of SAS) c�e Checked with local Board of Health-explain:,,6 guift rrilLd no Checkedwith local excavators,installers-(attach documentation) Yez Accessed USGSdatabase-explain/z;L`/2:.to wn., &aanz#_a ie.,ma.-uz /— You must describe how you established the high ground water elevation: /1,6ed. : Cape Cod Comm.izi:on !date2 Tame CoAl-ou2b And %ugiic ldatea Supp'ey OeH head p2o-tection a2eaz map., Sent 1995 Ua-te2 aezouacez o Ptice cage cod commt'6ton,' Top of Ground q � Leaching Pit feet Groundwater: Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method nerefore,the vertical separation distance between the bottom of the leachingit and the adjusted p � sted groundwater table is feet. I 11 I nnnn-7�•r'.��r-•'�'TOWN OF — BARNSmABr�. 130AIZD QR 11$AtT11 a9UIISURRACR AFhfAgF t)JSPU:3Ai,tiYBTP,M INSPECTLON FORM — PART D...- CER'fIF1CA�'JON "TY1�7'•5'tI/�T11f1•ti4771M111M9111/f�.t7/7Ml'�p111PR7"'AM �� - 1'r'•O►.r► TYPE OR PUNT0,,E R Y— A4 . PRO•PERTY rNSPZCTHIP STREET ADDLES$ 11:6"Content Lane cottuit 026�5 ASS•ESSORS MAP, BLACK• AND 'PARCE1r � OWNER's NAME Blair,W&1Theloved PART.'D UI�R�'•tFICATION NAME 'OF INSPECTOR Robert: A:':Paoiiri COMPANY NAME Mr COMPANY ADD.RMIS I'.O : ox•`66'..'cept .drvilj& M.j'1b-. 3.2_b068 stye k; Youn•or ty.. StaL�• p COMPANY TELZPHONE ( 508. 1: 7*5 " 3338 FAX 508',.790 f 57$ CT;RT•I-FICATION. STATEMENTmom I certify that I -have personal-17 .ins•peotea ..the sewage dig 'o �, t his nddress P . system tt t and that• �t1iQ' int.ormation reported .is true,. a.actira•te•, cad omplete aq of the time .af .inspections• The i h n e t i �F 4 io'n w recommendations regard-in as Performed and any g .upgrade•f .ma•intennnee,'. and repair .are• eon4is'tent with my training and experience in th o e r e P�' P furict�,•on• d site sewage disposal system$, anmaintenunoe of on� Check one; • ' tic'. System P-AS92D , 'The inopection «hic.ii J. have .•condupted has .,ncit' �ou'nd any infdrma•tion which indicates, that- .the system' Sails to ' adeuate,ly., protect '.pubii•a health or the env iro 1men t as defined in .31'0 CMR. l g 180.3 1 My failure criteria 06t •-evalua. 6d• are as stated in the FAILUIM -CRI IRIA .section of this form. System FAILED* The inepec.tloh which I Ira'vQ aotiiitt ted 'has '-found that the system fails to protect the public health gnd thq en4ronmen•t ' in acgerd•ance with Title 61 310 CMR 16 , 3Q8, and as • speeitioaliy noted 'on .PA'kT• C -. FAILURE CRITERIA of this inspecti, n %form. , Inspector 6ignature' W _10_04 , Dat$ `o ne copy of this certl f ioat•i'ah fnu$t 'he rov ided :to the .QWNgn., fh BUYER, where appli.osbls) and %:hl.o• DPARD OV HEA Z'I1. * Xf the inspeetton FAXL'Eb•, 'thb .cwnei''•ox"gperatox eh401 within one year of the da`t•e of the inspeotion, unless, al'lowsd p�the °yetem. n t.harw{ae. as Provided iri gj14 CMR 16 , 305 ,, , ar' required 1 i TOWN OF BARNSTABLE LOCATION �l� C�dn C�a� �,.� SEWAGE# VILLAGE ASSESSOR'MAP&PARCEL N yo > P INSTALLERS NAME&PHONE NO. e C �Ca a S� 7 SEPTIC TANK CAPACITY 1 CSza� LEACHING FACILITY: (type) 6�- -SD 6 (4 (size) NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 I aching facility) Feet FURNISHED BY t, t � t 1� /�� � � q � r TOWN OF BARNSTABLE LOCATION Z& � --- SEWAGE # MI,LAGE G�2 ASSESSO 'S MAP & LOT 0 —e SEPTIC TANK CAPACITY k LEACHING FACILITY: (type) � �e) NO. OF BEDROOMS BUILDER OR OWNER �o C PERMITDATE: MOMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 AL1WHbt; 11V.�Y,C;I:'1'lU1VJ LOCATION 1lfo r.on��te,, DATE 14q VILLAGE eaPtU A! AS ESSOR'S MA.P.& LOT �INSF>HCTOB SEPTIC TANK CAPACITY LEACHING FACILITY: (rypc), (sizc) NO. OF BEDROOMS 3 A ,� 1 BUILDER OR OWNER „�ILou. LQ616a® V OWNER MAILING ADDRESS 0 e � � i f I 66 (`�, 9 r 1'u 1s3�o / f f - TOWN OF BARNSTABLE LOCA11CN u J SEWAGE #ASSESSOR'S MAP &LVu.LAGE. OTI �. D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) a Oct c (size) GM g.6 I NO.OF BEDROOMS BUILDER OR OWNER C-a2J�N+RWN P RDATE: COMPLIANCE DATE: Separation Distance Between.the: Maximum Adjusted Groundwater Table and 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 Feet within 300 feet of leaching facility) _ ry N�l�-• Furnished by `a� Ltkk all r 30 No. V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for 0igpogal *pgtem Cowaructiott permit � Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./%C °fin 1 Pav r Owner's Name,Address,. Tel.No. Assessor's Map/Parcel w\--ko p-1cl Installer's Name,Addr{ess,and Tel.No. 1 Designer's Name,Address and Tel.No. `"!\CXE. N 4� Type of Building: Dwelling No.of Bedrooms Lot Size X sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requi ed) gpd Design flow provided gpd Plan Date 5 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 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 afore described 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 Board of Health. Sig Date 12 e—\ 0 (� a Application Approved by Date Application Disapproved y: Date for the following reasons Permit No. Date Issued .. i kp .. ..,. Wes•-;., '*.`C` m` r TvT..' .,.. No. _ .J �J " Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computeVYes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS .._ _. . gppltcatton for �Dtzpo!6af *p$tem Con.5trUCtton 3permtt Application for a Permit to Construct O Repair( Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No.116 n i en r Lc- Owner's Name,Address,end Tel.No. Assessor's Map/Parcel �p (��� (11 CIO Installer's Name,Address,and Tel.No. Designer's Dame,Address and Tel.No. ��.tA",/ 04#j N Q" rr Ros11.-1 \ Z_ <08 5'04- 4 a`RZ- Type of Building: :/ �" Dwelling No.of Bedrooms 3 ``, t�r? Lot'Size 4, sq.ft. Garbage Grinder (�) Other Type of Building /� , ' ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1 " Design Flow(min,requi ed) \ gpd Design flow provided _ gpd Plan Date / S Number of sheets' Revision Date Title Size of Septic Tank Type of S.A.S. 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 afore described 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 Board of Health. Siaed y Date l2 Q,.\ 7 O to Application Approved by p /�, q Date .. Application Disapproved by: Date for the following reasons r* w. " Permit No. •-Dat'e'"Issued�� ————————-——————— ——————— v r a THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtftcate of Compitance �r THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( f) Abandoned( )by n.o 14 C' (!!'Tv at �1� �_�e,,..rhas been constructed in accordance- with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer �"� t)4. ♦ _ `­,_. Designer � w. #bedrooms Approved design flow j' 14, gpd The issuance of this permit shall of be./onstrued as a guarantee that the system ill fun ' esigned. Date � � Inspector ------------ ——————— •. ./ HE COMMONWEALTH OF MASSACHUSETTS Fee PUBLIC EALTH DIVISION-BARNSTABLE, MASSACHUSETTS lwt000l *raem Con5trUctton Vermtt Permission is hereby granted to Construct ( ) Repair ( grade ( ) Abandon ( ) System located at 11(- and as described in the_above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the followingrllocal provisions or special conditions. Provided: Construction m t be co leted'within three years of the date of thi)rmi �. Date r , 0 4 Approved by / Town of Barnstable . Regulatory Services Thomas F. Geiler,Director t MAISM NAM Public Health Division. Thomas McKean, Director j 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form t Date: 109 ,0 ? Sewage Permit# -s3 '/Assessor's MapTa'rcel � a Designer: f Installer: r 4/ Address: M Address: On 2- '2 1 C,9,tk�, was issued a permit to install a (date)' p / (' ler) ll ,_ septic system at / I COA'f-� 1. 4/ based on a design drawn by (address) /0 dated /'S (desi ) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. 3 ZN OF MASS9c o� DANIELA. y�s� � OJALA A (Instal -Signature) CIVIL cn 41 No.46502 "GISTEP� r �� 10 0-7 SS�ONAL EN (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH_DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc AP d�-r . OARCM 2 nyr DATE 11116104 RECEIVED PROPERTY ADDRESS 116 Content Lane NOV 1 9 ,2004 Cotu.it� Na. TOWN OF BARNSTABLE HEALTH DEPT. 02635 On the above date, thW4eptic system at the address above was inspected. This system consists of the following:. 1. 1-1000 gaiion zept.ic tank., 2., 1-d.ista.igut.ion 9ox., 3. 2-1000 ga.e.eon .eeach.ing Ritz.. Based on Inspection, I certify the following conditions: 4.-7h.iz .iz a t.it ee dive zept.ic zyhtem (78 code) 5. 7he zept-ic hyztem ,iz in paope2 wo2k.ing oade2 at th 122e-6ent time- .-SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber . Son ing . Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775.3338 or 508-775-6412 jo%pH p. MACOMBER & SON;:INC' Tanks-Cesspools-4eachfiekis pump o .&..Installed Town Sewer-Conneotions P.O. Box 66 Centerville, MA,02532-0066 775433$ . 775.6412- COMMONWEALTH OF MASSACHUSETTS` EXECUTIVE OFFICE OF ENV1RGNMSNTAL AFFAIRS DMATMENT-OF +ENV M14MMAL PAOTICTION * r TITLE 5 OFFICIAL INSPECTION FORM—.NAT'FOR VOLUNTARY ASSESSMEENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM FORM PART-A CERTIFICATION. Property Address: .116 C o n.t e n.t"L u n e C0,4_UiL• Na Owner's Name: N.i co,e e Owner's Address: -,S i u g Date of Inspection: 11%1 6 1 0 4 Name of Inspector:(please print) Company Name: ,{7 P- .11nc M$.cA Mailing.Address: •. Telephone Number: 5 0 8—7 7 :3_3 CER'I`IFICATION STATEMENT I certify that I have personally inspected the sewage disposal system.at this address and thatthe.informatiou 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 fiinetion and maintenance of oni to sewage disposal systems.I am a DEP approved system inspector pursuant to�Saeetion.15340.of•T,itle 5(31.0 CbM,15:800). The system: xxz' Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority F Inspector's Signgtore: Date: In L Inspe f Health or The system inspector shall submit a copy of this inspection reportT.o the.Appmvmp Authonty. o(B ard o DEP)within 30 days of completing this inspection.If the system.i. a. hazed system or has a design now of 10,000 gpd or greater, the inspector and the system•owner.shall'submit 14e report to the appropriate'regional•office of the DEP.The origma)should be sent to the system owner ana copies sent to the buyer,if applica6ie,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspectibri'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. -, ii.ra+nnn nACP. I � Page 2 of 11 OFFICIAL INSPE,CTION;FOIIM—NOT FOR VOLUNTARY ASSESS11E1t1U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTA CERTIFICATION(continued) Property Address: 116. o n a n rnf�ii f� /�ln_ Owner: Ditto of inspection: 1 1/1.6/0 4 Inspection summary: .Chifc C A►;B C,D or.B•/ALWAY'5 eomptleteall of Section;D A. System Passes: 20 • I have not found any information.which'inahates`thaiany c'fthe faflore criteria described4n 310 CMR 15.303.or in 310 CMR 15.364 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: no— One or more system components•as described in the"Conditional:Pass".!section..need to be teplaced.or. repaired.The system,upon completion of replacement or repair,as approved by thb Board of Healt€u,will pass. Answer yes,no or not.determined(Y,N,ND)in-the for the following statements.If"not determined"please explain. no. The septic tank is.metal.and.over20 years old*or the septic-tank(whether•metal.or. n00.is-6tract<ually unsound,exhibits substantiaWnfiltration or exfiltration.or-tank•fal)ttre is tt inert;System will pass inspection ifihe existing tank is replaced with'a complying septic 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.. ND explain: 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 inspgction:if(with approval of Board of Health)- _broken oken.pipe(s).are replaced. . obstruddon is removed• distribritinn box is leveled l'eplaCed ND explain: no 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 obstruction is removed ND explain- 2 1`4ge 3 of 11 )pFICIAL IN&PECTION FORM.N©T l'OR y UNTARY ASSEB•SMENTS SUBkWACE SEWAGE DISPOSAL• YSTEM iNSP'ECTION1I?'ORM PART•'A . . ' C�RTIFI�A'T�I+OI�[trori�in�.ed� . Property Address: 1 1 6 C o n.t en.t Lane Owner:.lj( ^ R^ �•�^ 000. 0.,, 0� Date of Inspection: C. Further Evaluation•is Required by the Board of Health: n o Conditions.exist whichregvire fnrther..evahration by.the Bvard:of,,Heaith;in order,to:determine if-the system. is failing to protect public-health,.safety or thb environment. 1. System will pass unless Board•of gIealth detet�mingdtb Kaotrdapce with 310.CIAR 15:303(1)(b)drat the system is not functioning hi.a•matlper,whtch:wlA•protect public health,safety•an¢•tbe.environment: n o Cesspool or privy is within,50 feet of a•surface water ate. 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 matfner that protects theptiblic health,safety and environment: n o The system has aseptic tahk and soil sbsotp#on'system•(SA•S).:and the$AS is within 100 fe.et^ofa surface.water supply or-tributary to asurface water.supply. The system-has•a.septic tank and SAS and the:SAS is within a Zone 1 oft-public wateresupply. > The system has aseptic tank and.W:andtheSAS isv�ithinf50 feet of a private water.supply well. The system has aseptic tank and SAS and the-SAS is less than 100 feet but 50 feet oFa lore$urn 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 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 bet attached to•tbis form. 3. Other: Page 4 of 11 OMCL4L••IINSPECMN FORM-NUT FORVOLUNTARY ASSESSMENTS' SURBBURFACK SEWAGE DISPOSALL SYSTEM H-MECTI.ON.FORM PART.A CERTMCdATfON, (continued) Property Address: 11 h ('n n f o n f (n n o. Owner: Nico oD llo�PR�On,�o.� , Date of Inspection:.1 /717/ D. System Failure Criteria applicable to all systems:. You must.indicate•"yes'-or"no"to.eacis of•the1ollow- i9s for al Jnspections, . Yes No x Badmp.of'sewage,:iRI-htkffy ar'systems.component•due•-taoverloaded:or clogged•SASor.cesspool '.Discharge:or•ponding of effluent to the.sorface•Other.Aw.and or.sutfacematers due to.an•overloaded or clogged SAS or cesspool •• Static liquid level in the distribution box above-outlet invert due to an overlbaded or clogged SAS or cesspool 'hiquid depth in-oesspool is less than.6"below invert or,availabletvolume is less than%day flow X Required pumping more than-4 times in the last year NOT due to clogged of obstructed pipe(s).Number of times pumped r ' x Any portion of the SAS;cesspool-or privy is below high ground water elevation. _ Ariy.portion of cesspool or prig►is within 100 feet of a surface water.supply or tributary to a surface water-supply. x Any portion.ofe-cesspool•or•privy ns'.within>a:Zone:lbfapublic.well.. _ x Any portion of a cesspool-or privy is within 50-fed of a private water supply well. _ x -Any portion oft cesspool-or-privy is less-than i0A feet butgreater..than 510 feet from a.private•water supply well with no acceptable water quality.Analysis..[T,his system.passes if the well wateranalysts, • performed at a DEP certified laboratory,for coliform bacteria and volatile organic .compounds Indicates-that the well is free from pollutioq:ftom WtUacilftj►end:tho presenceof ammouia nitroge.n•and nitrate nitrogen is equal to or less than.5•ppm,provided that no other failure criteria -are-triggered.A copy of the analysis•niust bye attaehed.to this forte.] . no .(Yes/No)The system ai ,I.have determined that one ormore of the:above.failure criteria exist as described in 310 CMR 15.303,therefore the,.systerg-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.cop a large system'the:systiem must.serve.a4aeility,with a design flow of 10j000 gpd to>k5i000. a 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)' yes no _ • the-system is withitl'400 feet of a sur%ce'drinkipg•water supply x the system,is within 206 feet of a tributary to a swface drinking water supply x the.system is located In a nitrogen sensitive are, (Lnterim Wellhead Protection Area IWPA)or a mapped 77 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 cbnsidered 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. A Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VVOLUNTARY ASSESSMENTS WBSURFACE'SEWAGE DISPOSAE SYSTEM INSPECTION FORM PART P CIECKLIST Property Address: 116 C o n t e n.t L an e Cotuit,. a.• Owner: N.r r o.P v U v.0.0 P v,P_o v e d" Date of Inspection: t6/n G Check if the following have been done.You must indicate'pes"or"no"wto each..of tl;e following: Yes No s x — Pumping information was provided-by the owner,occupant,or Board.of Health x 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? - - , x Have large volumes of water been introduced to the system recently or as-part of fitisinspection? x _ Were as built plans of-he system'obtained and examined?(If they-were not availabletote is 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 condition 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 diff6rent from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the'Soil Absorption System(SAS).onrthe site.has been determined based on: Yes no x $xisting information.For example,a plan at the Board of.HeaM. _ x Determined in the field(if any of the failure criteria related to Part C is at issue approximetion.of distance is unacceptable.) [310 CMR 15.302(3)(b)] . ' Page 6 of 11 OFFICIAL A4SPECT-10N-IFI}RM-NOT FOR-VOL. NARY ASSESSWNTS SUBSU9FACE-STOWAGE OISPOSA-L SYST]gM<INSPEETION FORM PART.0 SYSTEM I"ORKATION Property Address: 116 'Content Lane. Cotri.it, 17a. Owner: N.ico e-e Qe.ign.iov d Date of Inspection: 1111.6104 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desjgro:.�3�... W=ber of.bedrooms•(actaal): 3 DESIGN'flow based 6h 110 C1VTT1;15. 03(for exaiiiple:l IO gpd z#.ol'be&bins) 1.1 Ox 3=3 3 0 gpd Number of current residents- -4 Does4esidence have a garbage grinder(yes or no):n o Is laundry on a separate sewage.system(yes or. o ¢if y..es separate insption required] Laundry system inspected(yes or no): Seasonal use:(yes or no): ' Water meter readings,if available(last 2 years usage(gpd)): 1 3 ACC J%?Z{ e6 l' Sump pum (yes or no):n o p ( , Last date of occupancy:�,4 2 6¢n COMMERC1A.L-/0- ,6USTRIAL ' Type of estaWN. atn.��Desk flawon 310 CMR 15.2U3):. n a -gpd Basis.ofd�io%flow(seats../persons/sq%ptc.):, na Grease trappresent(yes or no):'aa. Industrial waste holding tank present-(yes or no):n a Non-sanitary waste discharged to the Title 5 system•(yes or no):rt u Water.meter readings,if available: n a Last-'date of occupancy/use: .n, OTHER(describe):. GENERAL INFORMATION ". Pumping Records Source ofinformation:j.,P.,Nacom�e2 and son Was system pumped as part of the inspection(yes or no):l2 Q If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for-pumping: 7966N79e d--6'e 4.fib a 4 4,-7,41 /a&.. TYPE OF SYSTEM ,,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) _Tight tank Attach a.copy.of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 19R4 Were sewage odors detected when arriving at.the site(yes or no):,l 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:116 r n»font L a 2 v rnfiiif Plo -- Owner: Date of Inspection; BUILDING SEWER(locate on site plan) Depth below grade: ZZ" Materials of construction:_cast iron xx 40 PVC_other(explain): D' . :stance from private water supply well or suction line: 10( ) Comments(on condition of joints,venting,evidence of leakage,etc.): o de-ace ol leakage., System vented thizough home vents. SEPTIC TANK:."Vocate on site plan) Depth below grade: 2' Material.of construction: concrete_metal,_fiberglass_polyethylene --other(explain) If tank is-metal list age:n o Is age confirmed by a Certificate of.Compliance(yes or no): (attach a co of certificate) PY `^ Dimensions: 8' 6",Q o n cj/4 ' 10"w Ld n l 5' 8"high Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: Z' 6" Scum thickness:. 1" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 4" How were dimensions determined; Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural rote as related to outlet invert,evidence of leakage,etc.): &itY liquid levels - z.-Tank a2pea.,zz ztauc;tuaa.P2y sound. t and out het �e�s ate cn ac GREASE Tom:r�(locate on site plan) - Depth below grade:-na Material of construction: concrete_metal_fiberglass__polyethylene-___other (explain): n a Dimensions:_a a. Scum thickness:1,,, Distance from top of scum to top of outlet tee or baffle: n a " Distance from bottom of scum to.bottom of outlet tee orTaffle: n a Date of last pumping: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels cease ^a2 not 2ezent.. T;Nn Tnonr�tinn Fran„An;/,)nnn 7 Page 8 of I (WFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS :"RVA,A�'yA,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / /6 Con.ten.t Lane :)tr(4n : . Owner:. A*/-,*.@_ge 4' o rin ,. a, Date of kspectlon: ZZ-ZZ_61 04 a TIGHT or HQ.LDING TANK: n n (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: n rz Capacity: n n gallons Design Flow: n a gallons/day Alarm present(yes or no): n"rz Alarm level: n n Alarm In working.order(yes or no): rLq Date of last pumping: n n Comments(condition of alarm and flost•switches,etc,): 7;ah4. nn hnPding fn.nkA noi• (jaez nP�_' DISTRIBUTION BOX; i (if present must.bs opened)(locate on site plan) Depth of liquid level above outlet invert: no Comments(note if box is level and distributio> to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) 7_Onx hn.s_ to�n 1/nt_n_lzr�.Pz..IVo eviderice_ of eeakage o2 bo �ids 7 PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or.no): na Alarms in works ng order(yes or no): as_, Comments(note condition of pump.chambgr,condition of pumps and appurtenances,etb.): /7u%hrimP`on nnf •fie—Apnf I I • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENT r . SURS'URFACE•SEWAGrE DISPOSAL:SySnm INSPECTION FORM PARTC SYSTEM INFORNI<ATION(continued). Property Address: 9 9 6 C o n t e n.t Lan e Owner o v ed Date of Inspection: I v�0 4 SOIL ABSORPTION SYSTEM(SAS):r, {locate on site plan,excavation not required) If SAS not located explain why,. Type _,.2_jeaching pits,number: .2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativefalternative'system Type/name of technology: condition of vegetation, it con Comments(note condition of soil,signs of hydraulic failure,level of pondmg,damp soil, g etc.): ei �p n! D o�P hud2au.'cc �a c Qu2e. CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and.configuration: na Depth—top of liquid to inlet invert: n a Depth of solids layer: na Depth of scum layer: n n Dimensions of cesspool: na Materials of construction: Indication of groundwater.inflow(yes or no): na Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: n o (locate on site plan) Materials of construction: n a Dimensions: n n — �- Depth of solids: na condition of soil,signs of hydraulic failure, Comments(note con level ofponding,condition of vegetation,etc.): �2.iv of �5en� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SS FORM ESSMENTS SUBSURFACE SEWAGE DISPp��CYSTEM INSPE SYSTEM INFORMATION(continued) Property Address: Owner: ni; n 0 0 l,l 0 0 0 0. v e d Date of Inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells .a► -_ Estimated depth to ground water ,feet e check all methods used to determine the high ground water elevation: t Please indtca (check) . desi lams on record-If checked,date of design plan reviewed. n o Obtained from systemgn P n o Observed site(abutting Property/observation hole within 150 feet of.SAS) no Checked with local'Board avatarls installers-(attach documentation) no Checked'with local a . m u. u =ex lain: h base r'�n 7o���n Qnnn/.f y P,3 Accessed USES, data p �--, You must describe how you established-the high ground water elevation: 1 1 used;Gahert & MillerJu model used•USGS observation w used- Technical bul — wa er a eva ions. Vx Leaching Pit ;eat + p T�i t%Method Groundwater: Feet Bslow Bottom-of Pit High Groundwater Ad'ustment 1.8 ft per rnp Therefore,the vertical•separation distance between the bottom of the leacf ing pit and the adjusted groundwater table is &V feet. nrw.-^'1'r+r TT"''"'m,+n,+arrnna-e.*re*arrn.++ro'rr++r*�+n*+m•+rnw nun nT 'I.ONN OF Barnstable BOARD OF HEA.LTII SU(f3lJ(rFACF 9ENAGF (�Isf'UaAL SYSTEM IN811RCTION FORM - PART D - CERTIFICATION ,R/lT,LSI-rT7A7• � IT.Tt�'7t'Rt1.TRP1•.T,I'Pr•T•1• —,.^ �..,T,h.T..,.::,-.T.,IM1-.-•'T•`n�•^�ITMR -* '- -TVPt OR PAINT GI.EARLI'- PROPERTY INSPECTED STREET ADDRES$ 116 Content Lane ASSESSORS MAP , DkyOCK ANU PARCEL # OWNER' s NAME N-ico ee b)ej-jje coved ' PART D - CE1?TIFIC�1?'ION NAME OF INSPECTOR COMPANY NAME Joseph P. Macomber . &, `Son Inc COMPANY ADDRESS Box Centerville Mass 02,632 SIP street Town v Q tY FAX ( 508 j 790-1.578 COMPANY TELEPHONE S 508 ) 775-333$ q R Cr,R'rI FICAT1ON. STATEMENT I certify that I .. have personally inspected the sewage . disposil system nt this address and that the information reported is true., accurate, and complete as of the time of ,inspection•. The inspection was per and any 'recommendations regarding upgrade-, maintenance , and repair are consistent w.itll my' training and experience in the proper tunetion and maintenance of on- site sewage disposal - systems ) Check one ; xxx Systeoi .PASSED The inspection which I have conducted has not found any information which indicates that th.e system fails to adequately protect public health or tile.evaluatedeareaasdstated in the FAILURE 03 ,CRITERIA ailtire criteria nottsection of this form . ' System FAILED* The inspection which I have concatmted ha found that the system fails tc protect the j)itb.lic health and the environment in accordance with Title 6 , 310 CmR 15 . 3Q31 and as specifically noted o,n PART C - FAILURE CRITERIA of this inspection fortn., r, 4ate Inspector Signature . i. nd copy of this c,�-rcification must be provided to the OWNER, the BUYER .;'( where a�p the I30AR>� QA r{$nI+7'II llcable') and I * .If the inspection FAILED , �h`e- ow-ner or op.erator. shall vpgrado ' the eyetem- within one year or the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 1613.061 partd .do( Page 10 of 1 _ '.lNSPFCTIQN•PQRIVI :*NO'I'YI ''VQL�JI1i•EA3t 0 FORD T3 Q CIAO SE ACEMISP.O'SAL'SySTE�V .INSPE Sl Si�RPA ° PART C SYSTEM T, wRmATION(,continued) Propertx Address: ( nfnif Owner: /��n0o I,Io000_� Ooved Date of Inspection: a SHETCH OF SEWAGE-DISPOSAL SYSTEM ties to at least two perinat►erit refemco lgadMarks or Provide a sketch of the sewage disposal system incluOing all wells within 100 feet.Locate where publicvOer supply enters. benchmarks•Locate the building. Ip r tin l2 C� U l s :\-;., . '• . . •. III 10 Vrs A H V COMMONWEALTH OF MASS C USETT S EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ! ,4 Owner's Name Owner's Addres Date of Inspection: Name of Inspector:olease.print) /06 � Company.Name: / - 7 4, ti Mailing Address: i�d ys/m 1 i'W ' Telephone Number: 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 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 ection 15.340 of Title 5(310 CMR 15.000). The system: . Passes Conditionally Passes NeqJ9 Furt er valuation by the Local Approving Authority Inspector'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 now 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. Notes and Comments v ****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 u conditions of use. a 7 . Title 5 Inspection Form 6/15/2000 page I s Page 2 of I 1 OFFICIAL INSPECTION FORM-' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Ad A Owner: Date of I ection: / d P l Inspection Summary: Check'A,B,C,D or E%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: 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. Answer yes,no or not determined(Y;N,ND)in the 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`iniminent. 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 I - Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,(continued) Property Address: Owner: Date of lnsf ection: �D,�— 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. L System will pass unlesi-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 I of.a public water.supply. The system has a septic tank and.SAS and.the SAS is within 5.0 feet of a private water supply well. The system has aseptic 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 the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,pro.vided.that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: { 3 Page 4 of H OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: ' Date of In ection: D. System Failure Criteria applicable to all systems: You.must indicate"yes"or"no"to each of the following for all inspections: Yes No 7!//Backup ofsewage'into facility or system component`due to overloaded`or'clogged SAS orr 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 cesspool is less than 6"below invert or available volume is less than %day flow equired pumping more than 4 times in the last year NOT due to clogged or 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 form.] (Yes/No)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• 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) yes no the system is withinA00 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—I WPA)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 significant threat under Section E or failed under Section D shall upgra&the system in accordance with 310 CMR 15.304.The°system owner should contact the appropriate regional office of the Department. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:. ��(p Owner: 001 Date of I ection: c�/ �O/ 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 s ✓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? i/ _ 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 s� 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 Absol ption System'(SAS)on the site has been determined based on: Yes no 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(3)(b)] r 5 Page 6 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: P Y Owner: Date of 1 ection: —19 p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:'I 10 gpd x#of bedrooms):J�0 Number of current residents: 3 Does residence have a garbage grinder(yes or no): !Q� Is laundry on a separate sewage system(yes or.no)j (if yes separate inspection+required]" Laundry system inspected(yes or.no): �2,� Seasonal use: es or no (Y ) ,�JCO— Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):/2 Last date of occupancy:.J - yeevb%2,� 4ZV,&0LZa-eV' COMMERCIALIINDUSTRIAL/-Xh- Type of establishment: Design flow(based on 310 CMR 15.203): gpd . Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):._ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION . Pumping Records Source of information: Was system pumped as part of the insp ction(yes or no) If yes, volume pumped:R gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM X.ptic 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) _Tight tank _Attach.a copy of the DEP approval,, k. Other(describe): App oximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or nok_' 6 Page 7 of 11 r; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A, +4 Owner: . Date of I pection: /n/o/ BUILDING SEWER(locate on site plan) J Depth below grade.: Materials.of construction:.—cast iron _40 PVC other.(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,°evidence of leakage,etc.): SEPTIC TANK: ✓locate on site plan) Depth below grade:��.(x-A Material of construction: ,concrete_meta] fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , Dimensions: •S x Ca k Sludge depth: Cn Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:(p Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: r v . Comments(on pumping recommendations,"inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): X' GREASE TRAPjlvcate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee,or baffle condition,structural integrity, liquid levels. as related to outlet invert,evidence of leakage,etc..): , . 7 - J Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: p A Owner: Date of I 'spection: Va R/,o TIGHT or HOLDING TANKY2—"tank must be pumped at time of inspection)(locate on site plan) Depth below grade: l Material of construction: concrete metal fiberglass. Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: t,/'(if present must be opened)(lo.cate on site'pIan) Depth of liquid level above outlet invert: Comments(note.if box is level and distribution to outletsual,any evidence of solids carryover,any evidence of 1. kage into or out of box etc.): Q..��-'��2.L-Ii�i.r-1�t%��lX /.7.�1� Q� �7.�i.J�9� �d�. � � e ►�'c�y� PUMP CHAMBE�(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: Owner: Date of spection: SOIL ABSORPTION SYSTEM(SAS): L--(Iocate on site plan,excavation not required) If SAS not located explain why: TYPe f/leaching pits,number: leaching chambers,number: leaching galleries,number: ° leaching trenches,number; length: 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): CLc. And Ito °_- �- � 101 ° S' � I,a e G� c 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'or no): � Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 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.): 9 i I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; Owner• Date of spection: �) SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. �l 10 i Page I I of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of I pection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water %,J 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: Observed site(abutting property/observation hole within 150 feet of SAS) 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: mod'LC 11 t �.\ C0MM0\\\_EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF EIN-VIRONME\TAL AFFAIRS DEPARTMENT OF EN-VIRONN E\TAL PROTECTION ONE WINTER STREET. BOSTON. MA 02109 6'17-29:-5400 UILL1AM F.WELD . .:. 'ltt�c� RLDSr O✓ T e:icz Governc /��� N ARGEO PAL+1 CELLL'CCI 1p DAVID B �-R;L.1- LtGovcrnor SUBSURFACE SEWAGE DISPOSAL /SYSTEM INSPECTION FORM �� y�Oy0FAT9B 1998Comi357or. � - T F ®2- CERTIFICATION ._ Address of Owner: C1 Property Address;( � -. Ctt�►., t l.0 v� n _ �; 1 of different) 10 n• O E3 Date of Inspection: ('2, ""''��1 sP Bl Name of Inspector: I ��C�� C,f,►��t��E\�-� ¢� ' am a DEP ap,Proved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) i Company Name:�/[a fl4ni'c Ear rr'r"N we C,M-�-�/ l�'L� .Z Mailing Address: HA!9&4_t2_ H /g-0 2-6'41-C/ Telephone Number: r_5-e 7 � Zo CERTIFICATION STATEMEti7 it I ceru. that I have personally inspected the sewage disposal system at this address and tha, the information reported below Is true. acArate and comolete as o:the time of inspec:oo-. The inspection was performed baser on my training and experience rn the proper.function and maintenance of on-site sewage disposa; systems. The cvsterr:: Passes Concioonaii�.Passes leecs Furthe- Eva!uanon Ev the Local Approving Authorma�� , _ F 's Inspector's Signature: u=, Date: t!l I Tare Svs:e^ Insoe:o• shad' subm, a copy of this inspecion reoon to the Approving Authorih within them, (30) days of completing this inspection. If the system is a shared system o, has a design flow of 10,000 gx or greater, the inspector and the system owner shall submit the repo-, to the appropriate regional office of the Depa-ment of Envtronmenta' Protec-tion. The origma! should be sent to the system ow•nt and copies E-n, to the buyer. if applicable. and the approving authority. INSPECTIO'-SUMMARY: Check A, B, C, or D: AJ SYSTEM PA55ES:' ; I have not found any information which indicates that the system vioiates any of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indjqped below.. COMMENTS: t t . c lij 'N U BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, up( completion of the replacement.or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NDt. Describe basis of determination in all instances. If'not determined', explain why not. 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; the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rev-mod 04/25!97) D.Q. 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' " Property Addrass: Owner: Date of Inspection: BJ SYSTEM CONDITIONALLY PAS5E5 (continj,?d- _ Sewage backup or breakout or high static water level observed in the distribu4on box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system -dill pass inspection if(with approval of the Board-of Health). Describe observations: i t broken pipe(s) are replaced obstruction is removed - distribution box is levelled or replaced The system required pumping more than four times a year due twbroken or obstructed pipe's). The system will pass r_-,inspection if(with approval of the Board of Health): _ broken pipets► are replaced obstruction is removed J -. ._._ _._. . C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Boar"d of Health in order to determine if the system is failing to protect the public health. saiety and the environment. y 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE-PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prn-, is within 50 feet of a,surface water Cesspool or proov 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 APPROPRIATE) DETERMINES THAI THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a_septic tank;rand soil absorption system (SAS) and the SAS is within 100 ieat to a surface water supply or tributan• 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 supoiy well. The system has a septic funk and soil absorption system and the 5AS 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 we!), unless a well water analysis for co)iform bacteria and volatile organic compounds indicates tha the well is free from/$ollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to of less than 5 ppm. Method used to determine distance (approximation not valid). 3) _.OTHER Page 2 of to I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: r 1 D] SYSTEM FAILS: You must indicate either 'Yes- or 'No" as to each of the following: have determined that the system violates one or more of the following failure criteria a< defer%dr, 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 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pond)ng of effluent to the surface of the ground or surface v aers due to an overloaded or clogged SAS or cesspool. Sta:ic houid leyei in the distribition boa above outlet invert due/tonverloaded or clogged SAS'or cesspoo! Liquid depth in cesspool is less than 6- below invert or available voume is less than 1/2 day floe. Reouired pumping more than 4 times in the last year NOT dle to clogged or obstructer pipe's . ~umber o'times pumped Any portion o'the Soa Absorption System• cesspool or ,ri-.)• is below the high groundwater eieyation Ar.. por::on o=a cesspool or privy is withir. 100 feet f a surface water supply or tributary to a surface water supply Any porion of a cesspoo' or prwv is withir. a Zone I of a public well. An. pc-,ion c:a cesspool or pri.1• is within 50,�`feet of a private water supply well Any por.or. o:a cesspool or privy is less than 100 feet but greater than 50 fee: from a private water supply well with no a;ceotable Ovate• qualm analysis. If the wb has been analyzed to be acceptabie. anach copy of well water analysis for cohiorm bacteria volatile organic tompou/nds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: `rou must indicate either -Yes` or `No- as to each of tjhje following. The iolio%&mg criteria aop;. to !arge systems/in addition to the criteria above: The system serves a iacilit\ with a design flow of 10,000 gpd or greater (large System; and the system is a significant threat to public hea!th and safety and the environment because one or more of the following conditions exist. Yes No . the system is within 400 feet of a surface drinking water supply 1 • the system is within 209 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater;treatment program - - requirements-of 314* Cn1R.3.00 and-6.00. Please consult the local regional office of the Department for._furthe.r.informatioa.---- - - --- -- -- l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addcess: 4 6 OJT A�_Ir Owner• Date of Inspection: Check if the following have been done: You must indicate either 'Yes' or 'No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recentl. or as part of this inspection. As built plans have been omamed and examined. Note if they are not available with WA. The facile or d%velling was inspected for signs o-sewage back-up. _ The s\•ste�n does not receive non-sanitan• or industrial waste flow. _ The site was inspected for signs of breakout. _ All system- co-nponents. excluding the Soil .Aosorption System, have been located on the site. The septic tank manho;es were uncovered. opened. and the interior of the septic tank was inspected for condition of baffies or tees. matena; o`construction, dimensions, deptn of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption Svstern on the site has been determined based on The iac.lin o%%ne• %anc occupants. if drfteren: from ow•neri were provided with information on the prope• maintenance of Sub-Suriace Disposal 5vstem. Existing miornation. Ex Plan at 8.0 H. _ De;ermined in the field !tf an\ of the failure criteria related to Part C is at issue, approximation of distance is unacceotabie (15.3013t;bi? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert% Address: o(' "U'Act- I Owner: Date of Ih ftN�s ection: FLOW CONDITIONS RESIDENTIAL:_ Design flow p.d„bedroom for S.q.S Number of bedrooms Number o:'current residents, OU Garbage g•:.-der (yes or nol:� Laundry co-•^eaed to system (yes or no!�QS Seasonal use ryes or no,: I_j Water meter readings, if available (last two :2 year usage tgpd): _ Sump Pump (ves or nov N La<: da;e o'occupanCv COMMERC,kL'INDLISTRIAL: Type of establishment Design fio%% eahonsida- Grease trap present (ves or no_ Indus;ria! %'taste Holding Tani: present. Ives or no_ ':on-sancta-, waste d.scnargeJ to the Tape 5 system Ives or no_ %%ater meter readings if availabie Las:pa;e o;.o ,L.;.z-.c. OTHER: .De:cube Last date of occuoa-)c. GENERAL INFORMATION PUMPING RECORDS and source of Info manor. ���zy - e%j&i_� System pumped as par, of mspec;ion: tees or no.� If yes, volume pumped C}r s-eallons Reason for pumpingpny� TYKOF SYSTEM Septic tank/distribution boxiscid absorption system Single cesspool Overflow cesspool Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date tnsalled (if known) and source of information: u Sewage odors detected when arriving at the site. (yes or not (revised 04/25/91) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTE.AA INFORMATION (continued) Property Address:. Owner: &)a t;`ftM Date of Inspection: b BUILDING SEWER: b't (Locate on site plan) Depth below grade. Material of construction. _cast iron _40.PVC _other (explain! Distance from private water supply well or suction Ire Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK:=rJ Ilocate on site plan Depth below grade- Material of construction" Aconcre:e _me:a _Fjoergla5s _Pohethylene _othertexplam If tank 1s metal. 11s: age _ I: age coniirmec o% Ce^.fica:e o: Compuance _(lres.-No Dimensions Sludge depth Ii Dlsiance from top o: ,ivaee to bornrn o-' ou:ie: tee o• ba';e AS Scum thickness•, Distance from top o: scum to top of outle: tee or ba�.e � 11 Distance from bottom of scum to bo-.o,-r. o,.outte: to e• bzr.-e l - How dimensions were determinedtS`�� tv��s2E Comments trecommendatlon for pumping. condition o, iniet nd outlet tees or baffles. depth of liquid level to reiauon to outlet in v rt. structural i gnty vide ce of leak�e. e:c.t T v \lt tJl .( l �t GREASE TRAP:_ (locate on site plan; Depth below grade: 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 baffie: Date of last pumping: Comments: (recommendation for pumping. 'condition of i,ilet and outlet tees or baffles. depth-of liquid level in relation-ta-outiet-invert,-structur-al— integrity, evidence of leakage, etc.; (r•,-xAAd 04 75.'971 �.__ ... o . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.',t PART C SYSTEM INFORMATION (continued) Propem Address: i ( � Cek- r'(�T- Owner: e P(J4,-) Date of Inspection: TIGHT OR HOLDING TANK: #­�67ank must be pumped prior to, or at time, of inspection, (locate on site plan, Depth below grade. Material of construction _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions. Capacity-- gallons Design floes gahons.da. Alarm level Alarm ,n %:orking orde• _ Yes. _ No Date of previous pulmping Comments (condition of inlet tee. condition o- a!a•rr. and float switches, etc.) DISTRIBUTIOti BOX: (loca:e on site p;a- De:-:h of liouid Ie%e•. aoo.e outle: in�e' Comments !note d level and dis:r b on is eou-' evidence of solids rryover, evi ce o-flle kage into or out of boa etc.) � r 221 ti PUMP CHAMBER:_ (locate on site plan Pumps in working order: (Yes or No, Alarms in working order (Yes or No. Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-is: � Owner:(n)(LA'-'f>m Date of Inspection.61 SOIL ABSORPTION SYSTEM (SAS):19 (locate on site.plan, ii possible: exca� ion not required. but may be approximated by non-intrusive methodsi If not determined to be present, explain: Type: _ leaching pits. number. V%k leaching chambers. number:_ leaching galleries, number. leaching trenches. number,length: leaching fields, number, d.^nensiors overflow cesspool, number Alternative s-stem name of Tecnnoiogv Comments ino�t�e condition of soil- s!gr.s of hydraulic failure. level of pondiq. c d�a of vegetation, etc _ SC;S Vies L CESSPOOLS: _ (locate on site play. Number and configira:.on Depth-top of liquid to inlet Inver, Depth of solids laye•- Depth of scum layer Dimensions of cesspool Materials of construaior. Indication of groundwate- inflow• (cesspool must De pumper as par, of inspectioni Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 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.): (:e,,ia.d 04;25/97) page 8 oc 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continuedi Property Address: Owner: Date of lmpection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) _ r � y ( t- is 63"-'S f 3q` �3y r-S - 30` a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addres-- Owner: Date of Inspection: 1 Depth to Groundwater Lto Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with loca! Board o• nea!tr Check FEMA >aaps Check pumping records Check local excavators installers l•se LSCS Da:a r• a Desciibe in voi, o%%" v.orc, no'.% %o:: es:abhshed the !-+igh Groundwater Elevation. (Must be completed: I ., lrev:ied 0�;25'9'. Paige 10 of 10 LOt41'10N c � _ SEWA C E PERMIT NO. VILLAGE f INSTA LLER'S NAME a ADDRESS ® U I L 0 E R OR OWNER lqeA Ole- _ 0 DATE PERMIT IS UED, DATE COMPLIANCE ISSUED e!0 i e r t Fss. THE COMMONWEALTH OF MASSACHUSETTZ BOAR® OF HEALTH ..........................:................O F.......................................................------------------............. Appliration for Uhipati al Workii Towitrurtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �T..../6........C ' .......•.......(Ca.-tv�FA.I.V:T._.. L N�... ....---•-------------------------------- Loc n- d r or Lo No. --.F ._ ---------------------------- •---•••--......-•-••-•-•---...................•..... Owner Address a .....A&4T-----•--.......--•-•----•--•-•---•-•............... ........... •-••••.....----------....._................ Installer Address Type of Building Size Lot................. .........Sq. feet U Dwelling—No. of Bedrooms........ .....Expansion Attic (01 Garbage Grinder Ww) aOther—Type of Building ............................ No. of persons.................--..------. Showers ( ) Cafeteria WO Q' Other fixtures ------------------------- ---•- W Design Flow...........!9.S...................`Wagallons per person per day. Total daily flow............ ......................gallons. WSeptic Tank—Liquid capacityl ....gallons Length................ Width................ 'Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--h a.-.-.--.- Diameter...,l1a...-...... Depth below inlet...4�............ Total leaching area.19. ....... ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by..........&Of...... ...-.......... Date....................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......----............. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ---------------------- -----------•---/101•-•--•-•---•----------------................ . O Description of Soil--------------- ------------ = S._.......C.al4,f.---......1A�' �` �' � �- x c., x --------------------�r------ -��-------------------------------------------------------------------- ------------------------------ -•---•-•--•----------------- ��s ---•• L -- --- U Nature 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 TITii, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by th board of h lth. s Signed--X -. - -------------• :4o°l Date Application Approved By......---"7---�.eA:t..... --------------------------•-------• -------->...----- Date Application Disapproved for the following reasons----------------•----------------------------•--------------------------------------------------------_........-- ...........................•---•---•--....•--------•--•---•--•-------•---•----•-••---•---•-----••--•----- Date PermitNo......................................................... Issued Issued....................................................... Date . 6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ............... ......................._OF..............I...............-._..... Appliration for Disposal Works Tomitriirtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..¢ /?......... (._/l.d!! ' '..:...V�.............. �.�!:.�!��V�.•.....L'N�............................................ or Lot No. �. . ---------•-•--------------- ........................................................ Owner Address ..................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........,f...............................Expansion Attic ( + Garbage Grinder (lJY `4 Other—T e of Building ............. No. of ersons....................._.._.__ Showers — a YP g --------------- P ( ) Cafeteria � Other fixtures ----•---•---•-----------•------•---------------------•......--•••-••-•.._.. ...................... W Design Flow-•---••-•-_-C.$................... �s,gallons per person per day. ,Total daily flow............ .....................gallons. W Septic Tank—Liquid capacity. ....gallons Length................ Width................ Diameter--------- -------- Depth................ Disposal Trench—No. .................... Width......_...:......... Total Length.......... Total leaching area_:...:..............sq. ft. 3 Seepage Pit No.___r Y.A-__-__-- Diameter....,�0..._...... Depth below inlet....0�............ Total leaching area..S�T.._...sq. ft. z Other Distribution box ( ) Dosing tank ( - ) Percolation Test Results Performed by...._------ 0 ....._ --- Date.......e............................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... a .................................o . .................................... -••---....-•-----•-----•......................................................... Description of Soil.. ._:,. ' -.R',5 x '. -- ----- ..?t.....----- ��.----- ................... x 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 TAITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue bye boarY f hth; . P � Signed....�:>2.. •----- �`�.:.:..�"�.._ Application Approved B ...... - t.... ' Date Application Disapproved for the following reasons--------------------------------------------------------•----------------------------••----•--•--......-•---•.... ------------------------------------------•-•--.....---------•------------•----------...---•--.....-----•..-----------------------•---------------------------------------------------------------•.--•-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................................. Trdifiratr of Tomplianrr THIS IS.TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by % .........,", ?C ........................................-----------.....-------•---•----•-•-----•------•---•--....---•--------.....---•--------••-•--------. at................. Installler has been installed in accordance with the provisi nS of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... ' _--_ r! ......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM W L F49CTION SATISFACTORY. DATE...' �. ......................... Inspector .................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................OF......---............................ NO..A'?_:-Y.JP.P._ FEE..:"' ..--•----......-- �i��g��1 rk� �.�n�#rinn rrmi� Permission is_hereby granted............... -....................................-.................................................. I. to Construct .;) or Repair ( -) ,a• Individual Sewage Disposal Syst at No.•••-••-• ._...._.---------- ' T r Street as shown on the application for Disposal Works Construction Per No..................... Dated.......................................... Boar of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r: '-vr e" - ra�'c .0.,.K4 !Kr' t•y'•• }4?'"„r .M s 91 1r .� ...,yc x t- ,.. y:. t 7,. 5 � c• ) +..fir•*>w r � •} "4 Lrt` .t t. �"' r �� 'S. Z - � i � f�a. '^kl fr 'yn. "Ly� a -aa 'ST d tT��•N•? .:Y t. t ,, Y` • ' ��, .� *. ° � � t V �, i i f.,iy„ ,•�F i w.a' � 1 :.�`"'r" i. � y..,.,'vhiyy„� .. ,.-.. �. .• ' � "F's���/fr./fl./.. ..0�"` J .•�.�br„r� '.. ... V:yr..,..�,ery'�`• '. a ', .. gn L`VM Oe Al 14 .. - .. / l� / 1"iT�(�.r' �i.� G/,,. 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MUNICIPAL WATER IS EXISTING 44.0' MINIMUM .75' OF COVER OVER PRECAST 2X SLOPE REQUIRED OVER SYSTEM 45.0 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. a� 2" DOUBLE WASHED PEASTONE 41.3 RUN PIPE LEVEL OR GEOTEXTILE FABRIC QJ Pie *EXISTING FOR FIRST 2' 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO o�e� H- 10 Roue 28 c ' xISnNG loon *39.9' *EXISTING GALLON SEPTIC TANK GAS 6"SUMP 40.58' 5. PIPE JOINTS TO BE MADE WATERTIGHT. 39.43 --a:. BAFFLE 39.6' 0 0 0 0 ri o . 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH Z39.38'/ CJ � DO � C� � OC7 ' 6" CRUSHED STONE OR MECHANICAL 0 0 0 0 p p p p ED MASS. ENVIRONMENTAL CODE TITLE V. LOCU COMPACTION. (15.221 [2 2' 0 0 0 0 0 0 a O 0 a 4' 37.38' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO , DEPTH of FLOW = ( 1 % SLOPE) ( 1 % SLOPE) TEE SIZES: 3/4" TO 1 1/2 DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. , INLET DEPTH 10" 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. OUTLET DEPTH 14" 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FOUNDATION- *EXISTING- SEPTIC TANK 30' D' BOX 79 LEACHING 5.18' WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION FACILITY OBTAINED FROM BOARD OF HEALTH. LOV�S �P 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING , DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION SCALe: 1" = 2,000f *THE INSTALLER SHALL VERIFY THE OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO LOCATIONS OF ALL UTILITIES AND ALL **THE INSTALLER SHALL CONFIRM MIN. BOTTOM TH-2 EL. 32.1! COMMENCEMENT OF WORK. ASSESSORS MAP 40 PARCEL 29 BUILDING SEWER OUTLETS AND ELEVATIONS SEP>1C TANK SIZE AT 1000 GALLONS PRIOR TO INSTALLING ANY PORTION OF AND ITS SUITABILITY FOR RE-USE 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND SEPTIC SYSTEM REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE TEST HOLE LOGS REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. ENGINEER: DAVID FLAHERTY, R.S. WITNESS: DON DESMARAIS, R.S. DATE: DECEMBER 14, 2006 PERC. RATE _ < 2 MIN/INCH CLASS 1 SOILS P# 11582 ELEV. ELEV. SYSTEM DESIGN n 44.9' o" 4 44.5' A GARBAGE DISPOSER IS NOT ALLOWED LS DESIGN FLOW: 3 BEDROOMS ( 110 GPD) 330 GPD 10YR 2/1 FILL USE A 330 GPD DESIGN FLOW 10" 44.1' 19" 42.9' ZONE II LINE SCALED FROM SEPTIC TANK: 330 GPD 2 = 660 B A \ BARNSTABLE GIS MAP ( � LS ik1 **RE-USE EXISTING 10©0 GALLON SEP11C TANK 10YR 6 '/8 LS \ LEACHING 29" 42.5' 27" 10YR 2/1 42.2' SIDES: 2(25 + 12.83) 2 (.74) = 112 B 25 x 12.83 (.74) BOTTOM: = 237 C LS As TOTAL: 472 S.F. 349 GPD 47" 10YR 6/8 40.6' -... ..• USE (2) 500 GAL. LEACHING CH IG_RS (ACME OR•• ...�,,,,••• MS �'' . ,,•\• 47 EQUAL) WITH 4' STONE ALL AROUND PERC C ••�•••�• t}.ti_ a, Aso 2.5Y 6/4 MS L_j ;.� MA '� +� APPROVED DATE BOARD OF HEALTH 126" 34.4' 148" 1 32,2' - - 44 •• NO GROUNDWATER ENCOUNTERED <\ Lp SHED , 0 44 43 � up o a 00 O - 43 42 \ PAVED DRIVE F 41 �\ EXISTING 4� TITLE 5 SITE PLAN DWEo�� TOP N F G OF ELEV. 49.7' 116 CONTENT LANE 05 r (COTUIT) BARN!" TAm""'LE, MA BENCHMARK - THRESHOLD AT CJ� BASEMENT DOOR ELEV. 42.7 PREPARED FOR � I Content Line BLA.111"'"m WELLBELOVED LEGEND? LOT 16 � •�• �� DATE: DECEMBER 15, 2006 24,216 SF t \ •� 100.0 PROPOSED SPOT ELEVATION 9862 100x0 EXISTING SPOT ELEVATION 100 PROPOSED CONTOUR \ 100 EXISTING CONTOUR EXISTING WATER LINE W off 508-362-4541fax 508 362-9880 G EXISTING GAS LINE � �HOFM�Ss NOFMAss9 I °ti down cape engineering Inc. � � ,�Q DANIEL c � Scale:1"= 20' ��' DANIELA. �, A OCIVIL� " OJALA 0 10 20 30 40 50 FEET P �No. �No, 40 8 Cl I/lL ENGINEERS �7 ° �'ISTE�G,� e a F s` LAND SUR VEYORS G 17 SS/ONAL EN DATE oJALA, P.E., P. .S. 939 Main Street - YARMOU THPOR T, MASS. DCE #06-305 06-305 WELLBELOVED.DWG (DDF)