Loading...
HomeMy WebLinkAbout0322 COTUIT BAY DRIVE - Health 322 Cotuit Bay Drive Cotuit \ A= 055-005 �---- — --- -- r TOWN OF BARNSTABLE CATION WILLAGEO,C. ` ESSOR'S MAP&PARCEL ' NAME&PHONE NO. �r X knnorwal I Nd&-r SEPTIC TANK CAPACITY JQ0 LEACHING FACILITY. (type) (size) 000 NO.OF BEDROOMS OWNER a PERMIT 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 etlands exist within 300 feet of leaching facility) Feet FURNISHED BY t h•\r I P I•f v f f f f f • 7 f f r S I •e? f f f f f r r r .+ r f f ! r f f'r r f. - � v t \•h h,.h t h h t t 4 'v \ k \ h .t k t k t t ' / f•7 r P f f i f J ? ? f f i i r f f % f f ? f / f \.'\•\ h \ \ h 1 h h \ h h k h h h h \ \ h h h.\ h ' 'r f•! ! f f f f f r f ! f r f f r f f P-. r f ! f f f r r f v \ \ h h'•t \ \ t h \ t h t h v. h v. h h t h t h h'k t t t \ h t h r f f r f f- f ..f'f f ?' f r f• �f f 7 f r f r f.f t t h t t•tt ':?t•\ t t rtftft t•tft t`trt ♦rt h h h +. t ',.t i r r ? r ? ? �? f '? _ ?�•? r ? 7 f:? f f' f r�•? I t krh.h kr h tr +\ \lt hhr ti.r. \ h t•h \ tr.t.1 \ hr 4 t h h t \ h \ k t h 33 21 25 52 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A r 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is Cotuit MA 02635 April 15, 2011 required for State Zip Code s Date of Inspection every page. City own Inspection results must be submitted on this form. Inspection forms may not be altered in any way:Please see completeness checklist at the end of the form. Important: A. General Information_. When filling out forms on the I Wo computer,p ,use 1. Inspector: only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. — Company Name rab 189 Cammett Road µ Company Address too Marstons Mills -MA 02648 _ remm City/Town State Zip Code 508.428.1779 SI 12855 tom' Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev , tion by the Local Approving Authority N' April 15, 2011 Job# 11-53 VInsecto—rr's Sign ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t Title 5 Official Inspection Form:Subsurface Sewage DispoPiSystern•hgWe 1 of 17 0 l5ins•09108 , i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 322 Cotuit Bay Drive Property Address ' Thomas Melia Owner Owner's Name information is Cotuit MA 02635 April 15, 2011 required for -- - - every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in.310-CMR.1,5303 or in 31.0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need:of pumping at this time leaching pit had not been more than 1/3 full. B System Conditionally'all Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. . Check the box for"yes", "no" or"not determined" (Y, N. ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a'Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive — Property Address Thomas Melia — Owner Owner's Name information is required for Cotuit MA 02635 April 15, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken:pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. 'System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within.50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w., 322 Cotuit Bay Drive Property Address Thomas Melia _ Owner Owner's Name information is Cotuit _MA 02635 April 15, 2011 required for -- --- - - every page. City/Town State Zip Code Date of Inspection B. Certification '(cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health; safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply., ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance. This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a,.•''� 322 Cotuit Bay Drive _ Property Address Thomas Melia _ Owner Owner's Name information is required for Cotuit MA 02635 April 15, 2011 - — every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspooi of privy is within`100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of.a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El 1-1 Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 a r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive _ Property Address Thomas Melia _ Owner Owner's Name information is required for Cotuit _ MA 02635 April 15, 2011 - every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive _ Property Address Thomas Melia Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2011 required for _ P every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 - Number of current residents: — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): — Detail: ' Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 at 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is P required for Cotuit MA 02635 April 15, 2011 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped in 2004 — Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the.DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2011 required for — p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1976 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): • 1, Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 1 _ Depth below grade: feet Material of construction: ` concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide - 1000 gal. -- — Sludge depth: 2„ — 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2011 required for _ p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" — Scum thickness Trace Distance from top of scum to top of outlet tee or baffle b' Distance from bottom of scum to bottom of outlet tee or baffle 13" — How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and baffles were intact and clear. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: 1 - ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Scum thickness — Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2011 required for _ p every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: — gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is required for Cotuit MA 02635 April 15, 2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01 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.): No solids or high stains present. 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.): Soil Absorption System (SAS).(locate on site plan, excavation not required): If SAS not located,explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is p required for Cotuit MA 02635 April 15, 2011 - every page. Cityrrown . State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was empty at time of inspection with a stain line at 1/3 capacity. 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 l5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2011 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f . t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay-Drive - -- --------------- - Property Address Thomas Melia — -- Owner Owner's Name information is Cotuit MA 02635 April 15, 2011 required for - every page. City/Town -- State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately 32 ;% r J•ram .,r\/\,\ \ \ \•\•\`\ \ \ \ ,• r\ `• \r\!\r r_ \ \ h ! f 33 21 25 52 x Cotuit Bay Drive r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia _ Owner Owner's Name information is required for P Cotuit MA 02635 April 15, 2011 every page. CitylTown .State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells , , Estimated depth to high ground water: 20+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: a ❑ Checked with local excavators, installers ; (attach documentation) ® Accessed USGS database- explain: USGS topo map and town GIS. _ You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 20 and topo map shows property above el. 40. Before filing this Inspection Report, please see Report Completeness Checklist on next page. !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 322 Cotuit Bay Drive Property Address Thomas Melia Owner Owner's Name information is required for Cotuit MA 02635 April 15, 2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF 1VIASSACHUSETTS =ti EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMEoNT`OF ENVIRONMENTAL PROTECTION . PEAR PARCEL ® � J LOT �- 9 TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: oZ RECEIVED .Owner's Name: .1UN.. 2 12004 Owner's Address: /0 ( U TOWN OF BAR NSTABLE Date of Inspection: / HEALTH DEPT. Name of Inspec (plea e print) --t�'.�V� Company Nam � ) Mailing Address: Telephone Number: _ �' `7'7/.. CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete.as of the time of the inspection. The inspection was performed based can my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved.system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Is Inspector's Signature: Date: 1-71 ' The system inspector shall submit a copy of this inspection report to the Approving'Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/200.0 page I Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR 'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: / Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I/ I have not found any information which indicates that any of the failure criteria described in 310 CMR` 15:003 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,.upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 pipes)are replaced obstruction is removed distribution box is.leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION.FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A, CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing'to protect public health, safety orthe environment: 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the. system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a.manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. - The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A;copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ?)G Owner: _ Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding:of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number l of times pumped 1/j An onion of the SAS cesspool or privy is below high ground water elevation.Y P p p .�y g �r anon. Any portion of cesspool or privy is within 100 feet of a surface,water supply or tributary to a surface water supply. I/ An portion of a cesspool or privy is within a Zone 1 of a public well. YP P . P Y Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is,free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen,is equal to or less than 5 ppm, provided that no other failure criteria. are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large_system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd. You must indicate either"yes"or"no"to each of the followin-: (The following criteria apply to large systems in addition to the criteria above) 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—I WPA)or a mapped Zone Il.of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ,4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B' CHECKLIST Property Address: Owner: vjrq Ali ` Date of Inspection: Check if the following have been done.You must indicate"yes"or'n*o"as to each of the following: Yes 11No Pumping.information.was provided by the owner, occupant,or Board of Health - _Z 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 backup? ' (/ Was the site inspected for signs of break out? ` f_ Were all system components, excluding the SAS,located on site? _V _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner• Date of Inspectio : FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. . Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms):3 a) Number of current r esidents:2%—,t Does residence have.a garbage grinder(yes or no): /aO Is laundry on a separate sewage system (y s or no):/7()[if yes separate inspection required] Laundry system inspects y s or no): Seasonal use: (yes or no): Water meter readings, if a ilable'(last 2 years usage(gpd)):Aa � Zi 0(�O Sump pump(yes or no): �� y Last date of occupancy: r COMMERCIAL/INDUSTRIAL'At Type of establishment- Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats✓persons/sgft,etc* Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system.pumped as par'.of the in pection(yes or no)- If yes,volume pumped: gallons--How was qu tity pumped determined? Reasori for.pumping: TYPE OF SYSTEM OF tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy'.of the DEP.approval _Other(describe): prox'rnate a e of all co ,po ents,d to installs '(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no) 6 Paee 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:LAO � v Owner: Date of Inspection: BUILDING SEWER(locate on site plan)��.{� Depth below Grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK:Zoocate on site plan) Depth below grade: e� Material of construction: concrete metal fiberglass olveth ]ene — — b _P y —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes!or no):—(attach a copy of certificate) y Dimensions) , Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle. Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: 6 r. Distance from bottom of scum to botto of outlet tee or baffle: How were dimensions determined: /)dD� j� ,�pJ Comments (on pumping recomme elation , inlet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert evidence of leakage, etc,): �. Q GREASE TRA%locate on site plan) b .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.): .. 7 Page 8 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: (/ Owner:. Date of Inspection. 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.:- <ofher(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm.present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION B.OX: t/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:2&_2A Comments(note if box is level and distribution to.out equal, any evidence of solids carryover,any evidence of ,-1 kage into or out of box et ): Aej � C PUMP CHAMBER%(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Date of Inspection. SOIL ABSORPTI SYSTEM (SAS): 1/ (locate on site plan, excavation not required) If SAS not located_exp`lain why.: '' Type leaching pits,number:L 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, Awl �2 CES LS: cesC spbbl must be pumped as part of inspection)( ocate on site p n) 30 Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRI7-9—W-(ocate 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.): 9 Page 10 of I I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: `v Date of Inspection: _ O©Q SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. CV t Cowes , ,`gin K D)FS4('t rCX> 10 Pace 1 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: Owner: Date of Inspection: / CW07 SITE EXAM Slope Surface water Check cellar - _ Shallow wells Estimated depth to ground water j feet Please'indicate(check)all methods used to determine the hi-h ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: 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: E { 11 '. 1 A h Y i � Perrnit Number: Date Completed by: �L 1 C E HIGH GROUNIID-WATER LEVEL COMPUTATION" ` yzt Site Location: 1/ �i�• Lot No. fl w Owner: l'd'1 Address: i k ti. Contractor: Address: i as a Notes: STEP 1 Measure depth to water table � to nearest 1/10.ft. ...................... ...."........... .Date TMs:�r `" '� month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: },,�/� �� OA Appropriate index.well.:.:..................... 9" .IV " © Water-level range zone ........ ............................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to ay water level for inde), vmll ........................... as` T__) month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth. to water level for inde;< well (STEP 3), and water-level zone (STEP 213). determine water-level adjustment ........................................................................................... 1, 11 STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) ( from measured depth 'to water p levelat site (STEP 1) .... ..............................:.............:........":.............:......:........................... Figure 11--Reproducible computation form. 71 f� • _ t TOWN OF B�4RNSZ'ABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted GroundwaterTable'and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands e,ist within 300 feet of leac ng f 'li Feet Furnished by 9t t vit DATE: 6/14/99 PROPERTY ADDRESS: 322 Cotuit-- Bad Dirve___ ------ Cotuit, Ma. On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1 000 gallon septic tank 2. 1 -1000 gallon leaching pit L� 3 . 1 - Distribution box . Based on my Inspection, I certify the following conditions: 4 . This is a title Five Septic System. ( 78 Code ) 5. The septic system is in proper working �r order at the present time. 6 . Waste water is 50" below the invert pipe to the leaching pit . SIGNATURE:fZ6 Name:_,���L Company: Jose2h_P. Macomber-& Son , Inc . Address: Box 66 Centerville , Ma . 02632-0066 -------------------- Phone:-_ 08_775-3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY COS. P. MACOMBER & SON, INC. �� anks-Cesspools-Leachtlelds RECEIVED Pumped & Installed Town Sewer Connections tp' J U L 1 3 1999 66 Centerville, MA 02632-0066 775.3338 775-6412. TOWNUMNSTAM • FIEAITH DEPL �� r— COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COX Setreta ARGEO PAUL CELLUCCI DAVID 3. STRI'h Governor Co:r�.ss:cc. SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Nog-rTY Addr—:322 Cotuit Bay Drive Name of Own.,Marilyn Smith Church Cotuit Adaess of owns.:5 Snow Hi1T7—.;;ne 0su oI VupeCdcn: 6/1 � Medfield, Ma. 02052 Na me of Irup.etor:(Plaasa P oseoh P. Macomber Jr. I am a OEP approved system inspector punuarst to Section 15.340 of T1de 6 (310 CMR 16.000) company Nana: Joseph P. Macomber & Son, Inc. M-LW Address: Box 66, Centervi 1 le., Ma 02632-0066 T d.phone Number:5 0 8-7 7 5--j-3 j R CERTIFICATION STATEMENT I certify that I have personally Inspected the sewsge disposal system at thla address and that the Information reported below is true, accurete 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•31tt age disposal systems. The system: Passes Condidonally Passes Needs Further Evalu tion By the Local Approving Authority _ Fails �j inspector's Signature: > Date: The System lnspecto hall submit a copy of this Inspection report to the Approving Authority (Board of Health or OEP)within thirty 00) days or 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 Mall submit the report to the appropriate regional office of the Department oKnvironmenial Protection. The original should oe sent to Trx system ownst.and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS I I revised 9/2/98 Page Iof11 `� Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (co►tkwed) Property Address: 322 Cotuit Bay Drive, Cotuit Owner: Marilyn Smith Church Date of Inspection: 6/1 4/9 9 INSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure .criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDI'iIONALLY PASSES: One or more system components as described in the 'Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes..no, or not determined(Y. N, or ND). Describe basis of determinatJon in all Instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is Imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box Is levelled or replaced �- The system required pumping-more than-four-dmes a yeardue to broken or obstructed pipe(s). The System wHlpass-- inspection If(with approval of the Board of Health): broken pipe(s)are'replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 322 Cotuit Bay Drive, Cotuit °r"'" Marilyn Smith Church y 6/14/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Condidons exist which require further ov►Juadon by-the Board of Hsalth In order to determine If the system Is failing to protect tTe public hsalth, safety and the snAtonmont. f 1) SYSTEM MU PASS UNLE, S BOARD OF HEALTH DETFSt�tiNES W ACCORDANCE WfT1i 310 CI.tA 16.303 (1)(b) THAT THE SYS IS NOT FUNCTIONING W A LL&NNER W=KYALLPROIECT Trig PUBUC HEkLT)'AN0 SARTY AND THE DC BONM,FXT. Cesspool or privy Is within 60 testnf surface water Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)OETERS.t1NES THAT THE SYS-M FUNCTIONING W A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRON)AEM: NLb The system has a septic tank and toll absorption system(SAS) and the SAS Is within 100 lest of a turlacs water iuppry uibutary to a suriace water supply, The system has a septic tank and soli absorption system and the SAS Is wlthln a Zone I of a public water supply wau. The system has a septic tank and ao11 absorption system and the SAS Is wlthln 60 lest of a private water supply -au. The system has a sapdc tank and soil absorption system and the SAS Is less than 100 feet but 60 last or more from ► privats water supply wall, urtlsss a well water an►lysls for coUform bacteria and volatile orguvc compounds in6csca6 tr.a weU Is free hom poilutlon from that facility and the pros nco of immonla nlu Q ogen and Nuate Nuogan Is • ual to or lei, than 6 ppm. Method used to deta(mine distancs •�,$ (approxJmadon not valid).• 3) AOTHER XX /W i revised 9/2/98 Pats 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropeRYAddress: 322 Cotuit Bay Drive, Cotuit own,&(: Marilyn Smith Church Dana of Inspection: 6/1 4/9 9 D. SYSTEM FAILS: You must Indicate either 'Yes' or 'No' to each of the following: �J 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 1 5.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No , Backup of sewage into Ifeci4ity-or• m eie component due'to an overloaded orcbgged'SAS or cesspool. Y Discharge or ponding of effluent to the surface of the ground or surface water& due to an overloaded or clogged SAS or cesspool. Static liquid level In th 1dI t ibtytion box above outlet Invert due to an overloaded or clogged SAS or cesspool. Liquid depth in is less than 6' below Invert or available volume Is less than 112 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipelsl. 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 la-within a Zone l of a public well. Any portion of a cesspool or privy Is within 50 feet of a private water supply well. -y Any portion of a cesspool or privy Is lest-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the wail has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organio•compounds, ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either 'Yes' or 'No' to each of the following: The following criteria apply to large systems In addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd 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: Yes No _ �/ the system Is within 400 last of a surface drinking water supply the system•,is within 200 leatol�t+ibutary�oa surfaoodrinkKag 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 upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforirtadon. i. revised 9/2/98 Peee4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropaM Address: 322 Cotuit Bay Drive, Cotuit Owner: Marilyn Smith Church Date of Inspection:. 6/1 4/9 9 Check if the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following: Yes NV01, Pumping information was provided by the owner, occupant, or Board of Health. •None of the system<orrspoaertts.bs+w:hean pumpad4opat,leasttwo•v+eaJccarsr}the'rystem hasbaooaeceitbwg+w.aaJ 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. _ 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, All the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of baffle Of teas, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C Is at issue, approximation of distance is unacceptable) / 115.302(3)(b)J The facility ownar.Can d.n:c_upants.i1 diHaraW trout.ownerl.were.prcyided.with Intnrmatioa.on t"a p:zpw_zaa!n f SubSurface Disposal Systems. Page revised 9/2/98 Ps e l SUI SU,t�aCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop-tyAd&—; 322 Cotuit Bay Drive, Cotuit I Owrw Marilyn Smith Church` Date of Inspection: 6/1 4/9 9 FLOW CONDITIONS RESIDENTIAL- Design flow:�g.p•d./I Number of bedrooms (dasigNumber c )adrooms(ectual):�Total DESIGN flowNumber of current residentGarbage grinder(yes or no) ry% Laundry(separate system) es or kg--_:` :aparatsdnspaction.required Laundry system inspected y� or no) Seasonal use (yes or no): Water meter readings,It av ilable (last twc tee 's usage (gpd): Sump Pump (yes or no):YA,�l Last data of occupancy:'/,`,'.. L�r COMM ERCIALANDUSTRLAL: Type of establishment:___... Design flow; _opd ( Based or, 15.:::3) Basis of design flow___ Grease trap present; (yes Lr no) Industrial Waste Holding Tank present: (yes or ;. Non sanitary waste dischs:ged to the Title 5 s�: rn: (yes or nOW0 Water meter readings, If t v ailable:_��__._.._ Last date of occupancy:. OTHER:(Describe) _ _ _____ _ _ Last date of occupancy:__ GENERAL INFORMATION PUMPING RECORDS and 5:)urce of inlur� System pumpud z s part of inspec:ion: es or no) ff If yes, volume Pumpe _R_ -d: _ 5 ...ts Reason for pump.ng: _. TYPE 0 SYSTEM Septic tank/dist:i ution bcxlsoil ,,': sc: .. Dn system Single cesspool Overflow cessp_'.�l Privy Shared system (,-is or no) lit yvi, ar' previous inspection records,If any) I/A Technology .:z. Attach cui y A L:.. data operation and maintenance contract Tight Tank .( Copy of/DE-P Af; :. ral Other AP OXIt:1 T,EE AAGE c all G::o(npppnaaannu:, .':c i.: ',I'ad{il kno n)•an source,ol•information: 4')06 Sewage odors detected wi.an•arriving at u _ s:• ;yes or no) � revised 9/2/9�-) Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertYAddrau: 322 Cotuit Bay Drive, Cotuit OWTW: Marilyn Smith Church Dote of vw%pectton: 6/1 4/9 9 BUILDING SEWER: (LowI on site plan) Depth below grads:.; M&terial of construction:_cast lion O PVC,(?,d-other(explaln) Distance horjt,Q(Iv+te caster supply wall or suction line ' Diameter //yy// Comments:(condition of Joints, venting, evidence of leaJcage,-etc.) e . ' ent . x (louts on site plan) nn Depth below gr&ds:0p0 Matarlal of construction:__ concroteA/&otal8FiberglassovAPolyethylone;Llgother(explain) If tank Is metal, list age Js.aga.conNmed by CortJficate of Compliance (Yes/No) Dimensions: /!! Sludge depth: Distance from 09,29 udge to bottom of outlet tea orbs`j Scum thickness: Distance from top of scum to top of outlet tee or baffle Distance from bonom of scum to bottom of ouUot tee o batflo:a�wQ How dimonslons wets det&rmJned: Comments: (recommendation for pumpin , condition of Inlst and outlet too& or-baffles, depth of liquid level In relation to outlet inverl. rwcwro-;:�caGrr evidence of leakage, etc.) rum tank Inlet & Outlet iq tt s no evi ence GREAS (locate on sits plan) Depth below grade:�� Matsrial of con&Uucdonlf// concret*4*moW#lborglass4�dPolyethyleneVAther(e API ain) All Dimensions: Scum Wckness: Distance from top of scum to top of outlet tea or batfls:—" Dist&ncs from bonom of squin to bonom of outist.%so or baffle: � Data of last pumping: Comments: (recommond&tlon for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relauon to outlet invert. itrucrural int,,n evidence of leakage, etc.) Grease tra revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop*MAddre.s;: 322 Cotuit Bay Drive, Cotuit Own,": Marilyn Smith ' Church Date of 4upection: 6/1 4/9 9 TIGHT OR HOLDING TANK(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of constructlon-4concretedmetalll�Fiberglass��Polyethylenet Qothar(explain) Ia AW Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm In working order:Yestw N04 Date of previous pumping: )A _ Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) ig or holding tanks arp not present . DISTRIBUTION BOx:z (locate on site plan) Depth of liquid level above outlet Invert:_ Comments: (note if level and distribution is equal, evideno* of solids carryover, evidence of leakage Into or out of box. etc.) — — Distribution hay has one lateralaNe evidenee of- solids PUMP CHAMBER:(. (locate on site plan) �/ Pumps in working order:(Yes or No)14 Alarms In working order(Yes or No)v Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) Pump c'hnmhar i e uotpr-grg9 �+ revised 9/2/98 Page 8ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corronued) PTopaMAddrass: 322 Cotuit Bay Drive, Cotuit Owner: Marilyn Smith . CHurch Data of llspac6w: 6/1 4/9 9 SOIL ABSORPTION SYSTEM(SAS): fy�llecl. �� (locate on sit@ plan, If possible:excavation not required,location may be approximated by non-intrusive methods) It not located, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leeching trenches,number, length: leaching fields,number, dl ensions: !ir--I overflow cesspool, number Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation.,etc.) Loam o rau ion is n er isAvert- PTV- - CESSPOOLS: (locate on sit@ plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids Isyer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of Inspection) " oo s are not pr Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of.vegetation, etc.) ess o PRIVY: 604e- (locate on site plan) Dimensions: Materjals of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation;etc.) Pr revised 9/2/98 . Page 9of11 SUBSURFACE SEWAGE OLSPOSAL SYSTZM WSPECTION FORM PART C SYSTEM WFOR1dAT10N (con*x)od) PropoMAddrau: 322 Cotuit Bay Drive, Cotuit Gam^'" Marilyn SMith Church 0 du of 6/1 4/9 9 SKETCH OF SEWAGE DLSPOSAL SYSTEM: Includs tlaa to at'Isast two p@rmanant rslarsncs landmarks or benchmarks lout@ all wells wlWn 100' (Louts whirs public water supply comas Into house) \ \ � < L0 revised 9/2/98 Pall 10of 11. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ProaertyAddr-322 Cotuit Bay Drive, Cotuit Owrw:Marilyn Smith Church Date of kupect! 6/1 4/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record O�rved.Site (Abutting propert bservation hole, basement sump etc.) Determined from local conditions Checked with local Board of health �hacked FEMA Maps acked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map. Gaherty & miller Model 12/16/94 revised 9/2/98 Page 11of11 � •r.n r..-n TT�'TT-\rnlJIA•/.iPwl�"AII n+TJ•I..R RT'T 1TIr/TATRIAA TTwil♦T.I11T�1Ir1n .T•n•1-r�-T'.r-'..�...- TOWN OFBARNSTABLE BOARD OF HEALTH 11( SUBSURFACE SEWAQE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERrIFICATION 1 •Tt1•T•'•t:.-T.IIR�•TTTtn rTl'11.11r1 T{1fIR1fITnT•I'T�A7r1VPR11RRR�TT��IR1I..n•1r�1R� RA1n1nRRRSinrTT.Tr.++•.�r.rr't...�, �..� =TYPI OR PRINT CI.LARL1'- PROPERTY INSPECTED STREET ADDRESS 322 Cotuit Bay Drive, Cotuit ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Marilyn SMith Church PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber- Jr. COMPANY NAME Joseph P. Macomber & Son, Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 02632-0066 Street Town or City State !IF COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578 a 9 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 any recommendatlons regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . CheI c one : Systeui 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 conaticted has found that the system fails to protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature One copy of t)lis ertification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF WHAL7'1(: • If the inspection FAILED, th'e owner or•"oparator shall upgrade within one year of . the date of the inspection , unless allowedortrequiredhe m otherwise as provided in 3.10 CMR 16 . 306 . partd . doc TOWN OF BARS"TABLE LOCATION J5, t—Ed SEWAGE # r r'.LAGE ASSESSOR'S MAP & LOT SEPTIC TANK CAPACITY LEACHING FACILITY: (type) iCCE� gip' ' (size) AiL NO. OF BEDROOMS BUILDER OR OWNER /l Y�&d PERMITDATE: 4 f- q / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of WetlanAfffeac ching Fa i.lity any,wetlands exist within 300 f fa ilit Feet Furnished b j cr ' ay DATE: 2/5/97 PROPERTY ADDRESS: .322 -Cotuit -Bay Drive Cotuit,Mass . [DECEIVE® FEB 7 1997 02635 HEALTH DEPT. TOWN OF EARNSTAGLE 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 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. Based bn my insrwction, I certify the following conditions: 1 . This is a title five septic sy`stem. ( 78 Code ) 2. The septic system is in proper working order-- at the present time . 3 . No repairs needed at the present time. SIGNATURE: G`�( Name: J. P.Macomber Jr.. i Company:_`. P_Macogber & Son-_Inc . , Address' Cente_rvill,e LMass__02632 Phone:__-50•&_7.75�3338------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • 1 JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachf lelds Pumped & InsUlled Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775.3338 775-6412 Ul Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of environmental Protection Trudy Coxe BeKraury :� .. David B. Struhs U.GQ"v— (gfMlit�igrlfar s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 322 Cotuit Bay Drive Cotuit Address of owner. 5 Fields Pond Road Date of inspection:2/4 97 (If different) Weston,Mass . Nameoflaspect.or.Joseph P.Macomber Jr. 02193 Company Name,Address and Telephone Number. J. P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information repotted below is true, accurate sad complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and mainteasncs of on-site "wage disposal systems. The system: asses Conditionally Pasees Needs Further Evaluation By the Local Approving Authority Fails lospectoes Signature j / The Syrtem 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 syrtem 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 wd copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check & B, C, or D: A)27ve PASSES: _ not found may information which indicates that the system violates any of the failure critaria as defined in 310 CUR 15.303. Any failure eriaria not evaluated ate indicated below. 8) SYSTEM CONDITIONALLY PASSES: On*or more system components aced to be replaced or repaired. The sygtem, upon completion of the replacement or repair, passes inspection. Indicate yea, oo,or not determined(Y, N,or ND). Describe basis of determination in all instances. If'not determined',explain why not) The septic taak is metal, cra:kad, structurally unsound, shows substantial infiltration or estiltration,.or tank failure is =miaeat. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank u approved by LLe Board of Health. (revised 11/03/95) 1 One Winter street a Boston, Massachusetts 02108 a FAX(617) 55&1049 a Telephone (617) 292.5500 �� vnnied on R"kd rape SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) pr.pO1,t,Add,,a,[ 322 Cotuit Bay Drive Cotuit ,Mass . Owner. Frederick Shaprio Date of Inspeotion.2/4/9 7 BJ SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or huh static water level observed in the distribution boa 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 He": broken pipe(s)are replaced obstruction is removed distribution boa is levelled or replaced ij 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 pips(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:- A)1)_ 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: 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. _) 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. AeD The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. AlQ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. Aj�,4 The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. Ak The system 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 wall is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Is"than 6 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: 322 Cotuit Bay Drive Cotuit ,Mass . Owner. Frederick Shaprio Date of Imipootion: 2/4/97 D) SYSTEM FAILS: • I have determined that the system violates one or more of the following failure criteria as definad in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be neosasary to oorrect the failure. Backup of sewage into facility or ryvum component due to an overloaded or dogged SAS or cesspool. WO Dischargo or ponding of effluent to the surface c,f the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the nbution box above outlet invert due to an overloaded or clogged SAS or cesspool. -Le h rK - Alb Liquid depth in oesrpc,*•is leas than 6"below invert or available volums is less than U2 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. AO Any portion of a cesspool or privy is within 60 feet of a private water supply well. :O Any portion of a cesspool or privy is less than 100 feet but greater than 60 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: lVb The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public: health and safety and tbs environment because one or more of the following conditions aunt: the system is within 400 feet of a surface drialdng 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) 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 Author information., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropbrtyAd&.m 322 Cotuit Bay Drive Cotuit,Mass . owner. Frederick Shaprio Data of Inspection: 2/4/9 7 e Check if the following have been done: 2Pumping 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. _J N built plans have been obtained and wwaLued. Note if they are not available with N/A. facility or dwelling was inspected for signs of"wage back-up. The system does not receive non-sanitary or industrial waste flow 4The aite was inspected for signs of breakout. ,ZAli systam components,Iicluding the Soil Absorption System, have been located on the site. 2Ths septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of ballles or Zmaterial of construction, dimensions,depth of liquid,depth of sludge,depth of scum. The'size and location of the Soil Absorption System o rp ys a the site has been determined based oa esistiltg information or cep ted by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAd&v" 322 Cotuit Bay Drive Cotuit,Mass . OwIIer Frederick Shaprio Date of Inspection: 2/4/97 RESIDENTIAL- FLOW CONDITIONS Design flow: ns y-V'dAy s Number of bedrooms: Number of current resident,:fAjA Garbage grinder(yes or no):_Q Laundry connected to system(yes or no):.)�-5 Seasonal use(yes or no):A$ Water meter readings,if available Last date of occupancy: COMM ERCIAL/IND USTRIAL• Type of establishment:_ NA Design�w:�,gallons/day Grease trap present: (yea or no)Azd Industrial Waste Holding Tank present: (yes or no)-A/6 Non-sanitary waste discharged to the Title 5"tam: (yea or no),dlpo Water meter readings, if available:_.Z44 Last date of occupancy:_ OTHER(Describe) 4 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of ins ion: (yes or no)"/ If yes,volume pumped: ns Reason for pumping: 4/14 Septic YSTEM to Wdistribution box/soil absorption system -- Single cesspool Xn Overflow oewpool _ M Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: 1 y Py'S Sewage odors detected when arriving at the site: (yes or no)d22$ (revised 11/03/95) ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. • SYSTEM INFORMATION (continued) Property Address: 322 Cotuit Bay Drive Cotuit,Mass . Owner: Frederick Shaprio Date of Inspection: 2/4/9 7 SEPTIC TANK:-14V Tye (locate on site plan) Depth below grade:_ Material of construction: Zconcrete _metal _FRP—other(explain) Dimensions:_ Sludge depth: �r Distance from top ludge to bottom of outlet tee or baffle: Scum thickness:z�� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle:depth of liquid level in relation to outlet invert, structural •rity, evidence of leakage, etc.) arbage disposal present •-J.4 t rld outlet tee ar resen d tt rcr»ire nooraorl of %ho pposopt tJQQ GREASE TRAP. /L�We- (locate on site plan) Depth below grade:, Material of conslriwiion-:oncrete _metal _FRP_other(explain) Dimensions• Scum thickness. Distance from top v.t scum to top of outlet tee or baffle: A44 Distance from bottom of crom 1^honom of outlet tee or haltle-,4I /�' i Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, et�,I Grease trap nofDresent . (revised 6/15/95) fi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (000tlnued) PropertyA.ddr sw 322 Cotuit Bay Drive Cotuit,Mass . Owner. Frederick Shaprio Date of Inspootion:2/4/9 7 TIGHT OR HOLDING TANx:J#11�t, (locate an site plan) e Depth below grade:, Material of coastrud{oa: cacrete_metal_,FRP_othsr(explaia) IVA �lA Dimeaiioas: Capacity: AIA Yallons D"ip 0ow:__jA_jallozWday Alarm ImL- AM Comments: (ooadition of inlet tee,condition of alarm aad float switch", etc.) Tightor hoiding tank not present DISTRIBUTION BOX-.Z Aocats on aite plan) Depth of liquid level above outlet invert:_14 Commauu: (now if level and distribution is equal,evidence of solids carryover,evidsace of leakage into or out of box,etc.) Ili sari huti on box i s l PyPI ;ni St.ri but.i nn i s nnP l a t.Prn l -Nn P.VI dance r_. l_,Hq nnrrtr rrs No Pvl dennp of l PakngP in nr niit. of t.hP box. No repairs needed at the present time . PUMP CHAMBER: .fle (locate on sin plan) Pumps in working order.(yes or no).ALI Commsats: (note condition of pump chamber,condition of pumps and appurtaaaaoes, etc) Pump Chamber is not present (revised 11/03/95) 7 ' U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 322 Cotuit Bay Drive Cotuit ,Mass . Owner. Frederick Shaprio Date of Inspection: 2/4/9 7 SOIL.ABSORPTION SYSTEM(SASlc-1.11 (locate an site plan,if excavation not required,but way be approximated by non-intrusive methods) If not determined to be present,explain: 'YIW. Use pits,number... leaching chambers,aumbar leschin galleries,number. Ieaching trencbes,number,langth: /I Se ds,number,dimensions: O overflow cesspool,number. 0 Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) See Page-9A CESSPOOLS. (locate an site plan) Number and configuration:_ A).4 Depth-top of liquid to inlet invert: Depth of solids lw AI Depth of scum layer_ A/Xl Dimensions of cesspool: Al Materials of construction: AJ Indication of groundwater: AA inflow(cesspool must be pumped as part of inspection) CPssnools are not present Comments:(note condition of soil,signs of hydraulic failure,level of paading,condition of vegetation,etc.) ps uP 9A PRIVY: (locate an site plan) Maarial.of oonstrndion. Dimensions: Depth of solids:, Comments:(note condition of soil,signs of hydraulic&Burs,level of ponding,condition of vegetation,etc.) ri (revised 11/03/95). g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Cotuit Water Company 428-2687 .�� M a jA :z C 07Ui A Y,, D � DEPTH TO GROUNDWATER r 121 + depth to groundwater r,qthod of determination or �approximati�or: See bye 9A y '4 I PLOT PLAN SHOWING IN'ROPOSED BUILDING N COTUIT B A R N S T A E L E ' MASS. FOR LEONARD RITTENBERG SCALE ' I'f = 30' DATE: JULY 30,1976 CHARLES N.SAVERY INC. REG. C.E. d L.S. 712 MAIN ST. HYANNIS• MASS. 8g 16? 56' 26 N76° 51 20 t � i000G0i.i1 o 6D �ahin9 P 1h -J O / 20 \. 8�Dio.X6 OeV t0 •� ?,A25 5g 4 too°/o r i EXpon 10 �o • O o\ ,ao! m CID tick 00 • 6, a9" W c of T.s��./� sno SIT vo /fie r-c, T,r sl Gr-•�./ Fr/3/7t. . l e S S A4 &, •• S a �►I"or • d RoetFrt oqr. 4 �oiare /yo -760 31 LOCQTIO 32.:7" SEWO,C;E-7)P RMIT 1 O. T ivt VILLAGE IM57aLLER•5 IJ&ME ADDRESS. BUILDER 5 W &"F- ADORE 55 DATE PER" T ISSUED �— �_/ � � 76— — - - D ATE COMPLI &&ICE ISSUED : t i �1 >•nrnr+r.-n+r�-n- rnrmr•nmrnrTn+�'rm.n:r+l+srn++r*�++*�rre'ny*�►�nsrtr+ rT-�-ir-�+--...-•.r-•` -i,m OF Barnstable BOARD OF HEALTH I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION I «•T"1�T••••.:t—T.111.��TT1.1S T11'ft.1TITTIRlT.TT.T'�—'T r'IiT117RROfT�RR�It�I�TRt'TR�1 ,tAt :.Trl'T'r1..�..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 322 Cotuit Bay Drive Cotuit,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME Frederick- Shaprio PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & S.em- INc. Box 66 Centerville ,Mass . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE f 08 775 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT ft 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: !XXXXX Systeui' PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* \ The inspection which I have con ticted has found that the system fails to protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature 4 �' Date 2/6/97 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or• 'o' erator shall u p pgrade ' 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 w cn av THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8. 1995 Acting Director of the ' ' ion of Water Pollution Control Ldoe No..t-_� Fus...il:!�................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _._ . .._._.... - .. ._.._.. --....OF...................................... ....................................... Apphratiun -fur Bi,ipuuttf Morko Tomitrurtiun Vrruiff Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ®- .........................{ Z,,V.7--•-- ��'S--------._ P'Z_ i.P...- - p�s'_AV----- .fit. E....------- 0 `' T---------------------- or Lot No. .......... Location ........................ rw----- Ow ` L1:/T/4-'. i-e C ,!.I i� ........... Installer Address �� Q Type of Building Size Lot,071.................Sq. feet Dwelling—No. of Bedrooms-------------A_ ----.Expansion Attic ( ) Garbage Grinder (Vq) p-, Other—Type of Building ............................ No. of persons----------.. a Showers — Cafeteria dOther fixtures -------------- ---------------------------------------------------•------•-•-------------•---•--••--•-----•------------..._..---------------------- W Design Flow................. � _ gallons per person per day. Total daily flow................ O O g ------- --------- Mons. WSeptic Tank—Liquid capacity/!PWgallons Length-------8... Width------- ._.. Diameter................ Depth........ x Disposal Trench—No_ ___________________ Width:__ ----_-_---_-- Total Length........... Total leaching area--------------------sq. ft. Seepage Pit No........ --------__ iameter--------C...... Depth below inlet._ _3__ ..._. T al leaching area.2�t....sq. ft. Z Other Distribution box (`�/� Dosing to k �. a Percolation Test Results Performed b ---- ... __..._...._. Date._..:.* ,� � Pit No. 1. e_�_--minutes per inch Depth of "Pest Pit...............P._. Depth to ground water...._ .0,w f� Test Pit No. 2................minutes per inch Depth of Test Pit--------F_-_... Depth to gro nd water................-------- 04 ---------------- ---_..._ O Description of Soil--J �4 E� ��• �--`:.1 `` �� - --- ..................................... w 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be tie e boar of health. Signd - - --- - ---- --- - --------------- ----•-----------------ro# Date lication Approved B PP PP Y c�1rr D � A J Application Disapproved for "the following reasons: --------------------------- ---_---------------............................... --------------------------------------- •------------------------------------------------------------------------------------ ------------------------- Date PermitNo......................................................... . Issued...................... .................................L--------- ——--—---------------------------------------------------C Date t � �v r ///) No. = .. .tom... Fick l..Y................. THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH ............. .... __......... -- .OF............................................... ...-...-..- - Appliration -for Bi,ipotial Works Tonitrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: v. ......�..C;_ � _T`'`�. f'1 r J J`e..... ..._.`'o �- u1------ ----------------- �' Location-Address or Lot No. ........... ........................ ------- -• /____i,/_i.__R/� �-... -2--A,e�.................. Ow r Address Installer Address Q Type of Building Size Lot_.r _r __.{'r`.. _..Sq. feet U Dwelling—No. of Bedrooms..............�:----••--.---"•-._"---___-Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons----------- /"_-____-_.-_ Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------------------------------------------------------------------------------- == W Design Flow.................�«�__.._.._..-------gallons per person per day. Total daily flow................. ...�•�-- .........gallons. WSeptic Tank—Liquid capacitv_h�0611ons Length.......tL.._._ Widtli.......Fes._.. Diameter________________ Depth........4i"'-­ Disposal Trench—No____________________ Width___. -------------- Total Length................... Total leaching area....................sq. ft. Seepage Pit No.....___�_....._.. iameter........�_.--_ Depth below inlet__ _"_-!�_._--- To al leachit}}g area._:�__:e_.'_____sq. ft. z Other Distribution box (� Dosing to c �G� _ 3 7G ff Percolation Test Results Performed by----- L :.�. `�+' '..... � .._.__...._ Date---------- 4 W -�--=------ F .Tit Pit No. L!---Q-"minutes per inch Depth of Test Pit..._.._.. _--__ Depth to ground water...... !!.%__ _.. .-. f1.1 Test Pit No. 2................minutes per inch Depth of Test Pit--------- ......._ Depth to gro nd water--------------.-_---.-.- -- - .............. G ij Descriptio of Soil. off` ° �� G�+�.r--- ---- - - -------``------------- i� L ,(' W 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ued y-the boarc of he th. Sign d : .% = = -= _---•------------- /,��--�_� Date Application Approved By-------- __ �`.. Date Application Disapproved for the following reasons:._ ------------"------"---------------"-""---------------------------------------------•------------------•----------•------------------------------------------.---.-.-"--------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS I BOARD ,�F HEALTH - ....� .............OF...... . .... ..�1.i1 :a4........................ Qwrtif irate of fIontphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) at....�.G f�"'�v ._.. f1,T_ ller ._. ........ — has been installed in accordance with the provisions of : cle�X�of he State Sanitary Code as described in the application for Disposal Works Construction Permit No."_.._._-__--_55---------------------�F--...--"--___-._. dated.... _-1%.'_.7 .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE,--...........-------•----------------------................................... Inspector........tom. ------ .....•------ . -•--•----- . -----------------" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ............OF.....�..- . .. --- 0.... .................. FEE--- -d...--- MnVmal Norkii Tonitrnrtioat Permit Permissioni hereby granted.-----/---- -------------------- --------------"--------------------------------------_-.--------------------- ........................ to Cons-uct ( �o Repair ( ) n div'dual S a Di -os System atNo. � - /f'........... ---_------------------- � Stree� as shown on the application for Disposal Works Construction Per o._ __�____ ated__ _:�_�/_'_ .............. 9 - -------------------------- DATE--------------------------------------------------------------------------------- Board of Health J FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS PLOT PLAN SHOWING PROPOSED BUILDIMN I N ;: -,L= r ; N tt. F 1kr f 'Y 1i, f `k �� COTUIT 5� 8 A S T'A L E MASS x .,, �,� tt ° rt Fyt r.: FOR ,I t >' y t :H' + ,t+y t � 1vf k s i a r '{�"t ty}avtrt r j <.:,• a �N th^ t rt F r � rb,� � bra + �d,�ifk S + R ' a ,r"Y 1q t'�S.a � t a ,✓ � LEONARD ' RITTENB.ER�(i t SCALE .:. I" 30' : DAT.E: . JULY 30 1976 ` :h'' r'•� CHARLES N.SAVERY INC.'' REG C.E. 8kL.S. . 712 MAIN ST� HYANNISk•MASS k t yrfd :.S 4 r *• ,�_,�_ ._ ;*t ..,,+ x `kn vt F '+� R n,•'t._ '' 'p + + _ y "t, r .� . 11 e aka r w I r' 't {y'tt i t 'a- YJ .r �'�i�,:P rt i ss'� r .•�7. ��r,�(. a sty ,fig 1 s '7 f'i t ,� C�t i'� � + �.,t ,:t t-:d k J, d t `� ` ai it'• fir.•,,', °"I` .t!'i! X,,' t k"i '` —� _ q `t g A 'G dpy.`i + f f� k�h'� a r Y }���,J • �61 #A °. •� ^' r.� " 2 ,L6` E p.. N , 051 r *'r 'r;4 t t +,: g-e1p00X P g (p0 ON O x 6 in9 g t ` ' ` Depti . , 6 ' � ,+ r t£+'- ,r 1 E a �. tit y h-r k s i. ..20- �• 8 D o% €- \ •i yai F tr +r } ka Al a.t / DQ Ot�` OgSt.�OX rn C�,1+ t{ ''rF \\ ,..5} f• 1 %*"�',s.b n Ik 'I�ti P.+.. . `� y "'g�` tkxoo ' y ';tw a•"brw G '.t ''S w .„E. r � �,' < ,„�. ''.� / r.. iw ��`� �_ e5 r a a. .�n'ti `�' Q ^ •/�® �il� �pRS�n � �' t � � t � a, k R� `.} #' 'rx 3 k��l =r,Ta p '". .t �'.. � � � �' 1.._. .t x I.. rt�. t• •°i t � ;; +.�.�r ks + "' � , ri.>ty 'y �r +' 1 ' ��/ r ` ( ...•� ty rz . /t i r• �ye �` '�j = '�' pk ,� fl f+{ Vk 5 � r`t, A �• � 54 f � �i k � � • �n {+al � j,.k.f � 0". ., qV ,k_rt� S7 ,� ��;r• _ O y..M v '#�wkAd �...s.T , q qw7 � �e ' Z ny V ,.„.:t. /'�f� de ,'.5'• - ,' t:.r rt xt 'b,. .j.5 s k t.r#'`• �r't.. 'i 4e rat r~. Yk r. Y•' ^ � �p l I ' t �: u t ®� D A� �„ h a 11 tt i pg/� 6\v r Co yt�� v i �.A t :^x •/ " r' W W (i F 7/ ff Dt O O '.�31,f ,Y f .A.t ,3 LY , a y�..","''�{tF h� vie P \ 1 r 4 •D O S p it :....� , `r r q ti�9!,i�'� `llAf ,_ T, ''r 'P+ • , � ' O O R # �lt rr J♦s �.p r 't'9 +r C tr rfF.A y r'u .r ."r r ' -" " �- .+s f "Z ! tr: r V w•�, It �+ „�. � 4: 1 , .• r. a. t � T-'® sy \`` y,..�a5 �'�x "fir _' v,. t-a} ✓R•_,• ,,r a.. u' . t rer ' S'+ ® t 1+ � ,t. •C � wi, h tt.• ..ry it d , rzR:�f '9 r A• v,'"r#.k. y'_ d �. r r W / . .• v - # ' . fl{ rr; t + ++a}• ® t#P'`. Y� ±w` o Sri .,; + r! �(a �8 k• / .q.ti,:a `i t, �k r r.� �.. � -.ri a Y d n�e1 .t. r f.�E"r ;r'1te n, �+r� tF �:. ! :, ,r,' • f Ib� r.. t'�' r�, d °r ' s,iA'f kt, �q "t .'.� � y - .r '" !`r•.. /�; -r t�if ,.r n• s �.! •'' y 5 n i'� #f.dM rr f x "' p.q 42 2 +; + �yx sFe • t / .'j ysr r t+qr 4{ �� t•h �� � t �.r..�ci9 �s� 49 „r ya'i t t*tK + +::;•#.� � c + _. `� k V� ..q C A + F _'i Fs •': � y .r_ a, •�,.— q yam. 1-4 Y ..4 �i �.�n { r•+� A „� I i t ,� Ya �! } r� �+' f t �. !� a• � ° - n �.^w .. s •. j ' .q.:,ra k „ { 1 d e t,'.ai 6 A�F 'n, � Ir{ " p{• 'OVA;,If t �r�n �!t ,.f �9 t't� � :+k 4�s r '.•� /�/ �" '} t 'r« t � S� .. 1 iyt OF Q S s' a s t � S a w a� d►�n� t et � `` b r is Ix p r i�t tii r.,a +.e,sF..3.."4� ,v... Y-.9 S �..� �1.. � tt•�b °.ni h Ll ,tit.. ,. '^k.�!; 't4'1y Iki&+tib s`G A � � a I r .LOCQTI0 SEW�,C,E �RMIT 1.10. iWST&LLEWS 1J&ME 6 ;ADDRESS r BUILDER 5 Q &VAF- ADDRESS DQTE PERKA T ISSUED '=��' 7-6 �O NTE COMPLI &MCE ISSUED : -�_�� � 6 �®o r g 1 � 1 �,