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HomeMy WebLinkAbout0117 COTUIT BAY DRIVE - Health 117 COTUI7BAY DRIVE,COTITI'T _ 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 117 Cotuit Bay Drive w�a Property Address Pn Deagan Owner w Owner's Name information is :r' required for every Cotuit Ma 3-20-18 '. page. City/'Town State Zip Code Date of Inspection ram" 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. Imng out f rms A. General Information filling out forms on the computer, l use only the tab 1. Inspector: key to move your cursor-do not . Chad Hathaway use the return key. Name of Inspector H.P.S. Company Name P.O.Box 151 Company Address few Forestdale Ma 02644 City/Town State Zip"Code 774-274-2581 12866 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 m training and experience in the proper f Y 9 p p p unction 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 ` 3-20-18 Inspecto5pCignature Date The system inspector shal sl Owit 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 1 of 17 Via vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM „ 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for 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: ® -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: Septic in working order. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name. information is required for every Cotuit Ma 3-20-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) j ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for 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 El ® 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 'h day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every page. Cityfrown 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•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 117 Cotuit Bay Drive Property Address Deagan Owner Owners Name information is required for every Cotuit Ma 3-20-18 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? ® El 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: t Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): yU t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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: Sump pump? ❑ Yes ® No Last date of occupancy: bate 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 wM 3 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every 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: owner pumps every 2 years 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 P 9 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments M 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every 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: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ,Depth below grade: 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 20+ 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 gal Sludge depth: 3" t5ins-3/13 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 M 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every page. Cityrrown 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 31" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom'of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching. Concrete baffles in place. Liquid level at bottom of outlet pipe . Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 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 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for 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 M 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every 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.): Camera Inspected. DBox 3' deep no riser in place. DBox is solid 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: 6'x6' precast pit wit stone has riser in place. current water level is 30" below invert pipe no staining past that level to indicate past failure t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,„ a•'"p 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ Teaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innov Elative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t GM , 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every page. Cityrrown 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 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M SV0'� 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is ` required for every . Cotuit Ma 3-20-18 page. Cityrrown 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 P,mk ors Q 2 d O �� 3S l8 o 4 U L� o4- t5ins•3/13 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 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for 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: 25 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: town GIS mapping. el. area of septic'el. 32' low in area near water el 5' 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 W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 117 Cotuit Bay Drive Property Address Deagan Owner Owner's Name information is Cotuit Ma 3-20-18 required for every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 1'Ile rrthrlier '181002-8 11NRI'sC1S'1 LRrl)LAND tttanrri i CAPE COD TITLE&ESCROW E Deed!lank 26032 prl„e 106 L,crtrluat: , t'Irirr tlrruk 2rJ2 Tarr,r,26 lut a' 64 osvirer. MARGARET&GREGORY,III DEEGAN I REGISTkRED I:AND - -------- - - t{c>.11airk----- Itr:cl-_� _ d.rit(,�)- -------------- Darei 1019l20.18 . Certi rcate o l irle .. �1.c.cessrrr'a'r1/rr ;.56. d3lk: t,rrt'38' 0-118rrs a7rrct ,t?QRTC;AG'!;INSPCTIC)l�'I'I,AlV Scale. 11 60 i ' :.-_._ — _ _ _ . _ it7COTIJITBtrY.DRIVE, Coruna; `fin. 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I .Y}OR IS I aLA91'P 1 Rl1M YIUL'AT10N CNMURCI i111 N l A(71UN 1 NDk RrAIA�S t GNCRAI I A\Y 11TI I C'll �IIAYTkR AOA SF[1'IA�V 7 e� `":5 n $ .� 3r i h `� k a $ d Y S 1. s„�� S.'`. `h X X- r 3 4" F1,00D DF7lItM1NlTION in$Y SC�il,i: CHEDWFLLINC xS11C)WN 11]RP"`DgLS NC);1';J AI I'WII h11N AiPtCIAt I 1 CC)D 1IALARI7/Ot31�AS>DU 1Nk„q;JT[)Ui\n.MAk t7f CQIMMUS�17 Y ` B2i0(�IGU?43JA�GUNfXDA7'EUJI1b/14`IiYCHLNACIUNALTLUI.)IIfNSURAN44t?It()CIJ�gM ,� � ay ;` z «,q.«o - t w•,s�� 'm. °'°fix'�" a :�'� i :3' '' v^ �;"" x '�'1f `i �, y s � 15 \ +I vt, rf .— y.. f a P j Olde Stone:Plot Plan Servcce LLC � r �t , _ T '" i =3 PQ, $d 1166 t .+�. tit LakestlIe, lt?A 02347 } ;� ToI (, 0 993 ,,'0 2 . ' m 1, Fax..' 800 :933.3304 .. s'' v ?d 3 PLF,. SE NpTEg T�ris lnspechon Is not the[esyltsot an instrument suNey The structures as shown are approximate only An iPsilument survey £ n p would be--';-ed for an accurate determinat ap'ot.<bu!ding local#ons a tcroachmer is property fine dimensions=fenees,and,lei;confguFat on ' .and may reflect dlBerent lniormaGpn 1 shown Here The land as shown Is based on chant tl�nlshed lntarrna}Ion,only or assessors?trip$ occ 1paUon�a�d maybe sublecl to further oo t sales lakings easements and rights of way No_responsiblltty,s extended to}he,landownerAor " ar r surveyor)oroceupant T i s is[ne e[y rtgage iflspectwn nd 1s not be be recorded �p� s- f3-;. .yr w�u.•� '; ...4 � i_. I 1 -7 CAS SIP �6�C�4N SOS . 4,3 C (P?-Oo 1 x?-C } I I i J — ----------------� GM o � Id. ate) c ------------ � iC6 t f DATE: .7/17/96 PROPERTY ADDRESS: 117 Cotuit Bay Drive C r® Cotuit,Mass . Al 1996 HEALTH DEPT. 02635 TOWN OF BARNSTABLE On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 .. 1-1500 gallon septic tank. . 2. 1-distribution box. 3. 1-1000 gallon leaching pit. Based on my Ins:iP.ctlon, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) 2. The septic system is in proper working order at the present time . SIGNATURE: Nagle : J . P . Macomber Company: J• P . Macor0er & Son Inc . Address:_-Be�c-��i------ --- - --- _ CentervilLe j\LEass__02632 Phone:__—SQL 77S>-333b-- --- ---- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. M1ACOMBER &. SON, INC. Tunks-CeupoolrLeechf lelds . Pumped & Installed Town Sewor Connections P.O. Box 56 ' Centerville, MA 02632-0066 775-3338 775-8412 V AL Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WUllant F.Weld Trudy Cox* Govem« gwrt,y ic�RPaul Celluccl David B.Struhs t Commiulorar • i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION property Add resa: 117 Cotuit Bay Drive Cotuit,Mass . 7/17/9 6 Address of owner. Date of Inspection: #. (If different) Name of Inapeotor.Joseph P. MAcomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc,. Box 66 Centerville,Mass. 02632 508-775-3338 . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: J— ' } Passes — Conditionally Passes — — Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature- a�� Date: c The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: AI SYS TEM PASSES: _ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cm:ked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is imminant. The system will pass inspection if the existing septic tank is replaced with a lonforming septic tank as approved by the Board of Health. (revised 11103/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292.5500 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) 117 Cotuit Bay Drive Cotuit,Mass . Ownen Jeff Parsons Dstc of 111:i;ic ::7/1 7/96 Bl SYSTEM CONDITIONALLY PASSES (continued) &h Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced AZI� The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A)D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 10 Cesspool or privy is within 50 feet of a surface water j '0 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: &6 The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. !8 The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. LQ The system has a septic tank and soil absorption system and is leas than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 9) AAO//T^^HER '� (revised 11/03/95) 2 i' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: 117 Cotuit Bay Drive Cotuit,Mass . Owner. Jeff Parsons Date of Inspection: 7/17 9 6 D) SYSTEM FAILS: , s `b I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. f� Backup of sewage into facility or system component dua to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of ti,e 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. 1.c44CN Ar ZjZ6 Liquid depth in oeacpeel is less;than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Ar Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. w u to a w �Jy Any portion of a cesspool or privy is within 100 feet of a surface star supply or tributary surface afar supply. Any portion of a cesspool or privy is within a Zone I of a public well. Q�A, Any portion of a cesspool or privy is within 60 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: A110 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply IL4 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) 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 CMR 5.00 and 6.00. Please oonsult the local regional office of the Department for Auther information.• (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i Property Address: 117 Cotuit Bay Drive Cotuit Mass . Owner. Jeff Parsons Date of Inspection: 7/17/9 6 s Check if the following have been done: ,Pumping information was requested of the owner,cc c,u ..1a nt,and Board of Health. Zkone 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 recently or as part of this inspection. -.K.A.built plans have been obtained and examined. Note if they are not available with N/A ,VThe facility or dwelling was inspected for signs of sewage back-up. , The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. ZA11l system components,`.su luding the Soil Absorption System, have been located on the site. ZThlseptic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of banes or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. /The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 117 Cotuit Bay Drive Cotuit, MA ® 1>rec/c'cl ri,�/rl.c Icr Nnrt/1 13u�•Jirr huirlirl},. %%li,c hunts'/�ruricics an upcn.Jlctur/�lcur uncl lrunclerJirl hcamecl ecrlhedt-al ceilings. '1'ascs: $3,054 Acreage: 1.17 Price: $254,900 SunuMV)". 'total Rooms - 7, 3 Bedrooms, 3 Baths , F YER: 5'4"r x 6'lU•1) Tile floor: coat closet: SECOND FLOOR U ( . skylighl. BEDROOM #3: (I.I'9"t x 17'f) Oak Moor; two 4' x LIVING ROOM: (13'6"1 x 15'4"t) Oak floor.brick 47*closets: three panel Anderson windows. fireplace: cathedral ceiling with beams: four panel Anderson windom.- ceiling fan: recessed lighting. BATH 93: Tile floor: vanity with Formica lop: tub/shower with tilt surround. ® DINING ROOM: (I 1'4"i x 14'8•'f) Oak floor. four panel Anderson windoim. cathedral ceiling with BASEMENT/UTILITIES: Full basement: access beams: slider to flood deck. from Garage and house: 200 amp. electrical service protected by circuit breakers: town water; central BAT11 !!I: OII" Back Dim,: vinyl floor: vanity llilh station alarm system: new FI-IA heat by gas; ucw Formica top.. fiberglass slimm.: llindow., Grn and Kcal ccnlral air conditioning sys(.enr: oil hot water healer; lamp. ccnlral vacuum. KITCHEN: (8'5•1 x 14'4"±) Black and while vinyl GARAGE: "I'�lo car attached garage. Slone driveway. floor: I minted Blood cabinets: Formica and butcher block counter lops: Jcnn Air gas range Lop: electric EXTERIOR: Wood deck al rear of home: asphalt oveu: GE dishwasher: separate\let bar. roof;clapboard side alls: Anderson Nvindows. BACK ENTRY: Black and whilc vinyl floor: dUubic MISC.: Association tennis:deeded beach:deeded deep coal closet: laundry, door to Garage. slater dock. FAMILY ROOM: (I 1'3"1 x 13'6"t) Oak Iloor: brief: fireplace: cathedral ceiling with ceiling fan. AGE: 19781 skylighl: slider to rear deck: recessed lighting. SQUARE FOOTAGE: I.645i* (*according to Town of Barnstable Assessor's records) IIALLWAY: Leads to stairs and Bedrooms:oak floor: TAX MAP: 56 PARCEL: 39 linen close(. ASSESSMENT: $222.600 BEDROOM #1 (Master): (12'4"•1- x 14'3.) Oak floor: double closcl: lll'o .Ill in/i,rnuaion contained herein is ohlairacd from the urrnca• Anderson windows. aml i.e a.csanan! to he curn•e.c•t. .Ill nwasurearccMs are crppr•uxiurale and along; with the irr%urrnaliurr c•onlained herein, it is believed to be accurate bai is not warranted. BATH #2: .(7.0-± x 8'Y±) 'Pilo floor; fiberglass J//hro%iu:caalcspersar.crepresenlIhesellev,rrol the brrverill shower., .unity with Formica lop: single window. the nrarkc+ting, negotiation and sale of property, unless otherwise disc•loseJ However, the hrolu r.`salespersou has all ethical and Ic nl ohlil atiun to.burr hone.cly unrlfuiracss to BEDROOM #2: (I 1'4••:t x 12'T'1) Oak floor:double the hrrt�er in 31 lransac•lion.c. close(: two Anderson lrindolls: blue & while Laura Asidev wallpaper. Directions: Roule 28 to Old Post Road to right on Cotuit Bat' Drive. Cotton REAL ESTATE , 851 tllain Mi-eel, Oslerville,)1111 02655 Phone(508) 428-9115 Fox(508) 420-3161 6,School,Sll•ecl, (.'omit, 11111 02635 11hone(508) 428-9593 Fax(508) 428-6758 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M /A\� L DATA UItrAC:' S1?1i'AGE U19PUSAI.SYSTEM INSPECTION FU1t'.S P..RT C SYSTEM INFORMATION 117 Cotuit Bay Drive Cotuit,Mass . ' Jeff Parsons 7/17/96 FLOW CONDITIONS Design flow, Nun:bier of ti,drvoau: Number of current rcwidents: 1 Garbage grinder (yes or no):-�k—S Laundry oonnactod to g8tem(ycw or no):.Nil S Seasonal use (y Gc or no):IV6 )) _ Water meter read.in;.-a, if r, 7�/,y�Gl��itrlS /�l�t/ z s La:ct date of 7�!"�b CO\{RiF..t,••r,4_T,!1T�nT.tc:•rrtr.+,r Type of Divijn flow: "cr.. Grease trap pre"nl: (yu (;r z;,)AM Industrial Nrutte TI '.:' _ '. iu cr no) Non-c;tr:ir-r. Tii+'';r 5 iptem: (yes or no)&Y-Yt 10 Lu:+t date of GE:NEIU:L INFORALMON PUMPINU lti:..,. e,i f u:forra:ition Syutom Pu-n;x•d w p::rt of (ycc or no) s If yw, vol:n:c ., � as l? �� ✓ auou te: �.sue � I¢ T 11E, 00'Jyn...'..: :; ,:i•,iocs i:: ;::�tion rikon' if any) AI"'�►I'0% :i,::,; . t , dais u,rtolkd. (if known) and source of information: I`' GhJ LOCATIONS SEWAGE PERMIT NO• VILLAGE INSTALLER'S AME i ADDRESS 0 U I L D E R OR OWNER DATE PERMIT ISSUEQ. DAT E COMPLIANCE ISSUED i 41 .,_� � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) roperty Address: 117 Cotuit Bay Drive Cotuit,Mass . 1 wner: Jeff Parsons ate of Inspection:7/17/96 EPTIC TANK: jTco q ¢kk-,rU 06 e yOTiC 7A14A ovate on site plan) epth below grade.,_A/`� aterial of construction: concrete _metal _FRP _other(explain) imensions: :S' 1 :12, 6" ludge depth:, _ 7 istance from top of udge to bottom of outlet tee or baffle:,_ cum thickness: istance from top of scum to top of outlet tee or baffle: �. istance from bottom of scum to bottom of outlet tee or baffle. (.L omments: ecommendation for pumping, condition of inlet and outlet tees r baffles. de th of liclu'd,lPvel in relation to outlet 'nvert str ctu al �rity, evidence of leakage, etc.) Pump tank 'annua�ll •Gar ba e -dis.posal resent• Tnre & outlet 'tees ire in place ;The'sep is 'tank is . str� ura ly soun ; o evi ence REASE TRAP. /✓ � ovate on site plan) epth below grade:;W aterial of constrt.lrtion;R 40ncrete metal _FRP _other(explain) imensions• _ um thickness: istance from top u'i scum to top of outlet tee or baffle:AA istance from bottom nt srum to bottom of outlet tee or table- omments: ecommendation for pumping, condi—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural to ity, e ' ence of leakage, etc.) evised 9/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontlnued) PropertyAddrem- 117 Cotuit Bay Drive Cotuit,Mass . Owner. Jeff Parsons ' Date Of Inspebtions7/17/9 6 TIGHT OR HOLDING TANK:.g, LV , (locate on site plan) s Depth below grade:wA Material of construction Concrete_metal_FRP_other(explain) Dimensions: A)4 Capacity:_a gallons Design flow: gallons/day Alarm level: �H Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION Box (locate on site plan) Depth of liquid level above outlet invert:. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) Distribution box is level;No evidence of solids carry ovar!Nn avidanr.a of leakage in or out of the box. The di gtri bilti nn hnx imstrtiti�tttirall3r Qnund _ PUMP CHAMBER_4,&4Ae, (locate on site plan) Pumps in working order:(yes or no)_ Comments: (note nd4 wn of pump chamber,condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURF,-%Ck, br:'vN,xGL DISPOSAL SYSTEM INSPECTION FORM PART C r:M INFORMATION (ooutinuod) Property Addno6a: 117 Cotuit Bay Drive Cotuit,Mass . , Owner. Jeff Parsons D.te of Inspootion:7/17/96 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not rvquii—i, UuL uwy t,e approximated by non-intrusive methods) If not determined to be present, explain: Type: r leaching pits, number: leaching chambers, number leaching galleries, number: leaching trenches, number,length:—D- leaching fields, number, dimensions: - _ ,_.... .. overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic fuilun, level of ponding, condition of vegetation,etc.) ,4aP page 8A ------ CESSPOOLS: (locate on site plan) Number and configuration: M4 Depth-top of liquid to inlet invert: AJ Depth of solids layer: AA Depth of scum layer: AM — Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: ote condition of soil, signs of hydra;,lic fuilurn., ievel of ponding, condition of vegetation, etc.) /11e Y14 W�vr� PRIVY:&[ el (locate on site plan) Materials of construction: NIA — Dimensions:_ N-0 Depth of solider Comments: (4p�tcee condition of scil, signs of hydraulic failure, level of ponding, condition of vegetation,'etcj. v' (re t s ed 1 1/03/95) g I �ISPvSA.L PIT V;r-- ' Bi TTCdA.1 ArZtLf. j 'r• � I � ..I�.-.-r.'� I � 1 IL II r F'E ca L--AT I o/J rc i C_ 1 1 N 2 MlQ CQ j, I J • I-eST T oP F►-Iv too' ¢'•f;PE ,�- •.� lint . !: �. INV. I vc pl5r luv. IM/ j Soi. q,,., �,6YTIc I 77 I IGU� I'. 4� IUV. IUV. 1�.• f� GA,L. ! t_ LEAcu PIT wlTU 3/4 (fit wasuED G �.. e'er__I t 17 /a 7 C E2 T I F•I E ID P%-oT PL-A �2o F"I L - I•. 1 Cc>zTI FY T-HAT T►i� . suave PL_A. l� 2 Eec►�c� j ►-1�cZF�.-1 GoMPL_`f5 wlrH T11E- r�IDELIII� i �' L Sk:TBACl� �yulV.L-MEtiiT25 of TWE. j TbVcJ" OF DATA — I � �. � ,/ , rT:--... � -�� - �• . ' i ' ' BAxTEtZ > USE I�►c. �Is-rE Tz� �a,�n SUevEYv[:s; T111S pl AIJ IS UOT• T345E-D OL! Au IU4T2vMEuT AAA. SUe\/e/ T►� G OFF5ET3: 5"OULt> uOT $E U- F_p To 7'CTERnnI.1E LQT LIUF�,• APPUCAuT -•J SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks i locate all wells within 100 ' . ks- DEPTH TO GROUNDWATER depth to groundwater mkt od of determ' 41- or WAX roximatyon:- e low ..1.,.ter„•..... ..W,: L SEWAGE P � �: . . Ir ' II� ST ". LLER,S NIA ME i ADDRESS R UILuk w OR OWNER pr Yr 0ERMIT ISSUED ns � COMPLIANCE ISSUED THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macom ber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' •ion of Water Pollution Control r :+•rnnrre—n.•rem.•rr:rrrrmr•nss+rrrnnarrrsrar::•t++STarrJ+.r.s•mrn m•+•ti-ai trasrTerms+ nrr.•o�r•.�.:.�..•.r••F 11'OWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �J h•••rr ^T•'•"•:5—T.fIT.^•�4T1�51T.f•fltTTtTRTTTlf7TnT5•T^M1•I5•'IiTTR"07.R5R^T.�R51.Se�I.f�01R1t�tT7Qr7 mnn•m++r+m+v+r.-►+rr+ns+,�e�•-•rr-�.•.•,.� —TYPE OR PRINT CI.EARLY— PROPERTY INSPECTED STREET. ADDRESS 117 Cotuit Bay Drive Cotuit,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 56-39 OWNER' s NAME Jeff Parsons PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J.P.Macomber & S)6:n'•Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632- Street Town or City State L IP COMPANY TELEPHONE (508 j 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 complete 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 . Check one: XXXXXXXXXXXSysteai 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. Systew FAILED* The inspection which I have conducted has found that the system fails to Protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature r Date 7/1.8/96 '.'a�sraxsz:xssrrrsr J One copy of this Wr.t.ification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade ' the ayatem. within one year of the date of the inspection, unless allowed or required otherwise as provided in' 310 CMR 16 . 305 . partd.doc LOCATION �'� IL7 SEWAGE PERMIT NO. VILLAGE (� INSTArLLER'S NAME b ADDRESS BUILDER OR OWNER i DATE PERMIT ISSUED PF DATE COMPLIANCE ISSUED 14- 7 � i ER THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... T^^'..............OF...... d 1`..............................................----- Appliratirrn flax 43hgp teal Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: Location-Address - ( Lot No.a uC? �` .Y :&! ... t —1Y `'� 1�Pe.._..�! S_fD� 1 lJS.°... ......................... Owner Address Install r Address ' vS ^ d Type of Building Size Lot.........a............-------Sq. feet U Dwelling S No. of Bedrooms........................................Expansion Attic ( ) Garbage Grinder (i,.< aOther—Type of Building ----_...................... No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- W Design Flow........5.0------------------------------gallons per person per day. Total daily flow...............`-q�_-.___.-...........gallons.. WSeptic Tank*Liquid capacity..15ll---gallons Length_!D:n6-..._. Width. . .... 1� Q . Diameter................ Depth x Disposal Trench—No..................... Wi(�lid-----------.- Total Length.......-..._..-- Total leaching arca.__::j; sq. ft. Seepage Pit No.._�Q_00-------- Diameter_-`' Depth below •nle _..V0'_ Z..._..._. Total leaclt'ng area._-.sq. it. Z Other Distribution box ( yC) Dosing tank ( ) °�>;� - l® 12d- ?�- 0 ~" Percolation Test Results Performed by..._..&PJi.,L--f_s----------------------------------------- Date------------------------- W Test Pit No. 1................minutes per inch Depth of "Pest Pit..._.-_-_--_..__---- Depth to ground water........ (� Test Pit No. 2---------------minutes per inch Depth of Test Pit-------------------- Depth to ground water......... ..------------ 1 -----------------•-----------------------•-----•......................•.............................................. O Description of Soil "Q-NPA-.... ._SPH:P'�_..SU.�3__5oii. © i-------------- -E ivN1. 5 � Q �-------------------- (> W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable...-_..........................................................................................- ----------------------------•----•--------------........-------•--------------....-...-..-•------------------------------- ........................... .....-.......---------------------•------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si �• ........--.-•.--.-�.: --••.. ....�z/ .../gyp-------- Date Application Approved By----- - ---- - - -- - - -- -- ­-- - - ------------------------- ..... Date Application Disapproved for the following reasons------- --------------- -----------•--•-----------------------...------..............----...........-----••••-- ...--•-•-. •--•-•-----•-•-------•---------------•-----------....----------------•--------------------•---- Date Permit No......................................................... 7 --•--------------- Issued------•-- --------------------�_------------••---•-- Date '0-7�� No......................... ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... .. .... ...... ...........OF........... ........................... ..................................... ......... Applirailion -for M-4pooal Works Tomitrurtion Vrruift Application is hereby made for a Permit to Construct (11-5 or Repair an Individual Sewage Disposal System at: cuvulv mpk5s, ...................... ................................................... ..... .... ....................................... Location-Address _I 13 Lot No. _Dtt­ b ...5-su­ ......NI ........... ............. ........................................... ­a...0....... Owner ­1 Addre ass kw aq I--------------------- --------------------. 7 Instal r Address A Type of Building Size Lot............................Sq. feet j 11 71 DwellinglL No. of Bedrooms--- -------------...................._.....Expansion Attic Garbage Grinder Other Type of Building -------­.,­­-�------------ No. of persons._.___..........._.__....... Showers Cafeteria P4 Other fixtures -1� .......­­-----------------------------.................................... --------------------------------------------------------------------- Design Flow--------5.7 allons per person per day. Total daily flow__-_--_-__--_`+1 15� --- W .0...............................g, ----------- ------gallons. 9 Septic Tank-Liquid capacity.-MO..gallons Length.!D.7:69 ..... Width.-S V...... Diameter................ Del)tli-.-jk--C>--- Disposal Trench—No. .................... Width-_-_--_--.__-----:_. Total Length------------------...Total leaching area--------------------sq. f t. Seepage Pit No­!PD.0......... Diameter...6.7-0....... Depth below inle$­5-2. otal T leacluhigarea­Z4k------sq. it. Z .1 Other Distribution box Dosing tank Wr Percolation Test Results Performed by----- -Fa"ck.................................... Date-----_-----------------_-..------------.- 1 Test Pit No. 1----------------minutesperinch Depth of Test Pit.................... Depth to -round water..,--------I..........­ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.._....-__.._-----_---. � ---------------------------------------------------------------------­------------------------"-----------------------------*------------------------------------------ �0 Description of Soil- &P ----- So3--voit, ai- [Vl T 0 ­U ----------------­-- 4 U ........................................................................................................................................................................................................ -------------I----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Y 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ----- . ........................................:n-­--------­---­------------- ................................ Date Application Approved By-.-' ­ — 7,r,-i:------ xsi- ----------------------- ----/12-- Date Application Disapproved for the following reasons:.................... --------------------------\ ............................................................ ......................................................................................................................................................................................................... Date PermitNo................... .............................. Issued-.;....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........ ....................................................................... (9rdifiratr of T"alintlifittUrr HI IS TQTERTIFY, That the.' IndlvidXal Sewage Disposal System constructed or Repaired by..- ...11S................................................................................ Installer .........L or tAu, 6 4 - ------ ------------------------------------------------------------------------------ -------------------------------------- .....5A�4 - at 7 T- n 5!; 1, has been installed in accordance with the provisions of A I o The State Sanitary Code as described in the application for.. Disposal Works Construction Permit No...: .. ... ---------­- ------ dated----/.;-t '-. ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. ---------------- ................................. Inspector.......1.16—�4,114101*­� .. . ...... . ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -T-o W 3 1) .................. ..................�OF.........0.�tM.�A....W.c........................................... NO(&... FEE---- ............. Permission is hereby granted.- -- --------- -----A­V,4- ,k-a�......................................................................... to Construct &.-Y' or Repair an Individualevvage Disposal System at No.........Ef r................& ...................... ------- ......... -------- ------------------------ as shown on the application for Disposal Works Construction P �-Jec'No Dated-----1�21�-- -------------------------- .......................... DATE.3—.2 7-----6 Board of Heal ------- y.. .......................................... FORM 1255 HosBS & WARREN. INC.. PUBLISHERS -Z I I cp 'd -3 lvi RUZ u t>F—%A/4 LL ACEA BoTT &A 4�2 AW OIZ L-Er7S. PL TEST --------------- 70 L A-Z "V'G -4 'go-A, Tls Q 14 14 l000 1"T t u v. iwtugGAL. 1 • LF-ACW .-41 ?i T Uj t TV4 le WAiWED V---Z T i Lor-Av to LE=- ry- az C--Q C-f-- CE,'Cr,F"I T"AT T�,41E-- PL- 4. I--1 OF TWF- 41 IPL "OT BA-5 ED 0 U AU 1"sTIWAAEL4T OSTEtZvtti6AA d TWQ 7"OuLl> LAOT �5L L)I,F-r_> Tol.oT APPUCA."-r f\ WOOD DECK - SGNROOM I i LIVING ROOM DINING tl BATHROO BATHROOM NEW - - FV CLOSET ❑ -- CLOSET - BEDROOM 1 -� - 112 BnT — BEDROOM 2 — —'---------'—'— � BATHRM i i 1 KITCHEN - ❑ �I \ 2-CAR GARAGE -REDROOM 3 i i r FIRST FLOOR PLAN SECOND FLOOR PLAN 1/8"=V-0" 1/8"=1'-0" EXISTING CRAWLSPACE 4 mcADDlrlan - — . �•r aAmrox —_ .m XEW 268BI I L) - § m1 o I)W roi R.i U i . E q ar ® NEW e R S WALKdN CLOSET mBTINc z�s2 DN - 0 wlxoow XELauTEG. p EYIFNTOF _4 iaovE� h �� EXISTING BASEMENT - - BEDROOM i toe coXC F41E0 sDNDroBE Gx. _—___—__--_ A AIG FOOT FTG MIN.fQ BELOW ' GxAOE.BEARIXG ON UMISNXBEO - 7? , FLOOR PLANS DATE. DEC 21.NIB PROJECT: GREYWING DESIGN - BOGDANSq RESIDENCE FOUNDATION PLAN FIRST FLOOR PLAN SCALE: 114--1'-O' 117 COTOIT BAY M.,MARSTONS MILLS 131 QUAKER MEETINGHOUSE ROAD,EAST SANDWICH,MA 02537 ADDITION �� www.greyvAng.com (508)888-0886 ,,.�0,:,' °Oe ..°0B 8B°OB°° G181127 PROJECT NO: SHEET: OF2