HomeMy WebLinkAbout0009 COTUIT BAY DRIVE - Health 9 Cotuit Bay Drive
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 9 COTUIT BAY DR
Property Address
DIGAETANO I"tip
Owner Owner's Name rT�
information is rA
required for COTUIT MA 9-22-15
every page. City/Town 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: A. General Information
When filling out 614 11 10 2—
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
VQ P.O. BOX 145
Company Address
CENTERVILLE MA 02632
'e°0r' City/Town State Zip Code
508-420-4534 S14297
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
9-22-15
Ignature 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.
�aUrnVS
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal •Page 1 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every 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:
SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. FUTURE
PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED BY THIS
REPORT.
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):
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is COTUIT MA 9-22-15
required for
every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every 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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every 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. a
❑ ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. CitylTown 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.
❑ ® 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): 3per
assessing
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 COTUIT BAY DR
'M
Property Address
p Y
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D-BOX AND A LEACH PIT
Number of current residents:
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 ears usage d 14-490 13-334
9 ( Y 9 (gP ))�
Detail:
SYSTEM NOT DESIGNED FOR GARBAGE DISPOSAL
.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-3/13 Title 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 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. Cityrrown 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 Y uantit pumped determined?
q
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 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.):
Septic Tank(locate on site plan):
Depth below grade: 2
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 GALLON
Sludge depth:
MODERATE
t5ins•3113 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
9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. CityfFown 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
Scum thickness LIGHT
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?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING EVERY 2-3 YRS
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. Citylrown 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
Oil
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.):
BOX WAS VIEWED BY CAMERA AND WAS FUNCTIONING PROPERLY AT TIME OF
INSPECTION. BOX SHOWED SOME CORROSION TYPICAL FOR ITS AGE
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
PIT WAS UNDER 6X6 LANDSCAPE TIE AT EDGE OF DRIVEWAY. AT TIME OF INSPECTION PIT
WAS EMPTY WITH DAMP SOILS IN THE BOTTOM AND STAIN LINE AT AROUND 3 FT
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is COTUIT MA 9-22-15
required for
every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
C
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every page. Citylrown 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: GREATER THAN 4
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 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
M , 9 COTUIT BAY DR
Property Address
DIGAETANO
Owner Owner's Name
information is required for COTUIT MA 9-22-15
every 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-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f
SELVAGE INSFELTIONS
LOCATION _ 9 Cota it Bay Dg ive -DATE 6111103
VILLAGE Cota.it,Pla z. ASSESSOR'S MAP& LOT. a�S tJ r
-INSFLECTOR Zo seah P. Nacom8.ea 21L.
SEPTIC TANK CAPACITY 1000 gatloaz f Pox
LEACHING FACILny: (type) 1-LP-1000 (size)1500 gattonz
NO.OF BEDROOMS 3
BUILDER OR OWNER E.stat e O� John P zocto2
OWNER MAILING ADDRESS
'ChaAlaz A. Ste22.ing
State Staeet dank
225 Fzank$.in Staeet
�o.ston, l azz. 021.10 _.._._ _.._ . . . .. .
� Lorv. � �a.y �f"NK LcfTu-cl
N.
.001
14
wad
1
r.
DATE : 6111103
PROPERTY ADDRESS:9_Cotu.it-Bay Derive ----- MAP
Cotu.it, Na.�z. PARCEL ;
®2
--02635 ----------------- LOT - -_
-----------------------
On the above date, I inspected the septic system at the above address.
Tr)is system consists of the following:
1. 1- 1500 ya 2ion ze/2t.ic tank. RECEIVED
2. 1-Dicta igut.ion Sox.
3. 1- 1000 ya-tion /22eca.st .eeach.inq 12.it. JUN 2 0 2003
Based on my inspection, I certify the following conditions: TOWN OFBARNSTABLE
04.. 7hiz .i., a t.it.Pe dive •se/zt.ic hyztem. (78 Code) HEALTH DEPT.
05. The ae/2t.ic .6y.6tem .iz in /22o/2ea woak.iny oadea
at the /2aezent time.
6. bVa.6te wate2 i•s 61' ge.Pow the .iveat /2.i/2e of the
tea chin y 12.it.
SIGNATUR
Name : J . P . Macomber Jr . �7
Company : �Qagpr, _p�_ M�QQmt�gr 8_ Son, Inc .
A Cords s :__@Q� _��------------
-rejU-erYLL1e,_ Na__22_632-0066
Pnone : 508- 775- 3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MAC0MBER & SON, INC.
Tanks-Cesspools-Leachllelds ,
Pumped & Installed
Town Sewer Connections
P.0 Box 66 Centerville. MA 02632.0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:9 Cotu.it Bay Da.ive
o ut a.6.3.
Owner's Name�Ztate Of gohn / aoc o2
Owner's Address: 225 7aankiin Stiteet
Bo.6ton, Ma.6.6. 02110
Date of Inspection: 6/11/0 3
Name of Inspector: (please print) jozenh P, Nacogge2 Ia.
Company Name: 9_ p_ gnrnm0.on R Sin Inc.
Mailing Address: _13, AA
02632
Telephone Number: �8 775 3 3 ?8
CERTIFICATION STATEMENT
I certify that 1 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:
ty Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails o
g
Inspector's Signature: f Date:
The system inspector shall mit 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 I
5
I
Page 2 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Cotu.it Bay Da.ive
o u.c
Owner: f state o n aoc o
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D J1
A� System es f
1 have not round any information which indicates that any of the failure.cHttrJJ'a described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are,indicate"elow.
Comments: ._
7hv .s rzt-ie .st/.stem .i.3 in /?so/?ea woak-iny oade`
�y ni iho 12,ze,3ent
i
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.
X10 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is smicrurally,
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:
166 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:
Ve) 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):
broker'pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 Co.t u-..t Bay D z ive j
ot u.c t, ill a .
Owner: F� _ 04 gohn Paoc.toa
Date of Inspection: h/9 1/o 3
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(l)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
o0' Cesspool or privy is within 50 feet of a surface water
166— 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:
/vo 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 fept but 5 feet or more froth 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 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 Cotui;� 13¢y Dlt-ive
Owner:Ch1-ate o n / zoc o2
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ ✓ of sewage into facility or system component due to overloaded or clogged SAS or cesspool
� ackup
/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
xlogged SAS or cesspool
1/ Static liquid level in-the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool / 1-�'n llt�t) CCi"/)
v yiquid depth in oesspael is less than 6"below invert or available volume is less than %day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped 0.
Any portion of the SAS,cesspool or privy is below high ground water elevation.
4/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 J
_ _✓the system is within 400 feet of a surface drinking water supply
` the system is within 200 feet of a tributary to a surface drinking water supply
i the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I1 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 I 1
OFFICIAL.INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSA
L SYSTEM
S EM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 Co.tu•it 13ay Road
o t u.c t, III a.67
Owner: Eztate o 2 / 2oc o/z
Date of Inspection: 6111103
Check if the following have been done. You must indicate des" "or no as to each of the following:
Yes No
6�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
_L,-/Has the system received normal flows in the previous two week period ?
— V/ Have large volumes of water been introduced to the system recently or as part of this inspection ?
— 2were as built plans of the system obtained and examined?(If they were not available note as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back up?
Y Was the site inspected for signs of break out?
Were all system components;4luding 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:
Yes no /
_A Existing information. For example,a plan at the Board of Health.
4" — 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
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 Co.t u.t.t 13a y D'z iL)e
o u.c , 1773.
Owner: _E,6.ta.te O, John P 2oc oa
Date of Inspection: 6111103
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):!A10�
Number of current residents: 4
Does residence have a garbage grinder(yes or no): 40
Is laundry on a separate sewage system(yes or no):,Vo fif yes separate inspection required)
Laundry system inspected(yes or no):��-
Seasonal use: (yes or no): Xb,
Water meter readings, if available(last 2 years usage(gpd)): 2 0 0 1=101, 000 ya.P.eon,=27 6. 72 gi'D
Sump pump(yes or no):IUD = yu teon.6=241. 10 qPD
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): o
d
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):&$—
Industrial waste holding tank present(yes or no):A/
Non-sanitary waste discharged to the Title 5 systerp(yes or no):, i*
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): ,J�¢
GENERAL INFORMATION
Pumping Records
Source of information: 'e AP14
Was system pumped as part of the inspection(yes or no):ifJd
If yes, volume pumped: d gallons-- How was quantity pumped determined? i1
Reason for pumping: ,!>�
TYPZ OF SYSTEM
Septic tank,distribution box,soil absorption system
iGT 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 torrent 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:
A;-P�V M_44,,,,&
Were sewage odors detected when arriving at the site(yes or no):,"
6
I
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Cotuit Ba Dz-ive
o u.it, Ala,3,j.
Owner:u'ztate O� John P/tocto z
Date of Inspection: 6111103
BUILDING SEWER(locate on site plan)
it 4" L.ite weight PVC pipe
Depth below grade: 9 Z-itt.ing,6. 7h zough out the
Materials of construction: cast iron AZ40 PVC 20ther(explain):,j yA t am
Distance from private water supply well or suction line:1,o"A
Comments(on condition of joints, venting,evidence of leakage, etc.):
10.in aaReaa tight. No evidgnng 04 igg sae The eu, .stem ih
vented thaough the houze vent-6.
/ I
SEPTIC TANK: Y (locate on site plan) 1436 j714
Depth below grade: l,f
Material of construction: concrete,!�kmetaI4&fiberglasyV�i polyethylene
!f Ibther(explain) JO/�
If tank is metal list age:.O Is age confirmed by a Certificate of Compliance(yes or no):.2i (attach a copy of
certificate)
Dimensions: /0 dwr 6����4` a S'''J'� .�
Sludge depth: L2r
Distance from top of sludge to bottom of outlet tee or baffle:/ ;� eA,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:�'t d o�.L
Distance from bottom of scum to bottom of outlet tee or baffle:��
How were dimensions determined: A"AmAj
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage,etc.):
�11(m'n iho /onfir fnak o»eayi 3 yenaA TnP2-L R n1ii0of }oy/, nap
o� ieakage. Liquid Qevei at the outlet .invaat i,6 51"
GREASE TRAW"locate on site plan)
Depth below grade:
Material of construction:4A/ concrete y metally fiberglass j�polyethylene-'1J.lother
(explain): .--11119
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:� 0
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:.4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Cnvo.ty .in<in 1A nnf onvAvny
7
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Cotuit Bay Dlt-ive
o u.c , a.6.6.
Owner: E.etate V lohn Pa 72
Date of Inspection: 6/1 1/0 3
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: .aA
Material of construction:A�LconcretedAmetal, &fiberglass l polyethylene,Uot)ier(explain):
Dimensions:
Capacity: Pallons
Design Flow: gallons/day
Alarm present(yes or no): WIf
Alarm level:_.AA Alarm in working order(yes or no):.[f/f
Date of last pumping: -
Comments(condition of alarm and float switches, etc.):
7igh,t oa hoid.ing .tanks ate not p4e.sen
DISTRIBUTION BOX: 2(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
11i.,Aialgal-ion Ina h .6 one .2ate2ai No evidence o� .so.P.idz ca/zay oven.
&n. o>>irlonro n4 LPaknyP- inio oA out of the 9Ox
PUMP CHAMBEP4,jje,(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):-s
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
LIjmlp rhamPvn i A not /22 .s P n
8
I
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Cotu it Bay DIL ive
Cotu.i.t, Plazz.
Owner: Ehtate 0, lohn Pliocto2
Date of Inspection: 6111103
SOIL ABSORPTION SYSTEM (SAS): Y (locate on site plan,excavation not required)
1- 1000 aai.2on R2ecazt teaching R.it.
If SAS not located explain why:
Type/
leaching pits,number:�
AFO leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number: -.C—> \
AZ innovative /'/altemative system Type/name of technology: //�i�6� )-/6 7, �
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
f-oamu .6and to eine coa2ze .sand. No e.ignz of hydaauiie /a.iivae
nn ;?nncl.ing. Vegetation .i.6 no zmai, Qazte wate2 .ie 6 1" geiow
the inveat /2.i/2e.
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.):
Cea,3no0i.6 ate not pzezent.
PRI "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.):
/�a i_vy ib not naebent.
9
Page 10 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Co.tvit Bay Derive
Cotu.c , 11a.673.
Owner: Fsirzip QZ 7ohn /O2o e.t oa
Date of lospeetion:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
bcnchmarks. Locate all wells within 100 feet. Locate where public.,eater supply enters the building.
I
�8
r A
I
10
Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Cotai� Bay Dlt�ive
o u.t , a.6.6.
Owner: Cetate 0 ohn P/zocto2
Date of Inspection:6/11/0 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
r
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
NfL Obtained from system design plans on record- If checked,date of design plan reviewed: N4
qZ_�—Observed site(abutting property/observation hole within 150 feet of SAS)
Nam—Checked with local Board of Health-explain: 414
y Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:htt,?:1/town. ga znzta&.Pe. ma. ups.
You must describe how you established the high ground water elevation:
1.6ecl: Gah1te1-U R Mi.P.Pv,7 NorIP4 12116194 a2ound wa.te2 e.2evat.eonz moue Sea levee.
zed: LISGS: CLP�Iaea—ztion )oPP rlrifr., lino 1992
Abell: 1ISGS:7er_ c ;erj9 guUaf in 92-og9- 1 /129-ta 9 4121211f1Q—gnagPA Clje g,7nijarl wuie2
Leaching , N
Pit 86 :eet
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
11
y.•..n,� .,.,r..-•�,-..,.-,,,.•.n,....--.,.,,,,,,.,..Tr.,.•.....n,..T..,nn.,m„�...-..,.R.r., ..-n-,•,-•r-,r—.-:..,..;�...t
1 'TOWN OF Baanz.tcla..Pe WARD OF HEALTH l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�••S�T••._•.:.-�.tIT�.�TTi�I T.111'R.1SI T1Ti'Ci9I]'RT.T1:T'I."SITI!"1]I'Rlr'P•I.RR�Or7T ltl7trf rR n I rrr.__
-J
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 9 Cota.it Bay Dz4've Cotuit, Na.6.6.
ASSESSORS MAP, BLOCK AND PARCEL # 055-024
OWNER' s NAME Estate 0/- aohn Paocto2
PART D - CERTIFICATION I
NAME OF INSPECTOR _ lozenh P. Macomee2 Ia. ,
COMPANY NAME Nacoml?e2 9 Son .i.nc-r `
COMPANY ADDRESS Box 66 Centeay.iiie Ma.6z. 02632
Street Town or C1ty state llp
COMPANY TELEPHONE ( 508 1 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Chec one :
f
{� Sys teci PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or, the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED* \
The inspection which I have co 'Crcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CHR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection f rm .
Inspector Signature �r Dated
an6copy of this c t,ification must be provided to the OWNER, the BUYER
here applicable ) and the BOARD OF HEALZ'1(.
* If the inspection FAILED, the owner or"operator shall u
pgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 15 . 305 .
partd .doc
SEWAGE INSPEC" 1ONS
LOCATION 9 Cotait Bey DItive DATE 6117103
VILLAGE Cotuit, t'a.3,3. ASSESSOR'S MAP & LOTI)%S 62,E
-INSFkFCTOR _lozeRh %. Na,-omge2 Jz.
SEPTIC TANK CAPACITY 7 000 qa e eon-6 f Box
LEACHING FACILITY: (type) I-LP- 1000 (size)15 00 Ga teon,6
NO. OF BEDROOMS 3
BUILDERCROWNER C-6tate O� John Paoctoa
OWNER MAILING ADDRESS
Chaa ea R. Steaiinq
State St2eet Bank
225 Taankiin Staeet
Boaton� (7g��. 02110 _...... -- .....--._.......... - - ---- ..__._ . - ..
� :. �� ,�
-�� + / \ /
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