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HomeMy WebLinkAbout0187 COTUIT BAY DRIVE - HealthIIIIIIIIIIIIIIIIIIIIIIIIPI- 187 COTUIT BAY MR, COTUIT A= 056-036 i G r ,k i N10: 42 10 1I3 5S LTE es e e a i of 7 (Nv i►C,A'(rati c Q i i A asp_0844 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments NJ 187 Cotuit Bays V Property Address Todd McGee Owner Owner's Na e information is Cotuit Ma 02635 2-18-2021 t, required for 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:When filling out forms A. Inspector Information 61 f 5(laO on the computer, Daniel Hawkins use only the tab key to move your . Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 as Company Address Sandwich Ma 02563 City/Town State Zip Code rada (508)477-0653 S114324 r Telephone Number License Numbe r e B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails { Dan Hawkins Digitally signed by Dan Hawkins r Date:2021-02.2211:03:32-os'gg• 2-18-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Cade Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3,or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. Original paperwork from town shows a 3 bedroom system. An inspection done in 2014 (also done by B&B) shows the system can accommodate 4 bedrooms per a conversation with Board of Health agent (2/10/2014). 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i { Commonwealth Hof Massachusetts Title 5 Official Inspection Form - w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address 9 Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection 'Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. l ❑ 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): } I ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 1 ❑ 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): ❑ obst ruction is removed ❑ Y ❑ N ❑ ND(Explain below): J 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system isl failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5lns .doc•rev.7/26/2018 Titl e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. Citylfown State Zip Code Date of Inspection C. Inspection Summary (Cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or . more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . ❑ a Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts _ - =- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :,,s 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town Satet Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow ❑ a 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. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ n Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ n 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ❑ 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit t Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (Cont.) 1 If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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? ❑ El Have large volumes of water been introduced-to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components,excluding the SAS, located on site? El ❑ 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: El ❑ Existing information. For example,a plan at the Board of Health. ❑ 0 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .�Pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town j State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.263(for example: 110 gpd x#of bedrooms): 440/GPD Description: System okay for 4 bedrooms per Board of Health agent. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes Q No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes [g No See below Water meter read`ngs, if available(last 2 years usage(gpd)): Detail: i 2020- 106,000gallons 2019- 139,000gallons i Sump pump? ❑ Yes ❑■ No i current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Co i to t Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped May 2020 Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 l Commonwealth'l of Massachusetts =__ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1`/ �;,. 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is required for every Cotuit Ma 02635 2-18-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overnow cesspool ❑ I-nvy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ lnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age;i of all components,date installed (if known)and source of information: Newest pit added to existing tank and pit in 1995 Were sewage odors detected when arriving at the site? i ❑ Yes FE1 No 5. Building Sewer(locate on site plan): 111011 Depth below grade: feet Material of construction: i ❑ cast iron ■❑40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t � ' l ' 187 Cotuit Bay Property Address Todd McGee Owner Owners Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 10" Depth below grade: feet Material of construction: R 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 1 Dimensions: 500gallons 5° Sludge depth: 31" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle measured 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.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts : Title 5 Official Inspection Form - y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ o 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: I ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): d 'I f 8. Tight or Holding)Tank(tank must be pumped at time of inspection)(locate on site plan): NA Depth below grad ie: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: 11 l Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is required for every Cotuit Ma 02635 2-18-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Or' Depth of liquid level above outlet invert Comments note if box x Is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay 1 Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber'(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): NA I * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: I r Type: 2 leach pits ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: El inn i ovative/alternative system Type/name of technology: t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. One pit was dry and the other was 1/2 full when viewed. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts /e ig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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: 0 hand-sketch in the area below ❑ drawing attached separately REAR. 2 At-39` 131.34'' A3.52` 63.4T. A4.w 134-W A5.80` 3 B5.9W: 4 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts ... _ - Title 5 Official Inspection Form ~ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1� 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: I Check Slope Surface water Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 10'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 El 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: A previous inspection report on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Cotuit Bay Property Address Todd McGee Owner Owner's Name information is Cotuit Ma 02635 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ■❑ B. Certification: Signed&Dated and 1,2, 3, or 4 checked ■❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ■❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 n WAS T7 j (NV 0 CO ra F I F to CO Postage $ ru M �,� � Certified Fee f. 0 C3 (Postmark Return Receipt Fee C3 (Endorsement Required) Here Restricted Delivery Fee AR -5 2014 p (Endorsement Required) rq Total Postage&Fees s ( C p S ru John H`Jr & Annetta D Hoagland 187 Cotuit Bay Drive Cptuit, MA 02635 Certified Mail Provides: • A mailing receipt n A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery°. o If a postmark on the Certified Mail receipt is desired;please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. I IMPORTANT,Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 7Aftach `itemsl,2,and 3,Also complete A. Si nature estricted DelNery is desired. - El Agent name and address on the reverse X < ; ter. 12addressee can,return the card to you. B. Receivediby(Panted Name) C. Date of Delivery s card to the back of the mailpiece, front if space permits. D. Is delivery address different from item 11 ErYes 1. Article Addressed to: If YES,enter delivery address below ❑ No � John H. Jr& Annetta D Hoagland 87 COfulil. Bay Drive 3.-Service Type Cptu lt,'IM, '62635 ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number :` " t`! 1• ' <� (transfer from service labeq t } {t}i 7 012 ' 1010`'0 0 0 0 2 8`51= 18 9 0 vl 1 PS Form 3811.,February-2004 Domestic Return Receipt, 102595.-02.M-1540; UNITED STATE`§"AdSTAEI� it ^' vist Clads 1�1i1 . 1cn J... ermit I " Sender! Please print your name, address, and ZIP+4 in this box• I I Town I Regulatory Services Department Public Health Division { M � ; 200 Main Street j Hyannis, MA 02601 • Town of Barnstable Barn BOARD OF HEALTH M*n1ftCW 1 MAW ` 200 Main Street, Hyannis MA 02601 I 639 A�� 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 000 2851 2026 March 5, 2014 Annetta& John Hoagland, Jr. 187 Cotuit Bay Drive • Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located 187 Cotuit Bay Drive, Cotuit,MA was last inspected on 1/30/2014, by Matthew Gilfoy, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5(310 CMR 15.00). • Distribution box is in "poor Condition" and needs to be replaced per report. You are ordered to repair or replace the septic system within sixty(60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH • Thomas McKean,R.S. CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\l87 Cotuit Bay Dr Cotuit Feb 2014.doc Town of Barnstable Barnstable BOARD OF HEALTH 1 I '^R" 200 Main Street, Hyannis MA 02601 O D �b1639. p�� 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012 1010 000 2851 2026 March 3, 2014 Annetta & John Hoagland, Jr. 187 Cotuit Bay Drive Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located 187 Cotuit Bay Drive, Cotuit,MA was last inspected on 1/30/2014, by Matthew Gilfoy, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5(310 CMR 15.00). • Distribution box. 1 You are ordered to repair or replace the septic system within sixty (60)days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\187 Cotuit Bay Dr Cotuit Feb 2014.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=3647 4F rt nN a w� .� 4BA ��F Logged In As: Pa rCe d�� Wednesday, February C'� 26 2014 Parcel Lookup Parcel Info Parcel 056-036 I Developer LOT 67 ID Lot Location 187 COTUIT BAY DRIVE ri _ Frontage158 Sec( Sec ----v Road Frontage Fired Village iC TO UIT District i`'OTUIT Town sewer exists at this Road r-0359-9 address'No _ Index? Interactive r '� Map � �.. ISG Owner Info Owner IHOAGLAND JOHN H JR&ANNETTA D Co-Owner Street11187 COTUIT BAY DRIVE Street2 City lCOTUIT � State.MA Zip[02635 I Country if Multiple Ownership Info % Owner Name Owner Address 50 HOAGLAND, JOHN H JR 187 COTUIT BAY DRIVE, COTUIT & ANNETTA D MA 02635 50 OJHA, HELEN D 68 BRADHURST AVE, APT PH-1-I, NEW YORK NY 10039 Land Info Acres 1.03 � Use[S—in leFam MDL-01 Zoning RF r I N hbd 0108�� ra ToP o9 P hY I 1Above Street ! Road Paved Utilities jPublic Water,Gas,Septic Location Construction Info Building 1 ®# 1 Year _ Roof Ext,- - -- Built 1983 Struct(Gable/Hip J Wall lWood Shingle Living r526 Roof!Asph/F GIs/Cmp AC Central http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=3647 2/26/2014 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is Cotuit _ Ma 02635 1-30-14 required for 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use key the return Name of Inspector �� B&B Excavation, Inc. ( g —IC=V Company Name 14 Teaberry Lane Company Address Forestdale MA_ 02644 City/Town State Zip Code (508)477-0653 S113640 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 1-31-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ms•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. CitylTown State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): ,. 3'.:r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. Cityrrown 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): D-box in poor condition with aggregate showing through concrete. D-box must be replaced. ❑ 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 I ,r, •3 1+ 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 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owners Name information is required for every Cotuit Ma 02635 1-30-14 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 99 P ❑ ® 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 enc-,• _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. CitylTown 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. t51ns•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 w 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is Cotuit Ma 02635 1-30-14 required for every - __ page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: t3i 3'1:? Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 _ - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5uu•3;1.. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 _-- - page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 - -Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'6" feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10"feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good working order with no signs of leakage. Septic Tank (locate on site plan): Depth below grade: 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: 1500 gallon Sludge depth: 4" t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive M Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1 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 15" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good working order with no evidence of leakage. Tank not in need of pumping at this time. Tees are in working order. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <�M r 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 5in5•3 t 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is Cotuit Ma 02635 1-30-14 required for every _ page. Cityrrown 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 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-Box is in poor condition and needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Now Alarms in working order: ❑ Yes ❑ No" Comments note condition of um chamber, condition of pumps and appurtenances, etc.): ( pump P P PP ) 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: T,irs•3 3 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 ° 187 Cotuit Bay Drive_ Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 _- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 6'X6' ❑ 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.): At time of inspection leaching appeared to be in good condition with no sign of hydraulic failure. System consists of 2 leach pits-Old pit still in use with water cut off at this time by an up turned speed leveler in d-box. New pit-water level 4'6" below invert with stain line 3' below invert 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 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every 'Cotuit Ma 02635 1-30-1:4 . page. CityNown. 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 wellswith.in::1`00 feet. Locate where public water supply enters the building. Check one of the boxes below:: hand-sketch in the area below ❑ drawing attached separately C?Af O A� • 3�' '9 Z 4 5' 3 O A y /A 5 80' Q2 7q' GAS'- 90` } t5ins+3113 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts r W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >10"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: Used usgs topo maps You must describe how you established the high ground water elevation: see above 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 187 Cotuit Bay Drive Property Address Nettie Hoagland Owner Owner's Name information is required for every Cotuit Ma 02635 1-30-14 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 No. 201 q— 06 Fee ( VYe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS flplitation for Disposal *pstrm Construrtion Permit Application for a Permit to Construct( ) Repair 6) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / r-1-LSD. •Jf Owner's Name,Address,and Tel.No. Assessor's Map/Parcel esk —ia3 In taller's e A tress and Tel.No.�''�-yQ D-%f j'$ Designer's Warne,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 9A- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Alk gpd Design flow provided /� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ZVjag 11 //=,4i/ Z2 -&aX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. d Date Application Approved b - Date // Zd i Application Disapprov Ky Date for the following reasons Permit No. 7,01q—06 5 Date Issued J111 IZ,.,1�f No. !o' W �( FeeVYe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLHEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS pplication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair 6) Upgrade,( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No'. / Q D C •4Fwner's Address,and Tel.No: Assessor's Map/Parcel s In taller's Nape,A duress,and Tel.No.��—ya O-9'/3 e,Address d Tel.No. Type of Building: \ Dwelling No:of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.fPersons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow(min.required) ad ' n o g � gpd Plan Date Number of sheets Revision Date Title // Size of Septic Tank / Type of S.A.S. Description of Soil ^ M Nature,of Repairs or Alterations(Answer when applicable) Date last inspected: - Agreeingt f I The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ,i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of HealthISV . d Date Application Approved b Date 371111Zvlq Application Disapprov y Date for the following reasons Permit No. ZOtq — 065 Date Issued 3/14?111y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance _ THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) } Abandoned( )by at / > `�t�/i���' Cs �,l, TL/% has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Ob h dated T61 Installer /oi!,ci� //���j, ��'G?s� Designer #bedrooms Approved design flow gpd The issuanee of this permit shall n t be construed as a guarantee thafthe system wil1junetion as designe� !. Date � *:� Inspector No.201 L I —06 9 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal �&pstpm'Constrt1cti0n permit Permission is hereby granted to Construct( ) Repair(ZC) Upgrade( )``'^ Abandon( ) System located at 7 60 till T ?,4 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date �� � ' 20 1 Approved by ---�' O 7.3o Date: - — 1 ! — Scheduled For: / D 1 . Ex���v�l,i4lrn REQUEST FOR TITLE S INSPECTION Address: _Rn Y r Requested y: aL)Ll t NP-anti owners Name: e, Hinnn l Phone#: FaX#t Email Address: r/ Mailing Address: ' Iv # Bedrooms: #Residents:J� Last Occupied: Year Round? Town/Well Water: J D W n Last Pumped?_J)n L(1aw n Garbage Grinder? Laundry Tied into Septic? Water Usage Last 2 Years: L7 Referred By: U� \� Additional Info: f i Amount Due: E �C.�kr'a;i f o ��u•n c,nc� US cob a.- )'t,l)z I INi'v__ Title Five Inspection& Report r Town Fee Additional Charges TOTAL To Be Paid By: Report to be sent to: I contract B&B Excavation, Inc. to perform a Title Five Septic Inspection at the above referenced property. I verify that the information completed on this form is correct. I understand that S&B Excavation Inc. is not responsible for damage to any in,gr"ound irrigation, If damaged during inspection. Signed: 6 / 6 # 9LVL£6bbLL' b0£906L809:01 W0a=1`•WVVZ:20'66-L6- a � 03 NO... .... �CJ FEE.....�P....at�l.a.Sl..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphrativit for' Di-nVit Sal Workii Towitrnr#ion Frrinit Application is hereby made for a Permit to Construct ( ) or Repair kX�Xan Individual Sewage Disposal System at: ............j$.7----Cat>aid...?3Ay.--Dxime...CQ tuit......... -------------------------------------------------------------------------------------------------• Location-Address or Lot No. ............murl:ay...............••-----••----•-••----- •----•----- --------------------------------------•--------------------------•----........-----.....------.... Owner Address W J,.P...Ma.CBelk?ex_..J.r.-......................................... Installer Address UType of Building Size Lot............................Sq. feet ,.., g 3-----------------------------_-.Expansion Attic ( ) Garbage Grinder ( ) aOther—Typein oof Building n---------------------_.-.- No. of persons.......................... Showers ( ) — Cafeteria ( ) a W Other fixtures .-- Design Flow----------------------------------------------gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity.-.........:gallons Length................ Width....-..-..------ Diameter----__-. ..... Depth................ x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...----_---_------ Diameter-------------------- Depth below inlet..........-.-.------ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Perfor med by-------------------------------------------------------------------------- Date...................................... Pi --mnutes .. per inch Depth of Test Pit..-.-_------------- Depth to ground water......................-. (T Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ P4 ----------------------------------------------------------------------------------------------------......................................................... 0 Description of Soil.................................' U ------------------------------------Re, -im---S.and.....................................................................-------...................................................... W ............................... --------------------------------- ----------------------------------- --------------------------------------------------•-•---•---------------•----------•-•••--------- U Nature of Repairs or Alterations—Answer when applicable.l.--1.0.0.0---gall-onleaeh--pit---added...ta...... - ------t he---,-xis-a-n-g---tarok- &---pit......System---la--- n----fa I Iur-&------------------------------------------------------------ Agreement: a .bow_ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by he board of h alth. Signed fit.. 5..�.�.9 9..5 ------ I Date Application.Approved BY ........... l.�/. -.. ..� 0?-1T�.-� Dare Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------- ................ ..............`...... ........................... ............ Date Permit No. .'.:..15 .6..._... Issued �� ----- Date =� ._ V/ -53 ,,.. Fss.... ..... �.A.�1..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioit for lio tjoul` ork C�oBto rnr fon rruttt Application is hereby made for a Permit to Construct ( ) or Repair 'tX?kknn Individual Sewage Disposal System at: ............ ......... ------•---.....----•----•---------------•------------•--.......--•-•--•-•-•--.......----•---•--••. Location-Address or Lot No. .._..........!............------•------•---------------------•-•----•--•------••-----•• --................................................................................................ Owner Address a •--.........J� ...MaccamhPx..� .a ::�t,........................ -------------------------------------•------•-------------------••--••••-----•---------•••.••---- Installer Address Type of Building Size Lot............................Sq. feet Dwelling fir.No. of Bedrooms.........3---------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOther fixtures ----------------------------------------------------------------------- -------------- -------------------------------------------------•-------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity.---------.gallons Length---------------- Width.----.--.---_-- Diameter--.......---.... Depth.............. x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No...................... Diameter..................-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. 1................minutes per inch Depth of Test Pit-.------------------ Depth to ground water..-___--.--.-----.-..- <, f? Test Pit No. 2................minutes per inch Depth of Test Pit--------.----------- Depth to ground water........................ ...................------------------------------------------------------------------.-------------------- "Description of Soil........................................................................................................................................................................ V ..................................... edium__$and---------------------•--•-•-----------•---------------------------------------------•--------•---•--------------•---••-•-----••••••. W UNature of Repairs or,Alterations—Answer when applicable.1--1.0-0.0...ga-1_ Axl_lea-crl..-Pit...a.dded...to....... ............ &....p t 5y..%t tad Agreement: cE` I;- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bythe board of health: Signed ........ -. ... ... f���'f///,�..' .... .....5/1 9/95 . r Date A lication Approved B .�.. ---� ' c -- PP PP Y ✓Z_ Dale Application Disapproved for the following reafonf: ----------------------------- ----------------------------------------- ------- --------------------------------------------- --------------------------------- -------- ---------------------------------------------------------------------------------- /) y..�...- ------------------------------------------ Date Dale Permit No. >.S .. ... ... Issued ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE tLrdifi ate of 01-11IImplii nre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedXXX ) by .......J....P....Macomber_ Jx------------------------------------------------------------------ _ ------------------- ---- -- ----_--------------------------------------------------------- ��,ta��et at --------1-8. ----CQt-ui.t----1-ay....Dr-i-ue.-COtui t ---------------------- ----------------------.--------------------- --------------.-...----------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No.9_. ---'.. --------- dated ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r C�' -•� r DATE - .............�.-.W 1:•�1............. - Inspector -------- --�--- ---`--............ ............ ------ ---------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq No.--- _ ���� TOWN OF BARNSTABLE FEE... .•-•3n• -..0 d-._.�..:........ .. ----........ Ropooal Workv Tonotradion "rrntit Permission is hereby granted...)t P M CAmber___,Tr.> to Cons r c� ) or Nair (4X) an Individual Sewage Disposal System � �/ �otuit ay Drive COtuit atNo.. -- --- - ---- ------------- Street Street ss // ` as shown on the application for Disposal Works Construction Permit No.95.-� +Dated-- J.-�:'7f-..��........ ^/� Board of Health DATE.-----...... ---------------'--- -r..................................... FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS Via+ DATE:_ 11291D0__- PROPERTY ADDRESS:�8.7 ----------- ---Q2-L35----------------- 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. S( Ca 6 2 . 1-Distribution box . 3 . 2-1000 gallon precast leaching pits . Based on my Inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5 . 'fihe septic system is in proper working order r- at the present time . - - 6 . Waste _present pit is 59" below invert pipe .Old pit is dry . ( as designed ) SIGNATURE: Company: J e•Rh_P_ Macomber—& Son, Inc . Address: Box 66-------------------- __CentervilleL Ma__02632-0066 Phone:_ 508 775_3338 , ---- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P, MACOMBER & SON, INC. Tanks-Cesspool:-Leachflelds Pumped & Installed Town sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 RECEIVED t 0 8 2000 TOWN OF BARNSTABLE HEALTH DEPT. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROmCTION ONE WINTER STREET, BOSTON MA 02108 (617) 292•6600 TRUDY CO Secret ARGEO PAUL CELLUCCI DAVM B. STRU Governor Corn m i- io SUBSURFACE SEWAGE DISPOSAL SYSTEM-WSPECT)ON FORM PART A CERTIFICATION 187 Cotuit Bay Drive Property Addr*": Narn.ofOwna, Bruce & Vivian Antonangeli Cotuit ,Mass . 02635 AddressofOwner: 187 otuit Tay Drive Data Oflnspecoon: 1/29/00 Joseph P .Macomber Jr , Cotuit ,Mass . 02635 Name of kupector:(Please Print) P 1 am a DEP approved system kupector pursuant to Section 15.340 of TWe b(310 CUR 15.000) Carry Name: J. P.Macomber & Son Inc . Maau►g Address: Box 6 6 � r o z a,-Mass . . 0 2 6 3 2 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below Is true, accurate and complete as of the time of 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: r Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Falls Inspectors Signature: u Data: r The System Inspec ,hail submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wtWn 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 ktspettor and the system owns shall submit the report to the appropriate regional office of the Department otrEnvironmetual f'ratectlon. The original shouldlm,sent touts system owner and copies sent to the buyer, It applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page IofII i,Printed on R"Ied Paper ' 4y� c. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTiRCATiON(continued) Property Address: 187 Cotuit Bay Drive Cotuit ,Mass . owner: Bruce & Vivian Antonangeli Data of Inspection: 1/2 9/0 0 INSPECTION SUMMARY: Check A, B, C, " A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any failure .criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass'section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfUtration, or tank failure is imminent. The system will pass Inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipes) 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 - The system(squired pumping-rnore thanlour•tfines s yeardus to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pips(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) p,.opeirtyAddiress: 187 Cotuit Bay Drive Cotuit ,Mass . Owner: Bruce & Vivian Antonangeli Data of motion:l/2 9/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 46_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING W A MANNER WHICH WILL PROJECT THE PUBLIC HFALTILAND SAFETY AND.THE ENNZONMENL• Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ,( The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid).- 3) OTHER revised, 9/2/98 P2ge3of11 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property A eu. 187 Cotuit Bay Drive Cotuit ,Mass . Owner: Bruce & Vivian Antonangeli Date of Inspection: 1/2 9/0 0 D. SYSTEM FAILS: You must Indicate either "Yes" or"No to each of the following: ') 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of-sewage Into fecihty w-system component-due tto an overbsded orclegged-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 di i ution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth' 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 0 - Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for »coliform bacteria,volatile organio•compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd of greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within:400 feet of a surface drinking water supply / the system-is-withir;200 toot of-0441Dutary-to-6 4Urf60"rir"49-w41ter•-6upp1y• v the system is located in or nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforp►etion. Y i • 1 revise 9/ /d . 2 9 8 Page 4 of 11 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pn*mtyAd&*"• 187 Cotuit Bay Drive Cotuit ,Mass . . owner: Bruce & Vivian Antonangeli Date of Inspection: 1/2 9/0 0 ROW CONDITIONS RESIDENTIAL: Design flow: /la g.p.d.lbedro Number of bedrooms ldesigr�: Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) as or(g._; If yea, sepamto-kupection.required Laundry system Inspected or no) Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): Last date of occupancy COMMERCIAL/W DUSTRIAL: LA Type of establishment: Design flow: A�4 and (Based on 16.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)ld/d Non-sanitary waste discharged to the Title 6 system:( es or no Water meter readings,If available: Last date of occupancy:_ OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sou c of information: I System pumped as part of Ing ection:(yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE gi1SYSTEM ptic Septic t tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous Inspection records,if any) I/A Technology a c.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE APE of all cwnponents,date InstallediifLk�nown)•end�s#urceo 4229 CW*rmation: f;•• &4��:�A - - /U�'iU4GluYJG9.67 Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 Page 6of11 i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTiON FORM PART B CHECKLIST Property Address: 187 Cotuit Bay Drive Cotuit ,Mass . owner: Bruce & Vivian Antonangeli Data of 4►spec km:1/2 9/0 0 Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: Yes No f� Pumping information was provided by the owner,occupant,or Board of Health. None of the system•compouants.hak%Lbwn puwVad4aPmtJeasi two•awaake sad-tbe'systom h"J;"agscaiaiaywwsal Jlow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. 7Z _ As built plans have been obtained and examined. Note If they are not available with N/A. _ The 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. _ All system components;aEC'' luding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soli Absorption System orrthe site has been determined based on:.- Existing information. For example,Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C Is at Issue,approximation of distance is unacceptable) / 115.302(3)(b)) The facility owner.(and.----p-at ,.Jf didar&U frcat o nar),srcerapraxidad with iafauaatJoaan tha prcp g malat—s ^f SubSurface Disposal Systems. revised .9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrea: 187 C o t u i t Bay Drive Cotuit ,Mass . Owner: Bruce & Vivian Antonangeli Data of Inspection:1/2 9/0 0 BUILDING SEWER: (Locate on site plan) It Depth below grade:-; Material of construction•_cast iron Z40 PVC other(explain) Distance from private water supply well or suction line•/e Diameter venting,evidence of e,-etc.) Comments: (condition of joints,ve g, haka9 Joints appear tight No evidpnrp of JAnVngo SEPTIC TANK: (locate on site plan) Depth below grader Material of construction:ZconcreteI-V metal aFiberglass,4LPolyethylene,t Lother(explain) Th If tank is metal W r,�, Ulist age 1s.age-confirmed by Certificate of Compliance A(Yes/No) Dimensions: � f f U11dr, Sludge depth: Distance from top sludge to bottom of outlet tee or baffle z Q, Scum thickness:, . Distance from top of scum to top of outlet tee or baffle;lL�GL Distance from bottom of scum to bottom of outlet tee or baffle:. How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth)of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.)-! VUMP tank every 2-3 years Inlet & out-1pr rppg are in place Liquid dprh at _the �ut-let irty®s>; is fifty nnp i nrhaq The . GREASE TRAP: e. (locate on site plan) Depth below grade: Material of construction;lconcretelAmetal4Fiberglass4i4Polyethylengaother(explain) AA Dimensions: Scum thickness: Distance from top of scum to top of outlet tea or baffler Distance from bottom of scum to bottom of outlet tee or baffle:/ Date of last pumping: /U/T Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity, evidence of leakage,etc.) Grease trap is not prPqPnt revised 9/2/98 Page 7of11 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) Property Address: 187 C o t u i t Bay Drive C o t u i t ,Mass . Owner: Bruce & Vivian Antonangeli Daft Ofk-P--don: 1/2 9/0 0 TIGHT OR HOLDING TANK:J,�&,(Tank must be pumped prior to, or at time of,inspection) (locate on site plan) Depth below grade:—A2? Material of construction:42concrete ametaltA Fiberglass/APolyethyleno4 other(explain) Ah AA --- Dimensions: 4 W Capacity: 414 gallons Design flow: gallons/day Alarm present AM Alarm level: Alarm in working order:Yes Norio Date of previous pumping: AM Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tank.-, ara not pracant DISTRIBUTION BOX.z (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note-if level and distribution is equal, evidenoe of solids carryover,evidence of leakage Into or out of box, etc.) — -— is rl ution box has two laterals . No evidence of solids carry over . No evidence of 1Pnknga intn nr not of tha box. PUMP CHAMBER:4� (locate on site plan) Pumps in working order:(Yes or No) Alarms In working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Puma chambpr is not pra.ant revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTi7M INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddreu: 187 Cotuit Bay Drive Cotuit ,Mass . Owner: Bruce & Vivian Antbnangeli Data of trupec'io`t:l/2 9/0 0 SOIL ABSORPTION SYSTEM(SAS);_[_,/ (locate on site plan, if possible:excavation not required,location may be approximated by nondntrusive methods) If not located, explain: Type: leaching pits,number:,, leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number: Alternative system: /! Name of Technology: (,1J Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to coarse sand No siRns of h3rdran1 i r fai 1 circa nr pnnding .—Coo are—dFy . Veget:atj:efi �s nereta-1 CESSPOOLS:_Oq/e (locate on site plan) Number and configuration: 17 Depth top of liquid to Inlet invert: Depth of solids layer: Depth of scum layer: Dimensiohs of cesspool: Materials.of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Cesspools are not nrPePnt Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of=vegetation,etc.) -Cesspools are not present . PRIVY:&e- • (locate on site plan) Materjals of const on: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not prPsent revised 9/2/98 page 9orIi i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contInued) Property Address: 187 Cotuit Bay Drive Cotuit ,Mass . Owner: Bruce & Vivian Antonangeli Date of Inspection: 1/2 9/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) b �y �a ---0 00) NG �)xLd revised 9/2/98 Page 10of11 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimsed) Property Address: 187 Cotuit Bay Drive Cotuit ,Mass . Owner: Bruce & Vivian Antdnangeli Date of Inspec:1/2 9/0 0 NRCS Report name Soll Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please Indicate all the methods used to determinq High Groundwater Elevation: �'�Obtained from Design Plans on record C/,9bserved.Site(Absutina property, bservation hole,basement sump etc.) ZDatermined from local conditions Checked with local Board of health Checked FEMA Maps -zChecked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water Contours Map . Gahrety & Miller MOdel 12/16,/94 revised 9/2/98 Page 11oru •r.wnr+.-...Tv�•Te- n.-a.n•nswnr•nvl rnrRRr.7PT1+s.►l�T�.'IIn'1 rr�A1Y A-wt-1�T TOWN OF Barnstable BOARD OF IIEALTII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••TI.1^T•'.-:'.-T.111t^.TTTIT T.T1•A.1I.T9RIf�1TA11T'r^{•i TgV.R11.RR7►-TEA►�RRt A•1. •TI'T'1+1r -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS _187 Cotuit Bay Drive Cotuit ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Bruce & Vivian Antonangeli PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J. P.Macomber & Smcln' Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City state LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system w 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 . Che ck ne: System 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 con ted has found that the system fails to protect the public 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 Date Jail ,. ecopy of this c rtification must be provided to the OWNER, the BUYER On where applicable ) and the I30ARD OF HEALTH, * If the inspection FAILED, the owner or operator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd.doc N®•------- •- -- Fmc.....$_....3 Q-a--Q.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABL.E Appliration for i-ripaiial Works Ton.6trur#ion t1nnfit Application is hereby made for a"Permit to Construct ( ) or Repair ]kXkkn Individual Sewage Disposal System at: ............. $-?--C_QtUit---4ey•--DX_i e...Co-t-ult.--------- ------•------------------------------------------------------------------------------•------------ Location-Address or Lot No. ............murrAy-..................................................................... ----- L. Owner Address W , a ............. -------------------•------------------- ............................................ Installer Address Type of Building Size Lot----------------------------Sq. feet Dwelling-X No. of Bedrooms.........3_--------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of ersons____________________________ Showers — a YP g ---------------------------- P ( ) Cafeteria ( ) a4Other fixtures -----------------------=-------------------------------•-----------------•--•----------- W Design Flow---------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv---------___gallons Length................ Width----------------- Diameter---------------- Depth-............... x Disposal Trench-No_ ____________________ Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching"area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ rZq Test Pit No. 2________________minutes per inch Depth .of Test Pit__-_____________--__ Depth to ground water........................ P'r = ---------- •--------------------------------- -------------------------------- --------- -------------- ODescription of Soil-----------------------•---------•--------•----••---•--••----•----•-----•------------------------------------------------------------------------------------------------ -----------------•••••Medium•--Sand--------------------------••-- W UNature of Repairs or Alterations—Answer when applicable l_-1.Q_Q-Q___gall-onleaGh__pit___add�ed-__to.___._. - ---- - ---tank---&---pit......S-ystem---i-s---ire---fa1jur&............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by he board of h alth. Signed ....... ....... .....51.1-.9 5--------- Da Application.Approved By -------------------- ...... ". .... .- Date Application Disapproved for the following reasons- ............................---------------------------------------------------------------------------------------------------- - ..................-------------------------------------------------------------------------=------------------- ----------------------- - - ------------------- Permit No. ..................... Issued ------ Date - ------ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, J.P.Macomber Jr , hereby certify that the application for disposal works construction permit signed by me dated 5/2 2/9 5 , concerning the property located at 187 Cotui t Bay Drive Cotui t meets all of the following criteria: /There are no wetlands within 300 feet of the septic stem proposed P sY t/There are no private wells within 150 feet of the proposed septic system /The observed groundwater table is 14 feet or greater below the bottom of the leaching facility t� here is no increase in flow and/or change in use proposed There are no variances requested or needed. J SIGNE DATE: �d1 LICEN SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r.. Mal SENDER: • I also wish to receive the y • Complete items 1 and/or 2 for additional services. N • Complete items 3,and 4a&b. following services (for an extra V U Print your name and address on the reverse of this form so that we can feel: > 4) return this card to you. > • Attach this form to the front of the mailpiece,or on the back if space 1. El Addressee's Address N does not permit. ., t • Write"Return Receipt Requested"on the mailpiece below the article number. a « 2. ❑ Restricted Delivery • The Return Receipt will show to whom the article was delivered and the date V c delivered. Consult postmaster for fee. rx a> 3. Article Addressed to: 4a. Article Number e54/ /� C d 4b. Service Type � E ❑ Registered ❑ Insured CM 12 Certified ❑ COD c W El Express Mail ❑ Return Receipt for Ix Merchandise 7. Date of Delivery e (A dr se 8. Addressee's Address(Only if requested Y e and fee is paid) ISM4lure gent HPS Form 3811, December 1991 irU.s.GPO:1983-352-714 DOMESTIC RETURN RECEIPT i UNITED STATES POSTAL SERVI �, Mq O PM �� •.�. .. � 0i C Official Business PE PRIVAT i� �895 USE O ID I I I Print your name, address and ZIP Code here I BOald of HMft Town of BamSt8b1A P.O.Box 534 • Hyannis,Massachuni tS 0=1 9 A Z . 348 641 �i4 Receipt for. Certified Mail o No Insurance Coverage Provided �� Do not use for International Mail (See Reverse) Sant to rn t Street and No. P.O.,State and ZIP Code QPostage C) E Certified Fee O u- Special Delivery Fee Restr`ii.7ed^D'eliarr,/Fee' i I �Fie`ttiTn R`eceip$$Tiowirig� � to Whom&-Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL Postage &Fees Is Postmark or Date STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address In leaving the receipt attached and present the article at a post office service window,or hand it to your rural carrier(no extra charge). 0� 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach and retain the receipt,and mail the articles L 3. If you want a return receipt,write the certified mail number and your name and address on a I return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. co 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, M endorse RESTRICTED DELIVERY on the front of the article. 0 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If tL return receipt is requested,check the applicable blacks in item 1 of Form 3811. W 6. Save this receipt and present it if you make inquiry. 105603-93-8-0218 Town of Barnstable �tvsrests, i Department of Health, Safety, and Environmental Services b9. �� Health Division 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A. McKean FAX: 508-775-3344 Director of Public Health May 30, 1995 TO: David Murray 187 Cotuit Bay Drive Cotuit, MA 026 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 187 Cotuit Bay Drive, Cotuit was inspected on May 12, 1995 by Joseph Macomber/Peter Sullivan a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Liquid level observed above leaching pit(hydraulic failure) You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF BOARD OF HEALTH IS 3 Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health ASSESSORS MAP N0: . PARCEL N0: [Installer letter] TO: DGj,c\ hAu rra (Date) ftl 'Z(ar-� tS ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at ( "1 CAI J?gK ,D LIJC was inspected on M2y by T4s%h oPco,,,Lc -xMassachusetts licensed septic inspector-.V The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: C You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable l (sue I t 1 i is DATE:_5/2/95 --- PROPERTY ADDRESS:__1 IZ CD±a i t- .Bay—I)rLv-&-- Cotuit,Mass . --- 02635--------------- On the above date, I Inspected the septic system at the above address. This system consists of the following: A. 1 -1500 gallon septic tank. B. 1 -distribution box. . c. 1 -1000 gallon leach pit. Based on my inspection, I certify the• following conditions: This is a title five septic system. ( 78 Code ) . The septic system has failed. The - system is operating at full capacity and breaking out on ground-.The septic system should, be .upgrad(cd by add ing an additional leaching area. Owner has agreed to do so. ( 5/12/95 SIGNATURE: .��__ • Name: Company: J-P_Macomber &-Son_Inc. Address:_130x_66 ________ Centerville _NWz,_Q2-632 Phone: 508-775_-3338-- r THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 1 (667 CC7TU +-t A\( 2 j N 99S' ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , Address of;:pro' erty Owner 's na'm'e; .;: fJ.: 0,4v1dGflQlg 4Y Date of Ir. .?ection ,6-•.r;Z- 9 PART A CHECKLIST .. Check if the' fo;lowing have been done: _ Pumping 1 . formation was- requested of the owner, occupant, •and Board of Health•a,:. . ✓ None :°o ! ! system components have been pumped for at least two weeks ands)"stem has been receiving normal flow rates during that perio ;:.::. ,arge volumes of water have not been introduced into the system''re ently or as part of this inspection. °Alans 'have been obtained and examined. Note if they are not avaik bl 'Mth N/A. The facility .or dwelling was inspected for signs of sewage back-up ;•,. .';: g . y The site was inspected for signs of breakout. y All sysem•'components, excluding the SAS, have been located on the site The s:ept' •c��tank manholes were uncovered, opened, and the interior Of the septic tank was inspected for condition of baffles or tees, material` of construction, dimensions, depth of liquid, depth of, sludge;;`'..:e.pth of scum. The size and location of the SAS on the site has been de on existing information or a determined based approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided. with information on the proper maintenance of SSDS. 01 1,4 OF i2ecov_n qe: "cp,-q0 �,P �� S � �(� ►tit,P �`�'�� e 3. 2 ..� E SAS `o (-� -T-'►-LE: 5 N_54 e©uI VALE_�% 2 S' r SUBSURFACE SEWAGE DISPOSAL SYST EM INSPEC PART B TION FORM r f:. SYSTEM INFORMATION FLOW CONDITIONS ' If residential number'„of, bedrooms number .'of. currenb .residents garbage grinder,' yes or no, �. laundry connected to system, yes or no seasonal .use., ,yes.. o,r.::.no If nonresidential, calculated flow: Water meter ;re •:.: :, adin s ' 9 sf available; 92193 P 93/94 z14 , .0a0 s G.PO4 L E Last date:of:.occupancy . -GENERAL . INFORMATION Pumping records and source of : information: System pumped as part of inspection, yes or no if yes, volume pumped ' Reason :for.,pumping: Ty a of s�stem .. . .; I " Sept °b tank/distribution box/soil Single 66`sspool absorption system Overflow, cesspool..; Priv ' Shared system. (yes or no) (if yes, attach previous inspection records, if any) a Other (explain) , Approximate age of all components. Date information: installed, if known. Source' o ... P �STx�LL Nl A►2c_N � � � Sewage •odors :detected'when arriving at the site t . , yes or, no g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORKATION. continued ' 1w•' SEPTIC TANK: (locate on...site plan) depth below•:gr_ade: 1 :.r material o;f" cori.struction: _concrete metal _FRP _other(explain) dimensions,: erAt1_U" ko'_P" ' k 57-c sludge..depth 'distance' from 'top of sludge to bottom of outlet tee or baffle scum thickness distance: f.rom top Of scum to top Of. -Outlet tee or baffle distarjg-, f,rom bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity : - - evidence of; leakage, recommendations for repairs, etc. ) \,,c I, S C)(-I - C c>UL_D ; DISTRIBUTLON:.:pqX: (locate on. ste plan) Ar 02 Ae WF_�' epth of liquid level above outlet invert _ Comments; (note if level' .and .distribution is equal, evidence of solids carryover,evi ence of Ileakage into or of of box, recommendation for repairs, etc.) k 12CRA,l - S PUMP 'CHAMBER'.*?.". 14� . (locate On' ste`plan) PUMPS' in working order, yes or no + } Comments: (note condition�'of pump chamber, condition of pumps and appurtenances, recommendations' 'for maintenance or repairs,etc. ) MAY. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E PART B I SYBTEM ' INFORMATION continued SOIL •ABSORPTION SYSTE M . (locate —on—site plan, if possible; excavation not required, M approximated by non-intrusive methods) but may be. ,ry If' not dete.rmined .to be present, explain: Type leachin g pits and number leaching chambers and number l C)m&a4zCfJa.,t leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions' overflow Cesspool, number • . I gip. Comments: (note_'condition of soil signs of h ydraulic failure, level of, pondiri condition of vegetation, recommendations for maintenance or repairs etc: E L% OU l . L.6Yr-l_ S Vt OILS �(6,LQ �o� 501 c.. A&>�lG _) UVL (UT O F �LT� CAS S Oa c2 —CC�vt�tNt .CESSPOOLS•.:.(.locate -on site 1 .. ._.. plan) : .. number and configuration ° P p- of liquid 'to inlet invert depth of solids layer I. depth Of -scum layer dimensions of .cesspool t .x materials of ,construction I indication• o.f groundwater i inflow -(e'9sspool must. be .pumped as S Part.:of.';inspection) ,< Comments, a (note condition of soil, signs of hydraulic failutY condition of vegetation, recommendations for maintenanceleve o ponding, orrepairs etc. ) i • I PRIVY:' locate • �( on site plan) � :,•, materials �of construction IuQh1 �= dimensions. xt depth of solids {. Comments: . note iti .... . � co n 0 n of soil, signs hydraulic failurel - level of.ponding, } condition of, vegetation, recommenen dations for maintenance or re • ._ . Pairs, r. t g urr �,4 MAY Z '' }} SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF ,SEWAGE DISPOSAL SYSTEM: . include t"ids to at least two permanent references landmarks or benchmarks . locate all wells within 100' h£I. .Q�, Y� DEPTH TO:GROUNDWATER depthgroundwater met�• od. of determination or approximation: �5�C-�U t nl rt, �p -r•�ST. 1 S u2_O i CC'� 1�/ 1 �/� �— �TL� 1 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I FAILURE CRITERIA Indicate:' yes, no, or not determined (Y, N, or ND) . Describe basis of determination., in all instances. If "not determined", explain why not) Nia Backug;;.:of sewage into facility? v ,1 'sco,�'2.,�t1Dty O�= SotC. ,alZC>vC SAS C-c>,jp_0_ H`lanAUL%C- FA,%4_UeE; `LDischarge or ponding of effluent to the surface of the ground or surface waters? St kAS or-- fd LK. '' ' Static 'liquid level in the distribution box above' outlet invert? SAS Liquid- depth in <6" below invert or available volume< 1/2 day y Required pumping 4 times or more in the last year? number. of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank- failure imminent? Is any .. ortion of ' the SAS, cesspool or privy: below ) the high groundwater elevation? �b within '5.0, feet of a surface water? within . 100 feet of a surface water supply or tributary to a surface water supply? with.in.,a,.2.one I of a public well? ��... within 50 'feet of a bordering vegetated wetland or salt• marsh (cesspools and privies only, not the SAS) ? I�10 within 50 feet of a private water supply well? �D 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 grganic compounds, ammonia .nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION Inspector : Peter Sullivan PE Location : 187 Cotuit Bay Drive,Cotuit Date : May 2,1995 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. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Please note the summary of recommendations provided in the text of this report. V truly yours d leter Sullivan PE Distribution: Original to system owner OF Buyer Board of Heath PC n SULLIVAft No. 29733 °e �13T6A�,� AL s I v �OpA.i ;l d•1 _.tea"S''V .,,y t,. �. �, n .-- , art Q v p 5 O xr 7 bS y ?1 /r . O 15 ,P. 7 a• .4 ! R t 1 IM1 ,� a < \ q'Q'�Qf" q +y .GS _q'ys ;,:. .y t •!S } d x ` 4, Z:. E P S.Y C t t , t V ..y r- r i ", !;. ,W `/��/ s y r If, r. o t ,/ w' .. } " s 1- a r. a ,.5. f r , s .+:r - - 'e �:.oYJ 4 1 , f STgLL ON K Y . x N < y / - a ,. r y.� ;e� - i. ¢i _ t 'ilk ,4D t 9. T t 1 t , 1 .' .*'1� ya, re d tt_ !' °r} 1, -! r r '4, r S` .{ 1 Tt,.y t. { t. ' 1 e , e . Po:,00 ems. oo`oo 31 r\ s $t �� { ��� � N �;, % ? 1NS {t � '� i,tx) L "' yiaft �f 1+: F64—. } -d .q :/� rip'' ,tt r e? _ "t'.. P rl "'ten , r'i't✓C^,.a;Q 1+ ° µlt' �.A- 3` , - e s F \ c.= ;. wo .. 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TOWN OF BARNSTABLE LOCATION /97 CoQ, #'6� — SEWAGE # VILLAGE CCjU ASSESSOR'S MAP & LOT O INSTALLER'S NAME&PHONE NO. Vyl laG�7r►hb e�' SO t1 !aC SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Tas '4-5 (size) t 000 NO.OF BEDROOMS BUILDER OR OWNER M .A6464 PERMITDATE: ___COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Z , �p CpAs--r - q � 1 � � g � s ofO w � /cND TOWN OF BARNSTABLE LOCATION e1�/ a�/� vy ,f/��11N� SEWAGE # VILLAGEo/arr' ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS - PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VA,RIANU GRANTED: Yes No O � o lei co -rulr ISAy 0 ,<. No.... FEB .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF Appfiratiou for Uhipasal Works Tomitrurflutt ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ....PR ......................................................................................... Location-Address or L(0)No. .............................. ------- Ojwno,.;— Address ------------ ------------ .............................. ...... ..�4 Installer Address U T of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.-.',2................................Expansion Attic Garbage Grinder �4 PL, Other—Type of Building ............................ No. of persons.....................--..--. Showers Cafeteria Otherfixtures .......................................................... .......................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid'capacity/0—Mallons Length................ Width---............. Diameter--.---.......... Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...-----.---.--..... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) . Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................--. fTq Test Pit No. 2................minutes per inch Depth of Test Pit..--...._....--..... Depth to ground water.---................---. 1:4 ......................................................................................................................................................... 0 Description of Soil...................................................................................................................................................................... x U ...................................................................................................................................................................­.........................---------- ........................................................................................................................................................................................................ 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'1I'L U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee rl issue 4 by the b9ard of 11r. Signed......... ........ ......... ate ApplicationApproved By.....................................?................................................. ....................D'a't-e-------------- Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date ML...... ML Fimic ..Z.V.__............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................... ...............OF............... ApplirFation for Uhipoii al Works Tomitrurtion r ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location_Address �— or Lo o. •- .... �.T<_1��......--_.lam_r /.� .4 -�' ,� s": ' O r t Address �2. .. wne ...1. ..s Y Address a •------ ... _ Instal ler.ler- ................................ ----- ! d� .. .............•--••--- � ! Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.___:`__ _______________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No, of ersons____________________________ Showers a Other—Type g ---------------------------- P ( ) — Cafeteria ( ) QOther fixtures .---••-•------------------------ .....................--•----------------•-------------------------------...._•-•••_---• ------•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.Z. . llons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area---_................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •---------------•-------------------------------•...._..--------•---------------...-----•--...--•-...-••••-•----...---......._....-------..........._...--_-. 0 Description of Soil....................................................................................................---------------•---------•-------------------------.....-•--------- x U ---•-----------------------------------------------------------------------•----•------------------------•-----•-------------------------------•-•-------------------------••••--•--------•-----•------ W -------------------------------------------------------------------------------------------------------------------------------------------•--------...----•------------------------------------------- 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 TITLE 5 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 bo rd of he h. Si g �4r--• ry Date ApplicationApproved By.................................................................................................. ------•------•--- -------•--•-•- L1 Date Application Disapproved for the following reasons:-------•------••-------------•-------------------------•-----------------------•-------------------------....._ .........-•----------•-------------•--•------------...----------••---...---------•----•-•-------------------------------------------__.___...--••--------------------------•------------------•-------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... Tntifiratr of Tvraa pliantr �'*IS I� TO CE . Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( � y' /A.. -- `-...: _...........................`� -••--------------- -....----.._..------•--- -- - Installer l� J,/_f/,./.- as been installed in accordance...-.........- ----------- --------•----•-------------.-----------••------------------. ......................... ....... ------------------­ (___�h�a`s` rdance with the ovisions of TIME 5 of The State Sanitary Code �s, d cribed in the application for Disposal Works Con ru Ion Permit No.__.C! _'_ a_'________________ da.ted_. ._. .._.:..-�____.__________.__ THE ISSUJ NCE OF THIS CERTIFICATE SHALL NOT BE CONSTRl1E AS A GUARANTEE THAT THE SYSTEM WI UzNCTION SATISFACTORY. DATE..... . ....................................................... Inspector--• ---• -•-------•-----__--------•--•--•-----------_____________________-•-•-•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... Q No....U.. - FEE........................ Permissionis reby granted_- ._._.:..__!� 1,<la --•---•-•t -----------------------•--------•--•-----------•---•-•-•------...-•----...._........_...... to Construct'( o Repair ( ,) '�_ "div(.,,u,ual Sewage Disposal System at (JOS Streeta ;as shown 7.- application for Disposal VVorkstruction Permit No______________ __ ated_ ` ?_____.......__. -.� --------- --------------------------------------- paid of Health DATE - - --�--•----•-------------•-------------------•-----••-•---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOCATIOIN SEWAGE PERISIT NO. 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