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0200 COTUIT BAY DRIVE - Health
200 COTUIT BAY DRIVE,'COTUIT ---- 4- r I j', r LI �7 3 PM 1 3 DATE 8/1/05 �_..__.._�.11€�'f IOC PROPERTY ADDRESS 200 Cotu.it Bay �2ive :+ Cotuit Nazz 02635 `tic system at the address above was on the above date, theme®P Inspected. s� �,,�►� This system consists of the following: 1., 1-1500 gaiion zept-ic . tank., 2,, 1-1000 gaiion eeachin*g pit., r based on Inspection, I certify the following conditions: 3. 7h.iz .ia a 7.itie T.ive, Septic zy-6tem (78code) 4" Septic zyzte'm .ins .in /z2o,/zea woaking oadea at the pee,6en't time., SIGNATUR Name: Robert A. Paolinl Company: �eaoph P• MscQmber &S_onlll�s Address: P. O. Box 66• .. .. �ontewille. Mass 026 2 . Phone:, 5"877S�3338 or Q5 & OM JQSEpW P. MACOMRER & SONr,IIC� Ta»kaCe:spools-L.eoefiftelde Pumped &.•.Installed TOwn Sewer:donhehtl0ns P.O. Box 66 centerville, MA.02,f2-0066 776+33 .' 77.5.6412 COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS o DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-•NOT:FOR.VOLUNTAtRY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION 5 , Property Address: 2 n n coat-„i t- 'Pay rnr i ve Owner's Name• Owner's Address: Date of Inspection: Name of Inspector:(please print) ciA Company Name: r Rloaaa en R .S:on Inc. Mailing.Address:' en �av c e, a�sz. 026 3,2 Telephone Number: 5 0 -�7 7 5:3 3 3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal aThetinspetion was pess and aerformed based on my�d below is true,accurate and complete as of the time oinspection. systems.I training and experience in the properfunction n Sect on.15 340 ofTitle�5(310 pr4lk fl5:0disposal )alThe system: a DEP approved system inspector pursuant to• , XXX passes- Conditionall Is ANeeds F rby the Local Approving Authority a Inspectors Signature: Date: The system inspector shall,submit a copy of this inspection report to the.Appro�iing Authority(Board of Health or r has a sign ow of 000 If the system is a.;;har�d-system DEP)within 30 days of completing this inspection.o1 shall submit(he report o the appropriate regionalloffice of the _ gpd or greater;the inspector and the system DEP.The original should be.sent to�the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and hnder the e fut re u condtions of ust at that nderithe same or different ^ time.This inspection does not address how the system will perform in conditions of use. f./,a`)Ann page 1 Page 2 of 11 . SSMEM OFFICLM,INSPECT —•NOT-.FORIVCtLUNTA,R EFO SURkW,,kCE SEWAG'rE 1�IS PART�;Y$1'�'11Z iNS PVC:nONCERTIFICATION(continued) property Address: 20q Co uit Bay Drives ('ntu, t' MA 02635 own": Herbert H arnP Date of.Inspection: / 9 Inspeetio�#S pr�narY: CbilA A'+j37+r'D or R./41 `eomPletwall of Section A. System Passes: S NO 'l have not found any information which iu�ihates`thAf and+of the failure criteria described�n 310 CMR 15.303.or in 310 CIViR 15.304 exist.Any failure criteria not evaluated are indicated below. C mm mts: • ,geR��,e ,�yhtem .i� �2o/�e2 woak.ign •o.adea at .the �2e.3ent time • B. system ConattionaH YPas ses: ++ •Or• laced orients as described in the``Conditional•Pass .:section:need to b.4 rop N 0' One or more system comp and f Beal will pass. ov tho Board 0 mp .'fhe system,upon completion of'the replacement or repay,as approved by (Y N,ND)in the for the following statements.If"ndt determ +'ined please Answer yes,no or not.determined explain. NO • The�eptic tank is•metal:and.ow70 Years old*or the septle tank(w a hdr metal•orriot)•is rncturallY. stom �msound,exb�bits substantial infiltra0an or exfdtmtion.or tanlc•f$ildurby. $ Hal .will pass inspection•iftbe theard of existing tin*is replaced with'a complyi septicanl6as,appret. •A metal septic tank will pasi inspection if it is struchirally sound,_not•leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ' N 0 Observation of sewage backup or break out or high stitle water level In the distribution box due to broken or obstructed plpe(s)or due-to a broken,settled.or uneven distribution box.System will pass insp4ctionAf(with approval of Board of Health)s e lced• . broken pips)are rea .(. 1? • .., obsttitdt0n i§removed'' ''distiiKWb)2box b-lcveled'or.`eplaoed ND explain: N 0 The system required p uping:•more than 4 dines a year due to broken or obstructed pipe(s),The system will past nspection if(with approval of the Board of Health): ,. W broken•pipe(s)are replaced obstruction is removed ND-explain'. 7 Page 3 of 11 + $1V1�i NT$ �r�'ECTION FORM-N©T 'OSVR"��1p'r1;�' 1R1Vf O ICIAL E gFW��10E DISROSiAL SU'HS' ' pART A C tRT.WCAYRON`(io j**ed) e Address: 200 Cotuit aver-i ve°� Property owner:. e Da ection:Date of lnsp • uiired by the Board of Res ., , C. Further Evaluation•is Req tho Bo€Heaith:in oerto;deterneiine if3he system'. NU Conditions.exist whiehregpire eT' ' ationbY is failing to protect public health,.safet)`or the en0��t' mat the .s rotect ublic health,safety strtl the:•�xironmc�' es•i>s accordance with 330.cWM 15:303(1) l, System will pass unless Board*of Health detormin. ` � system is-not ftiuvetioi�g Wit `hich:wlll p p no Cesspool or privy is.within,50 feet of a surface water v4getated wetland or a salt marsh' is within 50:feet of•a bordering n o Cesspool or privy If an ,determines:that the ) Y Supplier; ater • p b�fc W . d u tlt act t. o Yd of Heat d eaviroumen ess the B a th safe an it un� c peal. ,safety 2, System Will fa in a mariner.that protects�ap�bli system is functioning ^ system has a septic tank and soil absocptZon'system•{SAS):.andthe SAs is within]OU feeto a no The cyst to a surface water.supply surface water supply or tdbutary ublic water!supply n oThe system has a septic SAS and the�SAS is within a Zone 1 of.a p rc oo tic tank and•SAS'andth°SAS is wift'SO fact of a private water.supply` • The system has a sep and SAS and the SAS is less than 100 feet but 50 feet or;more� !a n o Tlio system-has a septic tank v.i A u d i private water supply well"' •Method used to determine distance' wOTM ell water analysis,perforated at a LlEP certifiedfro poll pollution fr ni thatoratory,for lfacility and "'This system passes if them, ovided tat no other bacteria and volatile organic corinpounds Indicate'that the��to orcless than 5 PP � the presence of ammonia nitrogen and nitrate nitrogen ° ' e.pre criteria are triggered.. copy of the analysis must bo attached to this form. f • • 3, Other: Page 4 of I I OFFICIALINSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE:.DISPOSAL SYSTEM:INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 p p rot- ; i- Rau nrive COtuit MA 02635 Owner: _ ar uoarna Date of Inspections D. System Failure Criteria applicable to all systems:. You must indicate"yes":or"no"to.each of the.following,for all inspections: Yes N� _ Backup of sewage.into facility.or.system component duelo overloaded or.clogged SAS or cesspool Discharge:or>ponding of effluent to the surface of the..ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in-cesspool is less than.6"below invert or available volume is less than'/2•day flow -7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 10.0 feet of a surface water supply or tributary to a surface water supply _ X Any portion:of:a cesspool of privy•is within a.Zone..l.of a:public well... _ -7 Any portion of a cesspool or privy is within.50 feet of a private water supply well. �. _ 7_ Any portion of a cesspool or privy is less:than 100 feet but greater than 5.0 feet from a private water supply well with no acceptable water quality analysis..[This system passes.if the well water:analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates.that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered:A copy of the analysis must be attached to this forrp..] NO (Yes/No)The system fails.I have determined that:one or.more'3of the above,failure.criteria exist as described in 310 CMR 15.303,therefore the system.fails.The system ownershould contact the Board of Health to determine what will be necessary to correct the failure. L Large Systems: To be considered a large system the:system must serve.a facility with a design flow of 1.0,000 gpd to 15,000. gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 1 X the system is within 400 feet of a surface drinking water supply w X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(1nterim 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 signif cant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed-under Section D shall upgrade the,system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. 4 Page 5 of 11 TORM—NOT FO ROLUNTAR�ASSESSMENTS OFFICIAL INSPECTION ISTEM FORM SLt$SURFACE-SEWAGE DISPOSAL' TION PART CHECIKLIST Property Address: onn C'ntui t Bav Drive Co owner: F*PrhPr} Haar �• Date of Inspection: '^^ j"^ Check if the followin have been dyne.You ust In for"no"as'to each.of the ollowin Yes No X or Board of Health pumping information was prpvided'by the owner,occupant, _ X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? 7— ty Have large volumes of water been introduced to the system recently or as part of inspection? X Were as built plans of-be systern•obtained and examined?(If they were not availabl0ote as N/A) X Was the facility or•dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X . _ Were all system components,toluidingthe SAS,located on site.?• X _ Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with infortn4tion on theproper fnaintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on'the site.has been detemfted based on: Yes no le plan at the Board oflIealth: X Existing information:For example,a X _ Determined in the field(if any of the failure criteria related to Part C is-At issue approxirtiationof distance is unacceptable)[310 CMR 15.302(3.)(b)) � w Page 6 of I I 4P'F)GCIt+LL INSPEQ.UO!T:70RM`—NGT FOR VOLUNTARY .S1�S�1I MM•S)t '•AGE OISrOSALAYgr EC"T)<OI�T FORM PART:C -SYSTEMMORMATION Property Address: 200' Cotuit Bay Drive . CotuTt M 02635_ Owner: Date of Inspection: ^ FLOW CONDITIONS ` RESIDENTIAL Ntunber of bedrooms{actaal):3 • Number of be¢rool is(desJp)*•, 3 3 0 D)SSIG�•$ow liastd on'31a 15.�6�`('for e�teriiplei'I ID'gpd z#•6fbedroiirims)'i • Number of Cuzrent residents: ., Does'esidence have a garbage grinder(yes br no)-..110 Is 1$Imdry.on a separate sewage.system•(yes or.no):2 o (if yes sepawte bspgction reRuiredl Laundry system inspected(yes or no): n_o 20.03=128, 000 G l D='3 5 0., 6 8 • Seesonal use:(yes or no):n°O 2 0 0 4=17 9, 000 q.P D=4 9 0.� 41 'Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or n(): no Last date of occupancy: R a e-3 e n ' COMMERCUSTRIAL N/ Type of esta tt • r • - -• - - . Design 1IQW on•310 CMR 15.203)-, .apd' Basis.of d�cigri'E(seats/,persons/sq%4;tc,)', Grease trap'*sent(yes or no): Industrial waste holding tank present(yes or y J� Non-sanitary waste di.schar ed to the Title 5 s stem•(yes or. no)-„y Water•.meter readings,if available: Last date of occupancy/use: CXNERAL jgQRMAj1ON . PumpingRecOrds 7I29/05 /�um/2 7 maim a '! m¢co lea' Source of information: es or no): y e h Was system pumped d P 55 0 0 g.al the lop How pection was quantity pumped determined? m e a-3 u 2 e d If yes,volume pumped.' t Reason for.pumping: . .m a n TYPE-OF SYMEM n o &o x. X Septic tank,distribution box,soil absorptign.syslem • . Single cesspool - QverticW ce�sspo l - privy Shared system••(yes or no)(if yes,attach prevldus inspection records,if aay) Innovative/Alternative tecHnology.Attach a Copy of the current operation and maintenance contract(to be w obtained from system owner) h a.co of the DEP.approval Tight tank kry'. Other(doscribe): Approximate age-of al)components,date installed(if known)and'source of information: unknown Were sewage odors detected when arriving at the site(yes or no):n o f Page 7 of 11 INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS OFFICIAL INSPECTION FORM SUBSURFACE SEWAGE DISPOSAL SYSTEIVI PART C SYSTEM'INFORMATION(continued) Property Address: n Drive Cot»; t MA 02635 Owner: Herbert Hearne .Date of Inspection: BUILDING.SEWER(locate on site plan) Depth below grade:18__ Materials of construction:_cast iron X 40 PVC—other(explain): ction line: 10 f Distance from private water supply well or su Comments(on condition of joints,venting,evidence of leakage,etc.): ao . t�5 a eat t ht.,No evidence. o �eaka e. Vented thorough ou�se ven „ e site plan) 1500 gaUon on y locate p ) . SEPTIC TANK.�( . Depth below grade: 22" Material of construction:_concrete metal. fiberglass_polyethylene _other(explain) attach a co of If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_.( copy certificate) Dimensions: enrc � Y �� RnX5 � 7" Sludge depth: t.¢ace t2_ace_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: t2a c_e l a a c e. Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: t 2 a c e How were:dimensions determined: m a u 2 e gr tY� q Comments(on pumping recommendations,inlet and outlet tee or.baffle condition;structural irate i li uid levels as related to outlet invert,evidence of.leakage,etc.): et tees aae �n /�is ce.� l umI2 tank eveay 2 yeaa,6., Inie't Bout h . an �..6 .�. ucuc uza y .noun no cgn� o ea age. GREASE TRAPR o(locate on site plan) Depth below grade: Material.of construction:_concrete metal fiberglass___polyethylene_other (explain)`. Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Gaea,3e t1ta12 not paezent 7 r Page 8 of I 1 OFFICIAL INS•FIFCTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SO&W, .ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 200 rntiri t-Bav Drive rot,,; t MA .096 5 .. Owner:• Herbert Up4gnp Date of lt2spection: _ 2 •0 5 TIGHT or HOl,DING TANK:n° (task must be pumped at time of inspettion)(locate on site plan) Depth below.grade: Material of constructlon: _ concrete metal!fiberglass___polyethylene other(explain): Dimensions: Capacity: g,i l!ons Design Flow: gi:llons/day Alarm present(yes or no): Alarm level:_ Alarm'in wo ;-ing.order(yes or no): Dine of last pumping: Comments(condition of alarm and float-switches,etc,): light o2 hoid.ing iankA ngv nnj 4figAen_.t DISTRIBUTION BOX:'0 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D,zta.igut.ion fox i.3 not 12ae,3ent PUMP CHAMBER: no (locate on.sife.plan) Pump's in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, ett:.); l amI2 cham&ea .iz not ,2aeZent 8 . r Page 9 of 11 OFFICIAL.INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property YAddress: 0 ent, , Rai Drive e in�ui i- MA 02635 Owner e Date of Inspection: 7 2 9 0 5 SOIL ABSORPTION SYSTEM(SAS):_-(locate on site plan,excavation not required) If SAS not located explain why.: Located zee 12age 10. Type X leaching pits,number: leaching chambers,number: leaching galleries,number: . leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc): Loamy .to ;eine. sand., No zignz o� �a.iivae oa pond.ing.,So.iiz ate zy., Vegetation .cis no2ma CESSPOOLS: no (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: h Indication of groundwater inflow(yes br no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce.6-sRoo.E z ate riot 122e'zent PRIVY:n0 (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.). l2.ivy iz not R2ehent 9 ���Page l0'df'11 • f � � INSPEUTTON' +'O'R1VI NOT'�'4I 'V ASSESSMENTS -� t� Om. CML 5Y3I3EWINSPEGUONTO'RM PART C SYSTEM INFORMATION(46nthwedy' .. kti (�nti�; t Bas�..Drive ;Property Address, 2 0 0 Cotuit MA 02635 -,Date oilnspection: y TCA OF SE'WAG��DI$POSAIL• SYSTEM ties to at Least two perinanent refa Once Idad ub or Pro de a sketch of the sawage disposal system incluoin$ + ' benchmarks.locate all wells within �00 feet.Locate where publicwter supply CiltQrs.the building. s L Crr ���; � , '� 1 � • to • 4 Sxe'JfO r� 5 ,t•R • , , •�tivito ' n x DQ Co7 V/ f ow, W 10 _ Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYN FORNNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC PART C SYSTEM INFORMATION(continued) Property Address: 200 Catt,i t Rav nrive., f`n�_MA n7ti35 Owner: uArhPrt $AarnP Date of Inspection: 71 910r . SITE EXAM Slope Surface water Check cellar Shallow wells. Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: u es Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:a; a 11 % n ^n n no . Checked:with local excavators,installers-(attach documentation) ®ccessedUSGSdatabase=explainht 12�town. &aaahtagia-,ma. u!s You must describe how.you established the high ground water elevation: 11 I.L�,ed Ca e Cod Comm.i�s.ion !Jate2 Taa.�e Coritoua6 And l u�.2.ie Glatea Su�/�.2y bleii head aoteet io•n aaeaz map., Se t 1995 �atea aehouace.5 o ice ca e co comm Leaching Pit • raw .�� GroundwaterV-feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical.separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet: i 11 .ir.I...r...� Hers-�ars•�*erees+t .� 5• nT, _,,,, ,.,,ramr,M:�•�► wr�mT�T _ BOARD OF HEALTH 'TOWN OF � � INSpFCTION FORM - PART D CERTIFICATION SUIISURFACE SEWAGE, I)18PUSA1r SYSTEM •••rrt-•r•:-s: -•ntrs^.rr•nrerrm•ermri - YPt rn+ene4+raiemn�cKrsrt+r.tia�rmTYPZ R OA PAINT Ci•EARLY- PROPERTY INSPECTED ' STREET ADDRESS ASSESSORS MAP► BLOCK AND PARCEL # OWNER' s NAME Herbert."H PART D - CERTIFICATION .. NAME OF INSPECTOR Rogea�t PaDii-n•i 1 ' . . Nacom COMPANY NAM E o�sejsh ; 8.P-^ Son Inc MESS Bow-.' Centezv.iiia (7a�s,s 02632 ro.or City. stag ZIP COMPANY ADD. . stcQ�.t •• 1578 FAX 508 ,l790 COMPANY TELEPHONE ( 508 } 77.5 - 3338 1 CERTIFICATION STATEMENT ' that I have personal°1Y .inspected the sewage at I certify this address and that .ttie `inspection.►rTherinspectiQn was per-formed and any omplete as of the time o.f , p maintenance , alzd repair .are congisten recommendations regarding upgrade , rainii�,g and exp.e�rience in the proper functi'orr and maintenance of on- w i th my t site sewage disposal systems ' . ` Cheek one: ; Systeoi RASSD inf The insp ection which - I have -conductedto has .,n adequately ;field arotectopubliEn which indicates that the system fails CHR health or the enviroit� -ment as defined i failure of criteria Dot evaluted are as stated in the this, form. System FAILEDat the* g ection which I have con ted has founintacRordanceswithtem fTitleails to The inspection rrotect t}1e public liealth and the enViranment 6 , 310 CMR 15 . 303, and as specimically noted on PART C • FAILURE CRITERIA of this ins t ' f r Date Inspector Signature' .. " '' "`� ne copy of this certi f i.cat,io'n must -he p ovided 'to the .OWNER', the. BUYER where appli.aable ) and bhp DOARD �i� . , rade' the system. * If the inspection FAILED, this owner .oectionaturrileesslallowed or requ.i;red within o'ne vea�ovidedeina�10oCMR the 16306r otherwise as p par.td.:doc .. _ 5 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �I DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617.291 5500 9 d0 ulLLl.-01F N o EED J.`, Pew Go�cmor tn� � t' - ARGEO PAUL CELLL`CCI ) o� '�I D,= Li Go%cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �F9oOm PART A l�° CERTIFICATION f�lF Property Address: 200 Cotuit Bay Drive Cotuit Address of Owner: sa Date of Inspection: 1 O/22/97 (If different) Name of Inspector: ,7r)GPnh P MaeoLmber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass . 02632 Telephone Number:5nR-775-3-3118 CERTIFICATION STATEMENT I cen,fy that I have personally inspected the sewage disposal system at this address and that the information reponee oelo- s u e. acc_-. and complete as of the time of inspection. The inspection was performed based on my training and experience in Ine proper iur),--i,on jr maintenance of on-site sewage disposal systems. The system: _/Passes Conditionally Passes Needs Funher Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: /d-;*S7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty t30; days of comDm(el,r., -^:, inspection If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system o,T),-f s^all s, the report to the appropriate regional office of the'Depariment of Environmental Protection. The original shov c ce Sen, to ire saver, D- and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as deiined jr: 3 0 Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the `Conditional Pass" section need to be replaced or repaired Tne ss s:er- .. 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 esa.a,, The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a tee ', c-aie Compliance (artached) indicating that the tank was installed within twenty (20) years prior to the date of t-e sic o� the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exiittr;tior D, to failure is imminent. Thei system will pass inspection if the existing septic tank is replaced with a conform,ng s-D ,c -3 as approved by the Board of Health, tr.v,..d 04i25Wl r.9. 2 of 10 DEP on the Wono Woe WeD hftp:rnvww magnet state ma uvoep Pnnteo on RecycjW Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propeny Address: 200 Cotuit Bay Drive Cotuit,Mass . O»ner: James Mackenzie Date of Inspection: 10/22/97 e) SYSTEM CONDITIONALLY PASSES (continued) A, We, Sewage backup or breakout or high static wale( level observed in the distribution box is cue to o(o',e-- Dr oos _=c p,pefs) or due to a broken, senled or uneven distribution box. The system will pass inspection I (" ;n aroro,a Board of Health) Describe observations: r broken pipe(s) are replaced obstruclion is removed distribution box is levelled or replaced year due to broken or obstru�ed pip ets) The systern moars The system required pumping more than four times a y inspect,on if (with approval of the Board of Health)' broken pipe(s) are replaced obstruciton is removed C) FURTHER E-VALUATION 15 REQUIRED BY THE BOARD OF HEALTH: X-)b Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is laJing :o 0 ocec e public health, saiery and the environment 1) SYSTEM. WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONIN'C IN An N.NER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy Is within 50 feet of a surface wale( 210 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM: WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER.1,tINES TriaT THE SYSTEM IS FUNCTIONING IN 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 ;o a solace : 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 suapi, well , Q The system has a septic tank and soil absorption system and the SAS is within 50 feet of a prlvate -'ate( s_:, -el ,Z6 The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 ieei of -nore !to a private water supply well, unless a well water analysis for coliform bacteria and volanle organic cor-wo_res -c _a, the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ni,roge :s ; .__ less than 5 ppm Method used to determine distance _ i(- (approximation not valid; 3) �OTHER tr.�s..6 0�/Is/f7) D.q• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 200 Cotuit Bay Drive Cotuit,Mass . owner James MacKenzie Date of Inspection:1 0/22/97 D) SYSTEM FAILS: You must indicate e,: el ,Yes' or 'No" as to each of the following. i have determined that the system violates one or more of the following failure criteria as defined in 310 C�•'.R I for this determination is identified below. The Board of Health should be contacted to determine what will *.;e neces;;-� :o :o^ the failure Yes No l Backup of sewage Int0 facillry or system component due to an overloaded or clogged SAS or cesspoa Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloace-c or c age• cesspool. _4/Q•14t, Static liquid level in the distribution bos above outlet irwen due to an overloaded or clogged Ste: o: 'ess.._• w&kAr liquid depth 'a-Ee,+igeel is less than 6" below invert or available volume is less than 1!2 da� ilo Required pumping more than 4 times in the last year NOT due to clogged or obstructed p,Delsl Number of times pumped Q Any ponion of the Soil Absorption System, cesspool or privy is below the high ground ate Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributa� :o a s,.nace -a er s_D-D.• 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 ponion of a cesspool or privy is less than 100 feet but greater than 50 feel from a pri�a,e wafer suD:i. _e, . acceptable water quality analysis If the well has been analyzed to be acceptable, anach coon of welt ;:er a:'.a•.s�s coliform bacieria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen F) URGE SYSTEM FAILS: you must indicate ether 'yes' or "No' as to each of the following. The following criteria apply to large systems in addition to the criteria above. Aocb The system serves a facilrry with a design flow of 10,000 gpd or greater (Large System) and the system 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 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 public water supply well) The owner .Dr operator of any such system shall bring the system and facility into full compliance with the groundwater lrea:—e c s requirements of 314 CMR 5.00 and 6,00. Please consult the local regional office of the Department for further iniorrr.a;,Dr, Ir•v�r•d 0�/3s/971 P•q• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 200 Cotuit Bay Drive Cotuit,Mass . Owner: James MacKenzie Date of Inspection: 1 0/2 2/9'7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following Yes No / Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiv�ng nor-.al flow rates during that period. Large volumes of water have not been introduced into the system recer. Ii as pan of this inspection. _ 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. 9Cluding 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 cond,t,on of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum — The size and location of the Soil Absorption System on the site has been determined based on -C/ The facility owner (and occupants, if djHerent from owner) were provided with information on the proper m,a,n;er,�-ce Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Pan C is at Issue, approximation of distance s unacceptable) (15.302(3)(b)) (r•vl••d 0�/)S/97) P.g* 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 200 Cotuit Bay Drive Cotuit,Mass . Owner: James MacKenzie Date of Inspection: 1 0/22/97 FLOW CONDITIONS RESIDENTIAL: Design flow. M R.P.J./bedroom for S.A.S Number of.bedrooms:_ .Number of current residents: Garbage grinder (yes or no): � Laundry connected to system (yes or no): Seasonal use (yes or no):21—V-0 Water meter readings, if available (last two (2) year usage (gpd): H .'l'= Sump Pump (yes or no):,Va 1 Last date of occupant) YLLS_ COMMERCIAUINDUSTRIAL• Type of establishment: Design Clow: ,V/} gallons./day Grease trap present: (yes or no)_IVIO! industrial Waste Holding Tank present: (yes or no),&ZdL Non-sanitary waste discharged to the`Title 5 system: (yes or no)':jZsfl Water meter readings, if available Last date of occupancy OTHER: (Describe) AV14 Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and,4ource of informa ion: System pumped as 41 of spent n: (yes or no)'ye!; If yes, volume pumped: ,-00 gallons ) l Reason for pumping `r? L� �.✓T �C �`)lv2fifs LIIL�I if TYPE OF SYSTEM _ z$eptic tankJ4 +e bex/soil absorption system ,Single cesspool Overflow cesspool ,rsr) Privy jL Shared system (yes or no) (if yes, anach previous inspe(nion records, if any) ,/lam- I/A Technology etc. Copy of up to date contract( Chher 22 APPROXIMATE AGE of all components, date installed (if known) and source of information: T Sewage odors detected when arriving at the site: (yes or no) (r•vl••d 04/25/97) ➢•q• 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORm PART C SYSTEM INFORMATION (continued) Properly Address: 200 Cotuit Bay Drive Cotuit„Mass. owner: James MacKenzie Date of inspection:1 0/22/97 BUILDING SEWER: ;locale on site plan) ci Depth belo- grade material of construcllon cast iron "40 PVC _ other (explain) Distance fro%%ate water supply Well or sucnion line y,4 Diameter Comments (condition of joints, v nling. evidence of leakage. etc.) -70,Av7" t >, Z.t,ei ✓Cc9'�� -'5v SEPTIC TANK:_ .locate on site plan) a Depth below grade vfater-al of construction, �o,crete:=me(C . Fiberglass, "Polyethylene.;_-lother(explain) it tank Is metal. list age d&J Is age confirmed by Ceniftcate of Compliance//1Q(Ye No) Dimensions �rllG/"� Ll r/&4 Sludge depth._ Distance from top of sludge to bonom of outlet tee or baffle:�� Scum thicknes D.s(ance from top of scum to top of outlet tee or baffle: d Distance from bonom of scum to bonom of outlet to or baffle How dimensions Were determined F Comments rrecommendat.on for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relation to ou(jei n:?'t, str,;:7-:; mUnb, evidence of leakage. etc.) l 7- / L /fl / GREASE TRAP:,&AP./e ;)ocate on site plan) Depth below grade -w Nsalerlal of cons(ructlorAyconcrete/L/�etalVAFibe(glassi/, PolyethylenerALd2bther(explain) D'menslons: Scum thickness. Distance from lop of scum to top of outlet tee or baffler Distance from bonom of scum to bonom of outlet tee or bafle:," Dale of last pumping A4 Comments trecommendatlon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet ;nver,. ntegr (Y, evidence of leakage, etc ) Ir.vl..d 04/15/9)) D.g. 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 200 Cotuit Bay Drive Cotuit,Mass . Owner: James MacKenzie Date of inspection: 1 0/22/97 TIGHT OR HOLDING TANK:�/ (Tank must be pumped prior io, or at time, of inspection) (locate on site plan) Depth below grade Material of constructlon4A concrete.;4metalAA4 Fiberglassj/ff olyethylenez other(explain) y Dimensions: .!/y Capacity: P/,.32 gallons Design flow. Al/9 gallons/day Alarm level: y4 Alarm in working order ti/4Yes,,4/;4No Date of previous pumping: A-14 Comments (condition of inlet tee, condition of alarm and float switches, etc ) A^ 2 12561.t/T DISTRIBUTION Box-A, ve— (locate on site plan) Depth o: hcu,d level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ��7'r, jj- d PUMP CHAMBER:�Jv�/Q� (locate on site plan) y� Pumps n working order: (Yes or No)� Alarms in working order (Yes or Not Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) lr.vl..d P. . 7 of 10 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 200 Cotuit Bay Drive Cotuit,Mciss . Owner: James MacKenzie Date of Inspection: 1 O/2 2/9 7 SOIL ABSORPTION SYSTEM (SAS): .� ;locate on site plan, if possible. excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: Type I leaching pits, number: leaching chambers, number: leaching galleries, number: D 3 leaching trenches, number,length: leaching fields, number, dimension overflow cesspool, number:LL Alternative system: Name of Technology: Comments. In to condition of soil, signs of hydraulic failure, level of ponding, c ndition of ve etation, etc.) S lu e W js r CESSPOOLS: (locate on site plan) Number and configuration: xli ' Depth-top of liquid to inlet invent it Depth of solids layer: A114 Depth of scum layer: AM ."r' Dimensions of cesspool. A`114 Materials of construction: AIA Indication of groundwater: 14 inflow (cesspool must be pumped as pan of inspenion) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: 41�.Ve_ (locate on site plan) Materials of construnion: Dimensions: Depth of solids:�Z/141 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r.vl..d 04/25/97) Y69. 8 of 10 include ties to at least two permanent felefc:`"'" µ. locate all wells within 100' r 'o o 9� Ct\ dwp t U•v1 •C G,/15/f7) D•g• 9 of 10 SUBSURFACE SEWAGE DISP• SYSTEM INSPECTION FORM SYSTEM INFO): :tON (continued) Properly Address: 200 Cotuit Bay Drive Cotuit,Mass. Datedinspection: James MacKenzie Date of inspection: 1 0/22/97 Depth to Groundwater f y Feet Please ind-cale all the methods used to determine High Croundwaty HL.aaon. Obtained from Des,gn Plans on record -P-l'observaoon of Sae (Abuning property, obseryat,on hole, basemtrst•s,mp etc.) Oetermme it from local condit,ons Cheek w.th local Board of health _ Check FEMA~saps Check pumping records heck local e■cavators. installers Use USCS Data Descnoe , yout own words how, You established the High Groundv+u.cf E ievatton (Must be completed) Used Cape Cod Commissiom Map. September 1995 Cape Cod Water Table Contours And Public Water Supply Wellhead Protection Areas (r•vl••C 0�/75/f11 V•q• o! SO 1. i .. r+ nr'.•.-.r.r.-im.nmra-..r.mr.rn+r:•.�.•:rv.r:+.�.•n*n rrrr��u rro,trtcn m+ rr1-v.sn-�..�-_rn-r-T-r—r- _. ._rr TOWN OF Barnstable BOARD OF HEALTH SUIISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CEI171F1CATION 1 �_ 1..._.. r .--. i.---n..•.nn•n:rnr-,+r:m.arrrr.�-•.•t�n+e-..n+nsr�ms'w�m�nrr's-'wnsrs man•�mr�*rerrr.�.,-...:-rr•- .- _. _. .� —TYPE OR PRINT CI.CARLI*— PROPERTY INSPECTED STREET ADDRESS 90-0 Cri+n t 13ay ASSESSORS MAP , BLOCK AND PARCEL Map: 56 Parcel : 17 OWNER' S NAME James Mackenzie PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & ''ff n , Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 S t r v v t Town or City State tiP COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and an,,, recommendations regardi►Ig upgrade , maintenance , and repair are consistent . with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : ZY3teui' PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 - 303 , Any failL11-e criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con 'acted 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 le,o.1 Date One copy of this certification must be provided to the OWNER , the BUYER ( where applicable ) and the I30ARD OF IiEAL1'II. • If the inspection FAILED , the owner or"•oporator ehall upgrade within one year of the dnte of the inspection , unless allowed ortrequirrecm otherwise as provided in 310 CMR 16 , 305 , parts - doc ti _ S THE, COMMONWEi ALTH OF M.A.SSACHUSETTS DEPARTMENT OF ENVIRON MNTAL PROT_ ECTXON BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERT � { D TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laves . Issued by The Department of Environmental Protection. Acting Director of the 61 un yr W�tcr ('ollution Control r PROPERTY . ADDRESS:_200"-Uo£uiU' Bay' ..:Drive Cotuit _ Mass . 02635;' On the above date, I inspected the septic system at the above address. This system .consists of the following: 1 . 1 -1000 'gallon septic tank. 2. 1--1000 gallon leaching pit. Based on my Ins section, 'I certify the following conditions: 1 . This 'is a title five septic syst'em." ( 78 Code. ) 2. Theseptic syst-em is :in proper work ng or(T6-il, • 'at� 'the. present -time . t SIGNATURE: , Name:_J. P.Macomber J_r., ' _--_------.--- ---•---- ter,,.,......-.�,..:..m.,... Y Company:* om an J.P.Macon)ber & Son- -Inc • P Address: p� c. Centerville LMass__02.63'2 (y Phone:_-_548�7��3338------- - 1 `�'4 . S i► THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON,. INC. Tanks•Cesspoola-Leachtlelds Pumped & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775.3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs ®epartment of Environmental Protection William F.Weld Gmemor Trudy Coxe Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 200 CotUit Bay Drive CotUit Address of Owner: Date of Inspection: 9/2 5./9 5 (If different) Name of Inspector: Joseph P. Macomber Jr. Company Name, Address and 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: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D. A] SYSTE PASSES: 7I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: �Ilr3 One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) IINJ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 s Telephone(617)292-5500 +iJ Printed on Recycled Paper r-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 200 Cotuit Bay Drive Cotuit Owner: Robin Masteller ( Schirmer .) Date of Inspection: 9/2 5/9 5 BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced P The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: M Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 6V0 Cesspool or privy is within 50 feet of a surface water 1/ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: dW The system nas a septic tank anu suii absorption systen-, and is within 100 feet to a surface water supple cr tributary, to a surface water supply. A10 The systen, has a septic tank and soil absorption system and is within a Zone I of a public water supply well. N$ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tank and soil absorption system and 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• D] SYSTEM FAILS: -- 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. 40 Discharge or ponding of effluent'to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 • p i 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:200 Cotuit Bay Drive Cotuit Owner: Robin Masteller ( Schirmer ) ' Date of Inspection: 9/2 5/9 5 1 D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 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 organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety �� and the environment because one or more of the following conditions exist: A& the system is within 400 feet of a surface drinking water supply 41e the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well; The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 200 Cotuit Bay Drive Cotuit,Mass . Owner: Robin Masteller ( .Schomer ) Date of Inspection: 9/2 5/9 5 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. J_//The facility or dwelling was inspected for signs of sewage back-up. _L/The system does not receive non-sanitary or industrial waste flow 4—/The site was inspected for signs of breakout. All system components, @Kluding the Soil Absorption System, have been located on the site. _LAe 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 Soil Absorption System on the site has been determined based on existing information or /Te ated by non-intrusive methods. facility ov,ne� (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. RECOMMENDATIONS 1 . Septic tank must be' pumped. 2. New pipe and tee must be installed on the inlet end of the septic tank. 3 . Covers must be raised on the inlet & outlet end of the septic tank. 4. Distribution box cover must raised. 5 . The cover on the leaching pit must be raised. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:200 Cotuit Bay Drive Cotuit;Mass . Owner: Robin Masteller ( Schirmer Date of Inspection: 9/2 5/9 5 FLOW CONDITIONS RESIDENTIAL: Design flow:_ _gallons Number of bedrooms: :5 Number of current residents: In Garbage grinder(yes or no) Laundry connected to system (yes or no):\),o Seasonal use (yes or no):.&_0 p Water meter readings, if available: 1�3 �SD, �� 4 QS- QCt��afl� pArU(T t9-I I Last date of occupancy: (11 - COMMERCIAUINDUSTRIAL: Type of establishment: !1/� Design flow:4& allons/day Grease trap pr sent: (yes or no)40 Industrial Waste Holding Tank present: (yes or no),&/V Non-sanitary waste discharged to the Title 5 system: (yes or no) /V® Water meter readings, if available: , Jl Last date of occupancy: �/ OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source oof,,iinn ormation: e� ,(Jlllyl�� �• �UIII/L�wf� System pumped as part of inspection: (yes or no)ye-.S If yes, volume pumped. LLS0 d allo/ns Reason for pumping: -0,41 S'd1,/Gt' ly,4 4/14- TYPE Q YSTEM /. Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool d Privy AM Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) AP OX�I�TnE�- GE of all components, date installed (if known) and source of information: ,l Sewage odors detected-when arriving at the site: (yes or no)2 (revised 8/15/95) 5 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C. SYSTEM INFORMATION (continued) ' PropertyA6cjess: 200 Cotuit Bay Drive Cotuit,Mass Owner: Robin Masteller ( Schirmer ) Date of Inspection: 9/2 5/9 5 SEPTIC TANK: LV (locate on site plan) tr Depth below grade: Material of construction: �concrete _metal _FRP_other(explain) Dimensions: t r( N Sludge depth: Aq V Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: ..2 fg`t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: g 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.) o `,, .u/ S i !iv 6-9+kvow G 7" _ E c � Z�° -3 GREASE TRAP: (locate on site pan) Depth below grader Material of construction: co crete _metal _FRP_other(explain) . Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:—&- Y Distance from bottom of rt,m it, 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, etc.) I1�iP (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 200 Cotuit Bay Drive Cotuit ,Mass . Owner: Robin Masteller ( Schirmer ) Date of Inspection: 9/2 5/9 5 TIGHT OR HOLDING TANK: (locate on site plan) • Depth below grade: ) Material of construction: r-oncrete_metal _FRP—other(explain) 1L1 Dimensions: Capacity: gallons Design flow: allons/day Alarm level: Comments: (conditiop of inlet tee, condition of alarm and float switches, etc.) Ol lif_� DISTRIBUTION BOX:_z (locate on site plan) Depth of liquid level above outlet invert: Comments: (note Y level and distributiur, i� equal, evidence of solids carryover evidence of leakage into or out of box, etc. ` PUMP CHAMBER: i¢ (locate on site plan) Pumps in working order.(yes or -40 Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 200 Cotuit Bay Drive Cotuit,Mass . Owner: Robin Masteller Date of Inspection: 9/2 5/9 5 SOIL ABSORPTION SYSTEM (SAS):,,/ (locate on site plan, if possible; excavation not required, but I may be approximated by non-intrusive methods) If not determined to be present, explain: Type. 1 leaching pits, number: A leaching chambers, number:d leaching galleries, number:_ leaching trenches, number,length: leaching fields, number, dim sions: f� overflow cesspool, number. Comments: ,(note condit)on f soil, si s of hydr u ic,'failure, level of pond ng, coonditigp of vegetation,etc.) {J d sl! 1 Ive,14 CESSPOOLS: A0 (locate on site plan) Number and configuration: A11W Depth-top of liquid to inlet in e : Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comment �,e ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:/ �. (locate on site plan) a�, Materials of constru 'on: lU�// Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.) /POD (revised 8/15/95) B i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C 7 SYSTEM INFORMATION (continued) Property Address: 1200 Cotuit Bay ' Drive Cotuit,Mass . Owner: Robin Masteller ( Schirmer ) *Date of Inspection: 9/25/95 SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks Locate all wells within 100' `rilAP'✓v Gt/�¢7 • } 0 j \ boo lci ` DEPTH TO GROUNDER Depth to groundwater feet meth of d e,Lminati appr ximation• '� e� �e Lt/ �r° 1. Dist° A�o� ,e AZ M2 > (revised 8/15/95) 9 ` 1L TOWN OF Barnstable BOARD OF HEALTH j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION MI F..._...__.._...__.::-.._--.r.-•-:--:--.--r-....^...,__...�:.--......... .....----'-.-.-rr..._-.--r.=�__'��-s..-r.•s-n-rrr.-s-Err-r...-Err r-. I -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED a STREET ADDRESS 200 n„+;,; + Bay nr; ..o Cotuit.Mass . ASSESSORS MAP , BLOCK AND PARCEL # d OWNER' s NAME Robin Mast&ller f Schirmer ) PART' D - CERTIrICATION , I NAME OF INSPECTOR Joseph P. Macomber Jr COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State Lip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXX,X.X Systevi 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 conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date _9/29/9 One copy of this Fertification must be provided to the OWNER, the BUYER( where Applicable ) and the BOARD OF 11BAL711. * IP the inspection FAILED, the owner or.1.operator shall upgrede ' 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 Cc crwec: c ae 7,s Execumve vfilc , . � o yr �nVl(C('F�"e!�?tC; Department of Environmental Protection ' Water Pollution Ccntrol Tecnnlccl Asswcnce and Training Sections wlut,m F.W&d Trudy Cox• S•"W"y.ECEA Thomas & Poww• ;.a"convn...on./ 06/12/95 ATTN: Joseph P. Macomber, Jr. . Joseph Macomber and Sun PO Box 66 Centerville, MA 0263 Dear Joseph P. Macomber, Jr . , _ I am pleased to inform you that you have attended training, met , the experience qualifications, and have passed the Title 5 System Inspector exam, pursuant to 310 CMFe. 15. 340 . The passing grade for the exam was 39/52 or 75% . This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 . You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address : Kimball Simpson D. E. P. Graining Center 30 Route 20 Millbury, MA 01527 Thank you very much for yoar time' arid consideration in this matter. Sincerely, Kimball 7. S:mnson, r DEP Training 4r Director 2 4 0 5� •Route l • Millbury e, MA FAX V,8 755.9253 • „n• 508-756.7711 :'! r Water , ,. ..,.�� y Conservation SAVE Tips . . . ME! , . CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Loss Per Day Loss Per Month Size 120 3,600 • 360 10,800 • 693 20,790 • 1,200 36,000 • 1,920 57,600 3,096 92,880 0 4,296 128,980 ® 6,640 199,200. 6,9.84 200,520 8,424 252,720 9,888 296,640 ® 11,324 339,720 12,720 381,600 14,952 448,560 THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HE H AL ..-.'......OF....... 4,44. 4, / .. .................... Apphrutiun -fur R_qpuiitt1 Works Tonstrurtiun Vrrmft Application is hereby`made for a Permit to' Construct ( &I-or Repair ( ) an Individual Sewage Disposal System "Y 9 0 i., " .b ------- •--__--- .. .. ... ••--.. ............ -------•---•-- . -----...... o Loca i Ad res f of W --•--------•- - = 1 eL -/ '` ddress j" nstaller Address / �4 d Type of Building Size Lot..... .. .....:. Sq. feet U Dwelling—No. of Bedrooms.................. . .. Expansion Attic ( ) Garbage Grinder (6 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures w Design Flow.............� -----------------------gallons per person per day. Total daily flow........�U�.....................gallons. WSeptic Tank L Liquid capacitvl'J'1*0gallons Length................ Width................ Diameter----- .--.-_-- Depth_.--.-_-..._. x Disposal Trench—No. .................... Width.... --...... Total Length.._.-_-__._-_..__..- Total leaching area--------------------sq. ft. 3 Seepage Pit No........ Diameter.l ..T� ......` Depth below inlet.................... Total leachit area..-..------_.----sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4- f-I�- `7T /e Percolation Test Results Performed by----------................................................................. Date--------------------------------------- Test Pit No. 1................minutes per inchDepth of "Pest Pit.................... Depth to ground water........---------------- fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water......-.._---------.---- �+ ---- •-y , '/ Description f S tl `'.L �' ' -----r•... - _ . .z w �� ' ----_----------------- VNature of Repairs or Alterations—Answer when applicable---------------------------------------------......................_....__-----.__----- ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ued by e lbr heal /J . jg 0 Date Application Approved By......... t;:. ----------------------- .', -.7.. Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------•-......•----- •---•--•-•--•--------------=-------------------------------------------------------•--•----_-------••----_---••-------------- ........................................................................ Date PermitNo........................................................ Issued........................................................ Date No......................... FICIC..1......................... THE COMMONWEALTH OF MASSACHUSETTS [BOARD F HEAL H Ao"phrFation -for 1 poliFaf Workii Towlitratrtion Vrrnift Application'is hereby'made for.a,Permit to Construct ( or Repair ( ) n Individual Sewage Disposal'y System at Lgca Ad e �!. W .. er : ... ...... — ddress 4 Installer Address Type*of Building g �� , ! Size Lot_...����__Sn. feet . .� Dwelling—No. of Bedrooms--__ __ ___ __________________ Expansion Attic ( ',-) Garbage Grinder a Type of Building ....'__._.__._ No. of persons., .................. Showers ( ) — Cafeteria ( ) .. '� .r - p., Other d Outer fixtures ....•......... ........... Desi n Flow ._. ___ Mons er erson er da Total dai] flow-_____- 111ons. g g P P P' Y daily flow-------- - g< W - R; Scpt.c A tih� Liquid capacity�,� gallons ;Length________________ ���idth_. Diameter___.....:_ .____Depth -• Disposal'"Trench No VVi th_._ �J------- Total Lengt .. .'_:____.. Total leaching area............. ... sq. ft.� "Seepage Prt No I_ Diameter__ .......... Depth below ui]!et___________________ Total 1 ac 11}�area--_. ._-.--_ sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Q�:.l l�• 73' / L __ �.. aPercolation Test YZesults .Performed by------- -- ----- ---------___--- ...... Date-, } Test Pit„No 1 ,;;_ „ „ minute q�er:;irich ...Depth of- Lest Pit?-:-;: ____ Depth to-gr„ound 'vat-er.:__:-. ..� N... a..L.... �.r....... ., t (� Test Pit No. 2..... __:____minutes per inch. Depth of Test Pit_--- _--------------- Depth to ground P'+ J water_- ------ t UD Descriptio f�S it : fie(/ --•- «•. .--"� -- - •----- ------------------ --••- --• ----• . x = ••--------------•---•------ - ----- -•--- U Nature of Repairs or Alterations Answer when applicable .______ ? ............. :. . ............. r ----- -- ------------------- -, ---••• ....................................... ----- -- ------ --------- --------------------- Agreement: The undersigned agrees 'to, install the aforedescribed Individual Sewage'Disposal System'in accordance with the provisions of Article XI of the 'State Sanitary Code— The undersigned further agrees not to place the system iti. ' operation until a Certificate of Compliance has been i ued by e}bz "bf hea Sign I ----. .. Date µ. Application Approved By-;.; _- ,2 .-..7'? ---- Application Disapproved for th, j6llowging reasons: ------------------------------• .__------_-----_••----__- _._-----. .Date--.--___•_-•__ , rt,, ........................................ _______ - __ v __ _ ____ ---__--_---___ __-_-_ __ Date ;. hermit No....... ••= :. ..,a �, Issued- x Date THEOMMONWEAL,T,H.,,OF MASSACHUSETTS BOARD OF EALTH OF... t:L „ THI S T C R 1 That the Individual Sewage Disposal System constructed ( ) or R paired b — Y •• - ........................ = /<--� fi1- ------ --- d - ---- - ------------------------ has been installed in accordance with-the provisions of ; X} The State Sanitary Code as described in the application for Disposal Works Construction Permit No-_._ ....i----------------------- dated '.:`9+ "'�-.�7�.............. THE ISSUANCE OF THIS ,CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THEE, SYSTEM WILL FUNCTION SATISFACTORY � J DATE In ! spector C v ., '. m; THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH V. No............. ( FEE: + zrkV Permissionereby granted. = to Construc ( or epriir'( ) anen�vidia e t sal S at. No.~ ��!'. { i tree ----------------------- - --------- S -----_--- r' as shown on,.-,the application for Disposal Works Construction it Dated_-.-- "' " !'7 e� ---•--•----...................... .G Board of Health DATE.• •--G--.. - FORM '1255 HOBBS & WARREN,.,;INC..'PUBLISHERS