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0266 COTUIT BAY DRIVE - Health
266 COTUIT BAY DRIVE Cotuit TOWN OF BARNSTABLE LOCATION Z(,C, C'�1o%-} o�s ����L SEWAGE# Z020. 192 VILLAGE ASSESSOR'S MAP&PARCEI )0�1 INSTALLER'S NAME&PHONE NO. J;r,B EXCaLxx4 iOn -I'17. OGS3 SEPTIC TANK CAPACITY /` 00 � FI Z O LEACHING FACILITY.(type) -TAtJ D BOX r-olacemcni onlu �t NO.OF BEDROOMS OWNER 1- a PERMIT DATE: 1,-Z9- ZO COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ell A2. �Z Q Gora9c A4- g S AS" 3 �S q No. 2d C 1;L s Fee 1 OO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y Z PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLatlon for MispoSal 6pstem Construction permit Application for a Permit to Construct( ) Repair(,/) Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. 2 toV C.CA%iA 60% DC'NQ/ Owner's Name,Address,and Tel.No. Teff GrandchamP Assessor's Map/Parcel (,o}J;; —0 2 07 y IS- %2 Z. 9521 Installer's Name,Address,and Tel.No. g`j Q L t(cmow-k o n Designer's Name,Address,and Tel.No. 344 Aook-e, 13o So►ndw�o� Sod 0(as 3-.. NA • 0•box onl Type of Building: Jr Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 k on Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ln4cak neo 1560 ape �On CAA(, +0^1C and d-boyonl�� 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. Si M, Date -$ Z0 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued zG No. U d I Fee Q Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS rt 2pplication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(,/) Upgrade( ) Abandon( ) ❑Complete System [,JIndividual Components Location Address or Lot No.1 b(s Cc>A Q,4 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel r o2 v �, - 02 C, y( 2 2 ct 5 g 1 Installer's Name,Address,and Tel.No. pj j r c,,)(.,,} Designer's Name,Address,and Tel.No. . '14`1 Aou�w 130 �,ant�w c1•, �p� •c.t�-4 OC��. N� �oc onl Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) s Other Type of Building No.,of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 14Y 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 n t 1 , nrl 11 , c Prj a Pk Date last inspected: Agreement ; r` 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. , Sign Date r { Application Approved by f Date Application Disapproved by a: Date for the following reasons F Permit No. o.2 a - Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS haX (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(J) Upgraded( ) Abandoned( )by R3 at �� , �r.1., a (� nc, c has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N� _f`7�, dated Installer _ 3 R ,c.r �n r . Designer - #bedrooms . 114 Approved design flow gpd The issuance of this ermit s all not be construed as a guarantee that the system1 fun ion1as design Date ( U Inspector l! "tr �� -- - - -----Z_--------------------------------------------------------------- ------------------------------------------------------ No. 2C)jo / 2 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS i Disposal *pStrm (Construction f-lermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at' ' 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:Constructi n mus be completed within three years of the date of this permit.Q) Date L }v Approved by 1 lf Y 1�Y _ 1. . . { s Ctim�tete items 1,2,and 3. A Signature I N Print your name and address on the reverse X O Agent { so that we can return the card to you. ❑Addressee M Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery or on the front if space permits. 1 ` tress different from item 1 T ❑Yes { - delivery address below: p No MOORE, JOHN F ESTATE OF 266 COTUIT BAY DRIVE ..; COTU IT, MA 62635 I ' i 3. Service II Type o Priority Mail Express®I�III01 III I01 I IIII III II I I I II II III�� I I III ❑Adult Signature ❑Registered MaiITM ❑ dult Signature Restricted Delivery ❑Registered Mall Restricted I , Certlfied Mall® Delivery 9590 9402 5745 0003 5532 81 d Certified Mall Restricted DeliveryReceipt for ❑Collect on Delivery l Merohandise i ?- Article_NunlbeLCfCaaSfer from service labeJ7 ❑Collect on Delivery Restricted Delivery CI Signature ConflrmationTm ❑Signature Confirmation j I 7 015 1730 0001 4987 7 8 5 5__ ill Restricted Delivery Restricted Delivery PS form 3811;JUIy'2015 PSN 4530 02 b(]1-9053 I I . �_ Domestic Return Receipt of`"E*Owl Town of Barnstable f m 1R Public Health Division B,RN ABLE. ' 200 Main Street YN., - y . U.S.POSTAGE>>PITNEY BOWES I MASS. 8 pfFD MP�P`e Hyannis,MA 02601 r, ZIP 02601 006.900 7015 1730 0001 4987 7855 �. r 02 4VV - - 0000.37314.3 JUN. 24. 2020. +A:,i?+ sE MOORE, JOHN F ESTATE OF QAV IICI\/C. NIXIE els PE 1 . 0006/29/20 RETURN TO •SENDER . ATTEMPTED NOT KNOWN UNABLE TO FOPWARD i a Ai 5..i: OZ60149026*0 p * 1522-01646-25 - 43 i �tTti Town of Barnstable Inspectional Services HAMSTASM t 16 9. ,�� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 7855 June 25, 2020 -_ 1v10ORE;JOHN F ESTATE-OF-- 266 COTUIT BAY DRIVE COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 266 Cotuit Bay Drive, Cotuit, MA was inspected on 06/11/2020 by Darrell Stone, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted. • The Health Division recommends removing the large 40' tree growing over leach pit#1. You are ordered to replace the distribution box within one (1)year 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\Title V Inspection Report Letters Mail ing\Conditionally Passes Letters\266 Cotuit Bay Drive Cotuit.doc � sT Town of Barnstable ti 4 Inspectional Services BARNSTABLC p ""' i6J9. �' Public Health Division �� 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 7855 June 25, 2020 MOORE, JOHN F ESTATE OF 266 COTUIT BAY DRIVE COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 266 Cotuit Bay Drive, Cotuit,MA was inspected on 06/11/2020 by Darrell Stone,certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted. • The Health Division recommends removing the large 40' tree growing over leach pit#1. You are ordered to replace the distribution box within one (1) year 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\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\266 Cotuit Bay Drive Cotuit.doc Town of Barnstable y BARNgrABM 039. ,�� Inspectional Services Department Public Health Division 200 Main Street,Hyannis MA 02601 ,Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO t Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last,year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to.a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE`CRITERIA o Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) So dd OT R .Q OVVI ..�U�U re MUvn Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form - lo Subsurface Sewage Disposal System Form Not for Voluntary Assessments {_, —� e% 266 Cotuit Bay Dr Property Address - Estate of John F. Moore Owner O .,•t wner's Naryfe G information is COtUit � y °` required for every MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection .: To .. 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 A. Inspector Information filling out forms p �gSQ9 on the computer, vvjJJ use only the tab Darrell Stone key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return key. Company Name - .. •. P.O. Box 1466 Company Address Harwich Ma 02645 rr— City/Town State Zip Code earn <;'` .:• (508) 240-2500 { S14995 Telephone Number License Number 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 Fu er valuation by t Local Approving Au on 4. ❑ Fails e ' 6/14/2020 Inspect is I ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board p 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 eeport 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 R � Commonwealth of Massachusetts �. Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments e% 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection C. Inspection-Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: }� 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): The septic tank is leaking and requires resealing or replacement The D-box is root infested and requires replacement There is a garbage disposer in the kitchen sink A large 40'tree is growin over the center of leach pit#1. This needs to be removed before it causes a problem. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts p Title 5 official Inspection Form I; Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every COtUIt MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summ' ary (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. ❑ 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): a 4 { t - • ❑ 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 Ej-ND,(Ezplain below): 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 is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M % 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection Co 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: i 4) System Failure Criteria Applicable to All Systems: You must indicate `;Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool :Sinsp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 r Commonwealth of Massachusetts Title 5 Official .Inspection Form w Subsurface Sewage Disposal System Form- Not for Voluntary Assessments e % 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is COtUIt required for every r MA 02635 , 6/11/2020 page. City/Town State 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than A 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z. - 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 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 CM 15:303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. t 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �m ,IF Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 266 Cotuit Bay Dr f Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection Ca Inspection Summary (cont.) r 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 ❑ ® 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)] 15inso.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 1 Commonwealth of Massachusetts �n Title 5 official Inspection Form k Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 266 Cotuit Ba v Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom residential dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El 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: 8/2018 _ 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 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is Cotuit MA 02635 6/11/2020 required for every City/Town/Town State Zip Code Date of Inspection page. Y � � D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: `Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: z5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form' l= b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required forevery COtUIt MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy, r ❑ 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): Approximate age of all components, date installed (if known) and source of information: 1977 per BoH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30 +/_ feet Material of-construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: . feet Comments (on condition of joints, venting, evidence of leakage, etc.) . Apparent good condition t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts b p Title 5 official Inspection Fora & Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): . -Depth below grade: 24"feet Material of construction: 1 ® 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: 1250 gallon Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is leaking and requires resealing or replacement Concrete tees Recommended next maintenance pumping within 1 year Recommended maintenance pumping every 2-3 years t5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �m 119 Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection Do System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ poi eth lene• y y El 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.): r 8. 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 t5insp.doc•rev.7/26/2015 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Tile 5 Official 'vial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 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): Depth of liquid level above outlet invert . 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Grade to box 27" 2 outlets Root infested The D-box requires replacement 5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 i r ` Commonwealth of Massachusetts p Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is required for every COtUIt MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection Do 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.): s - t * If pumps or alarms are not iri working order, system is a conditional pass. 11. Soil Absorption System SAS locate on site Ian excavation not required): p :q ) If SAS not located, explain why: 4 S " Type: . ® leaching pits +' ' number: 2 ❑ leaching chambers number: • ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑. , overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.7/26/2018 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I, Commonwealth of Massachusetts �rt I Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 266 Cotuit Bay Dr Property Address Estate of John F. Moore ' Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 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.): 2, (6x6') pits with stone P1 Grade to pit 33" Bottom 117" Dry Staining @ 12" from the bottom No sign of hydraulic failure A large 40' tree is growing over the center of this pit and needs to be removed. P2 Grade to pit 32" Bottom 116" Dry Staining @ 12"from the bottom No sign of hydraulic failure 12. 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 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 r Commonwealth of Massachusetts A Title 5 Official ,inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 266 Cotuit Bay Dr Property Address Estate of John F. Moore I Owner Owner's Name information is COtUIt T required for every MA - 02635 6/11/2020 page. Clty/Town State Zip Code - Date of Inspection D. System Information-(cont.) - 13. 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.): x • ICI 9 t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 II, Commonwealth of Massachusetts Title 5 . Official inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z � 266 Cotuit Bay Dr Property Address Estate of John F. Moore Owner Owner's Name information is COtUIt required for every MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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: ® hand-sketch in the area below ❑ drawing attached separately ' I•— •— •— ? i 1 3 � J P;L r A Bl I3•-7 7_ % t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r, Commonwealth of Massachusetts im I Title 5 Official Inspection Form .w Su bsurface Sewage Disposal System Form -Not for Voluntary Assessments . ^ 1� 266 Cotuit Bay Dr Property Address. Estate of John F. Moore Owner Owner's Name ' information is required for every Cotuit MA 02635 6/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells . Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers'-(attach documentation) ❑ Accessed USGS database-explain: You must describe'how you established the high ground water elevation: Elevations from USGS maps are approximate Property ELV. 34.0 Bottom of SAS P1 ELV. 24.34 ' Bottom of SAS P2 ELV. 24.25 GW ELV. 15.0 Adjustment= 0.8' MIW-29 Zone C 6.32' May 2020 Separation >4' - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts z . l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 266 Cotuit Bay Dr u y Property Address Estate of John F. Moore Owner Owner's Name information is required for every Cotuit MA 02635 6/11/2020 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 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 t 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 AsBuilt Page 1 of 1 %A F� LOCATION S E W A _E PERMIT NO. VILE E _ . INSTA LL`ER"S . NAME & ADDRESS B UIlDE R OR OWNER DATE ' 'PERMIT ISSUED /-5 -, �' DATE COOPLIA.NCE ISSUED t http://issgl2/intranet/propdata/prebuilt.aspx?mappar=056029&seq=1 4/11/2019 7� - 7,� LOCATION S-EWAC,,E PERMIT NO.. VILLAGE INSTALLER'S NAME & ADDRESS ,A�g B UI-LDE R OR OWNER DATE PERMIT ISSUED7 DATE COMPLIANCE ISSUED t2�� G � No 6).7-3..... e FER THE COMMONWEALTH OF MASSACHUSETTS BO.ARD OF JHALTH Appliratinn -for Uii oiial rkii Towstrurtion Prrutit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal (Qystem at• R p J`'' . • 6 . ._- a. .............................. .................................... . ... ............ .---•---_---............----._........ ocation-Address or Lot No. _ Owner ( Address X;� a ... ................... ----------------------------- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_.__.___.................•.__..•_.=.__Expansion Attic (l�� Garbage Grinder (VD P14 Other—Type of Building ---FZA&fe__:.... No. of persons--------*----------------- Showers ( ) — Cafeteria ( ) a Other fixtures ------------- w Design Flow------------------------------------I - tllons per person per day. Total daily flow............................................gallons. WSeptic T•:nk- Liquid capacity gallons Length---------------- Width.------ ._..... Diameter-_--__.-._.-.-- Depth---------- Disposal Trench—No. Width.--------- - Tot Len ------------- Total leaching area sq. ft. Seepage Pit No..___`�.•.....____ Diameter. .. l�be�m e _..�............... Total leach G e i __ sq. it. ----------- z Other Distribution box ( ) Dosing tank ( ) — ®,,�, ;j�' �`- 7� P Percolation Test Results Performed by--------------............................................................ Date............--------------- ---------- `�a Test Pit No. 1......__ _____minutes per inch Depth of Test Pit____________________ Depth to ground water----------- ............ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-. --__----.---_---- f� Description Of it------ v ......' - --- ----- ----- U 02-------IL7:------- ......e, -?�Z/ wN-------------- --------------- --------------------------------------------------------------------------------------------------------------------------------------- -------------------------- UNature of Repairs or Alterations—Answer when applicable......----------------------------------------------------------..__.-----.--_._-____------___.. Agreement'• The undersigned agrees`to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beMnssued by the board of health. ed..- .....-- 6 '-=--a------=------- ............ �i Date Application Approved By.. -•--• '�`' .. Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -_-•--...._..---•------•--_-----••••-------------- -••--•---•-•-••--•--------•----•-•---__----•-------_...---------••---•-•_-----•---•- ----------- ................................................. Date PermitNo......................................................... Issued........................................................ Date No.. . ._ _+ Fizz... '".'........ THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH .. --...-.,OF I Application -fear DhiVl ,iittl Works Tn' tuitrurtinn Vamit Application is hereby'made:'for a, Permit to Construct ( ); or Repair (: ) an Individual Sewage Disposal Syst at ocauo - d ess t No ' ... Owner � Address - a . ........................ 5 •. --- -••-•••--• '------._--- --•.......... ......... Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_____�___ _______________________________Expansion Attic ( Garbage Grinder a`4 Other—Type of Building __-___//- yp g �d`-�t�l�'.f�_____. No. of persons______'________________ Showers ( ) — Cafeteria ( ) QOther fixtures ----- ------------------------------------------------------------------------- ---- W Design Flow___________________________________.�g4lpllons per person per day. Total daily flow------------------------------- ---------------gallons. WSeptic Tank—Liquid capacity ; ,_ ,_gallons Length----------_--- Width---------.-__-- Diameter___.-----_-____ Depth----___-__-__--. Disposal Trench—,No_ ___________ _______ Width_.__.._..___ Tot Len 1 Total leaching area-------------.------sq. ft. x M Seepage Pit No.___��_`_::__:_:_ Dtameter_ Q �..� 1 ' Total leach3t e e ow in .___.__ e sq. it. Z Other Distribution box ( ) Dosing tank ( ) .►.�, f "' s Percolation Test Results Performed by..---- _____-__-:_. ,: I at '" _' � �$ � Test Pit No. 1................minutes per inch Depth of 'lest Pit 6 Depth to gr nd water z I f� Test Pit No. 2_-"_____________minutes per,inch Depth of rest Yit DeptI to g ound iyater 'air � ....I� r ' M A D Description of it---=- �f � �� Wj� sw a x - --------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ ----------- --------------------------------------------- --------- UNature of Repairs or Alterations—Answer"when applicable-----------------------------------------:......I..________-__--____-_:-_.-------------------- ------------------------------------------------- - -=------------------------------------ Agreement The undersigned agrees to'install the aforedescribed Individual Sewage Disposal` System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be:, ' • sued by the board health. dI TA ` n ---=-ed. ' ------ 'r e s D to Application Approved B l� Date Application Disapproved for the following reasons:___----•---••-•---•----=-----------------------=----------------•-•------------••-•----........................ -••-•---•--------•-----..--•-•-•---•---• -•---------------------••--•---••-------•-----•-•-•-•-----------••---..-:..----------------------------------- Date Permit No.-------_-- Issued------------------------------------ Date THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH , ....• f•- t?!..............OF..... ... :. ..� ........................................ >x 0. /' %rrtifirab"�>af f�nntVli nrr THIS S,:TO GERTIFh', That thg Individual Sewage Disposal System constructed ( or Repaired ( ) .... by ._...._. ......................... ------- s Iler 7- JG_ has been installed in accordance with the pro ions of Arti I of The State Sanitary,Code as described in the - application for Disposal Works Construction Permit No---` __.......'„?.........__ dated-.-- :e _____________ THE IS OF THIS 'CERTIFICATE SHALL NOT BE CONSTRUE© S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ............... -- ..... -------•---- Inspector_...... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD QAJ HEALT No.,................. FEE.__ __ ..._.._.. %spm tt .>arkii T . gtrnrt nn "prrntit Permission is hereby granted_._:._ •--- •= ' ...* -- - -------------------------------------....................... to Construct or Repair an ndi al Sew Di'ltspos treet * � .,.,�� _ as shown on the application for Disposal Works Construction.P it No. ated .-----•-_.__ Board of Health DATE................. FORM 1255 HOBBS & WARRENt' INC..h PUBLISHERS " 1.3 ` .amr • , :w i : ; .ram r Cc �t =-Yi 'l TvfJA,tz-rzv ' �8 To cc�� Ns �M A Bruce Associates f,v PLAN SCALE 0 ENGINEER LOCATION HOUSE SIZE Zoo � �: