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Home My WebLink About0360 COTUIT BAY DRIVE - Health 360 Cotxlit Bay Drive, Cotuit IAA=055 - 007 p1 I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for llhiposal Works Tonstrur#Uan 1hrmit Application is hereby made.for a Permit to Construct ( ) or Repair (r Individual Sewage Disposal Systemat: -------------------------------------------------------------------------------------------------- Location-A ress - or Lot No. .. _..... .l (1t�.a. .... ._... --- - --- . w Add s .. Installer ddress d Type of Building Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) �--[ '4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria Other fixtures -----•--------------------------------••--•... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' ------------------------------------- •------------------------------ ----------------..-------------------------.------•------------------------------------- 0 Description of Soil---------------•------...----------------•---.........------......-•---...........--•---------------------------------.................................................. x V --------•-•--•--------------------------------------•------------------------------•-----•-••------------------------•------------•-•---•----••------•-----------------------------•----------••-------- -------------------•--------------•----------•------------------------------------------------------ -• -------- - ��``�� U Nat e of Repair or Alterations— nswer when ap licable...... y� ..... ........�LK1�_._- `_ ,s '�.....d .............. // Ag eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code-The undersigned further agrees not to place the system in operation until a Certificate of Com iance s b the board of health. Signed --- ----- ---- - ------------- ------ --- �� - A Application Approved B cti ---- ------------ . ......---- - ------ ------.....--------- ---1.. -=PP PP Y '` ... D---------------------- ue Application Disapproved for the following reasons- ------------------------------------------------------ --- --------------------............................---- --- ------- ------------------------------------------------------------------------------------------------........................... ---------------------------------------------------------------------------- ----------------- --------------------- Date Permit No. - .��------------------- Issued ----------------- Dale --------- --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE j Appliration for Dis'nsal Works Tonstrnrt' n .erntit 000li hereby made for a Permit to Construct or Re air an Individual Sewage Disposal Application s er b �) g PP Y - ( ) P ( P System at: ....:.:... :- --... ....__'.(L... ..--•---•---••------••--.....---•.................•-.....-•---•-----------_---.................-- Location- ress or Lot No. �_.... . .(��.11 - Q�1t ........._ p 1� -- 11 , ._.._. a � Installer ;AHdress d Type of Building m ,� Size Lot-______ '.____.............Sq. feet 0-4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p,I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aI Other fixtures -------------------------••-•----••--••--------•- . W Design Flow.......................:.:?----------•---__gallons per person per day. Total daily flow__._......_...............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •---------------------------------------------•-------..............-•--•-................--- •-----•-----------•-----•-----------••-•--...........---....-- O Description of Soil = - ^` / ' ...... .. . ' == �...---------••--- V ------•. -'=) -'•------•-••------••-•----•-•---------------••-....._--•------ --------•--------------------------------------•-•--..-_._.............-•-•-------................_........•-_----- W ---------------- -----------------•--- ----------- r � ------------•-----•-•-----•-----•- � c lrr Alterations— wwhn applicable-. _pa Natuof :r -RD- -----�foyJ --------------------------------------V Ag eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Corn liance s b .the board of health. Signed �" ... ..... /�� = ..... --.- A Application Approved B J -- --- --- . /..a?.-..D-... �1. PP PP Y -------- -- ��' V »are Application Disapproved for the following reasons- --------------------------- ------- ----------! ..............................-----............................---------------- -- ----------- --- ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- .................... ........... Dare G �7 Issued ------------------------------- --------- Permit No. --------- ( -....73 Dare ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J TOWN OF BARNSTABLE Certificate of Cgnmyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( �• ) Installer at - ----------- r � ?'f n ,.� `'` ........... ("?rr`. ....... has been installed in accordance with We provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...-....5,��-.. _f- ---------- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ,f '�+ .. a7 f...G '� Inspector ....... �� ,.s.�r.. /,i �'�f-, �' /f - F . ,-- -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QQ TOWN OF BARNSTABLE Dispersal Works ,Tonstrurtion Vpnufit Permission is hereby granted.......... .- `gin_-✓__ ___.t).. ...----.:Le..-•----.....--•--........-•----•---•..............•.... to Construct ( ) or Repair (' ) an Individual Sewage Disposal System at No.--- �' �5 �'° _ Street �y as shown on the application for Disposal Works Construction Permit No..!1;cj_-....3 7.3-5 Dated ..................... U .....� _ �- ..................................... Board of Health � DATE... .. - `. _ .......................................... FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS �. „cc C-17)1 No........S.�P�..... Fms...3 ................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH U ...............OF......-..-... - Allp irFa#iou for DiopoiiFai Workfi Towitrurtiou Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i.S t j ocation-A� ess or Jet N . �P Owner ,/ Address --------------------- --•-- Installer Address UType of Building Size Lot.,.;.,. :_ . 9---:-Sq. feet Dwelling—No. of Bedrooms..........._a.............................Expansion Attic ( ) Garbage Grinder aOther-Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ' ) Otherfixtures -----------••-- --•••-•---•.........................•------•----•-•------•--••......_._..-•-••- W Design Flow......... ...:........................gallons per person per day. Total daily flow__.___...�l�......................gallons. WSeptic Tank—Liquid capacityl.:S” tO..gallons Length................ Width................ Diameter----------- Depth:-............ xDisposal Trench—No- -------.-_-- --- Width.................... Total Length.................... Total leaching area:...._._.__..-_.__sq. Seepage Pit No...`_ __ Diameter.................... Depth below inlet.................... Total leaching area................•-sq. ft. Z Other Distribution box () Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground-water................_........ -••----------------------------------------•---.....-•------ ---..._...------••--•---...-----•-•----•--•------=-..........•----y----..................................... }� .04 O Description of Soil......0.--.-TA--.... = ...........iP?ALV---- .... `'aces `.......... ...lZ-...A � =-c�IJ V .......................................--------------------•---------- W s. U Nature of Repairs or Alterations—Answer when applicable......................................................................................._........ ...---••-•--••--•••••••--•_.. ......................................................................................................................................................................... Agreement: The undersigned -agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITl.i� 5 of the State Sanitary Code— The u lersign d furt ier agrees not to place the system in operation until a Certificate of Compliance has been ' y t o - d f h It . Sign ` ...4............ ......•-- �" Date Application Approved By......... G,, tJ^ 7 ... '--.- 7............. Date Application Disapproved for the following reasons--- -------------------------------------------------------•------------------------------------............... .................................•-•-----..........------.............-•-----------•-•-•------......-------..........••-•-------••----••-•-------•---••-----•-••--•-•••--•-----••---•--••------••••••--- Date Permit No......................................................... Issue(L----------------- :--•------- ....-..— � -....---•---- •------- -- ... � --------•-•---...........Date ..F Fim HE COMMONWEALTH OF MASSACHUSETTS L 3� i BOARD OF HEALTH ......... 3 ... OF........&R-A&STA6.06.................................. Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit"to Construct O or Repair ( ) an Individual Sewage Disposal System at: •-- �� - €.;t......�C .1 .....b_4!.4 .................. .......................O„C` - ...........--- `�+► �,I�'ocaation-A .ess or t................................................. N . . .... Owner Address a .......... r ....• s.�iLt ................... - � 4?�.....fla A�................................................. Installer Address Type of Building Size Lot.......1.....:'.a4'�_•.t....Sq. feet aDwelling—No. of Bedrooms........... ................. .....Expansion Attic ( ) Garbage'Grinder ( p•, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ----------------------------- W Design Flow.........l.t.c)............................gallons per person per day. Total daily flow......... .................gallons. WSeptic Tank—Liquid capacity/-<4.C?-gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit N6:.J.000_: iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box,X) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test'Pit..................... Depth to ground water........................ a -•--•--••-•-•-------------•--••--•--........----•.......... ..-----•......•• -•-.--•.----....• --- D Description of Soil......0...TA........Z`6.A.-I•----..1,0t.t!&.. .....�?�' ',�?t.-4 ------.... ��-gip--f`' U --•-----••••••----------------------------•----•-------- ---------------------------•---------•------------------------------------------------ .................................................. 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 TIT E 5 of the State Sanitary.Code— The u ersign dkfurAer agrees not to place the system in operation until a Certificate of Compliance has bensKe y t o rd f Sign � f Date Application Approved By.....-• � .._ } --•----•--------------•-........_...._... ,�"' " .- . ........ Date Application Disapproved for the following reasons:.............:....__........._....._..__.•.._.. ................•----------•-----------.... -----------------------------------•-•--...-•----------------------------............. ..... .................................................. Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "+ . �n. tO Al -' .............:OF.....gVAt .... .........:...................... Tertifi atr of Tontplinnrr t THIS I 0 RTIFY�—That the ndividual Sewage Disposal System constructed ( ) or Repaired ( ) s aller has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the 7 application for Disposal Works Construction Permit No----- ..__ .-............. dated_...... " __ __ .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C'► .. ... .........OF o .N ...... FEE Q ,.,.,..w......�.Disposal Vorkg Tonst urtion rruttt Permission is hereby granted............................ .......................................... to Construct ) or Rey air ( ) an Ij�divldpal Se Ta a Disposal System at No...._..._ O Cl. `" 1t2 E'"" ..d .t ......_.. 1. . Stmeet p as shown on the application for Disposal Works Construction P r_ >t No Dated.._._I'" "..7----- ------------ -�- ---- ------•-------•— „, Board.of Health DATE............................................... FORM 1255 �HOBBS & WARREN, INC., PUBLISHERS - le.P-V /70 v E 1 C500 C L. utSPo05AL pVT Uz;f J000 4 . /2. 00NS R,T rd '� exF BOTTOM A ZMA 'l$Six .i.o = �•PD ---- . ... (7�Cpt.AT toe.1 QA`iC• I t N 2 MUJ ot2 LDS. Fu 7Z, cat .� . ,y -cop Fop too' G ==zrrW�� aL R� f Q"�o6 DlST tend C*A.L. sox.' 9a - ZrPri� ►Coo aS g Iuv. f' Pi T ED YVA4tl6D . cTourx �8a Ce:T t F 1 W-X> P,2o FI 1.. Lcac,�►.'�1o�..t 60TU IT t:L $5 12 Wo Spa ZGAt_� U AT L D W gee—. I C-M=lFY T"Ar Tµf-- 0v T'iaw 541ow�,t "ral = 11.4 CQMVPL.`{S W A T M T4.4F— stll>e%-14- — L �OT f3 �.�► AWV SETBACK . OF TIWC- T4 (r, PL-4" 19. 4.YDT BASED or.l AU 'W4TQ)mF%4T pSTE.2Vt4.L6 A�A.�+S. T4a& oFF"SET S"ouLb UoT ZE. U5eDAPPUC.Ab.tT To 'PETr-V-MI NE t.oT Ulisx. { e i - a iV, MA � j 704 0UV DNS r COMMONWEALTH OF MASACHUSETTS meµ`i w EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M055 P007 L86 Name of Owner JOHN MARIAN Address of Owner: 360 COTUIT BAY DR.COTUIT,MA 02636 Date of Inspection: 3117/00 Name of Inspector: JOHN C7RACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS . r Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluati the Local Approving Authority Fails Inspector's Signature: Date:3/17/00 The System Inspector shall sub it a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life:" THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3/17/00 INSPECTION SUMMARY: . Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: ' One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. n(a 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. WA Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box Is levelled or replaced n!a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02636 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3117/00 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: . The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla(approximation not valid). 3) OTHER n/a J revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02636 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3/17100 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ X Liquid depth In cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Il. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, _ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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 _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(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 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 360 COTUIT BAY DR. COTUIT, MA 02636 M055 P007 L86 Name of Owner: JOHN MARIAN Date of Inspection: 3/17100 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: . i Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ 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. X _ As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was Inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was Inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 I SUB SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M065 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3117100 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow: 440 gpd Number of current residents:2 Garbage grinder(yes or no):YES Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd , Sump Pump(yes or no): NO Last date of occupancy: nla COMMFRCIAI/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of Information: 1979 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: . 3/17100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 22" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) _ THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 16" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other - explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 �� . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M056 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3/17100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene —other Explain: n/a Dimensions: n/a Capacity: n/a gallons ' Design flow: nla gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) - Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3117/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(2)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: ; (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.ONE PIT WAS EMPTY AND ONE PIT HAD 1"OF WATER IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a Inflow(cesspool must be pumped as part of Inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9098 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3117/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) �,sZ t e �p AA'N A-9 t �c 3y III 4 r�3a y revised 912/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 COTUIT BAY DR. COTUIT, MA 02635 M055 P007 L86 Name of Owner JOHN MARIAN Date of Inspection: 3/17/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet n/a Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2198 Page 11 of 11 Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection ,To}ttt Grad One winter Street Boston Ma. 02108 ' D.E.P. Title V Septic Inspector P.O. Box 2119 �j /�� Teaticket,MA 02536 WILLIAM F.WELD J-i a�`� ! �SOg� 56�1-68 13 Governor j ARGEO PAUL CELLUCCI 12 Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORPART A tit F CERTIFICATION REcv ED O , Property Address: 360 Cotuit Bay Dr.Cotuit - Address of Owner: OVI 6 1997 16 Date of Inspection:1012/97 (If different) TOWNOFBARNSTAg Name of Inspector:John Grad Ed Molina 14 ALTHDEPT. LE I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) G► Company Name,Address and Telephone Number: L CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X_ Passes This inspection is based on criteria defined in Title V Conditional P ses code 310 CMR 15.303.My findings are of how the system is performing at the time of the inspection.My inspection does Nee/ubmit a valuation By the Local Approving Authority not imply any vrarrantyorguaranteeorthelongevitvofthe Fail septic system and any of its components useful life. Inspector's Signature: Date: 1012197 The System Inspector shall copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not Idetermined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127/97) One Winter Street • Boston,Massachusetts 021108 • FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 360 CohAt Bay Dr.CotuR Owner: Ed Molina Date of Inspection:10/L197 — Sew.aae backua or.breakout.or hiah.static water level obser.ved.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection ff (with approval of the Board of Health). Describe observations: „ broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is'within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance. (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes'or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 04127197)' IuI i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property AddreSs: 360 Cotuit Bay 0r.Cotuit Owner: Ed Molina Date of Inspection:10/2M7 D] SYSTEM FAILS(continued) 5 Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).. Numbers 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 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. 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: 4 You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: 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 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the'groundwater treatment program requirements of 314 CMR 5.00 and 6:00. Please consult the local regional office of the Department for further information. .{: 5 (revised 04/27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CH ECLIST Property Address: 360 Cotuit Bay Dr.Cotuit Owner: Ed Molina Date of Inspection:10/W7 ` Check if the following have been done:You must indicate either"Yes'or"No"as to each of the following: _X_ — Pumping information was requested of the owner,occupant, and Board of Health. , x — None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. X — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. —y— — The site was inspected for signs of breakout. X — All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. x _ The size and location of the Soil Absorption System on the site has been determined based on . The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(f any failure criteria related to Part C is at issue, approximation of distance is unacceptable)115.302(3)(b)j 1 (revised 041V/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION Property Address: 360 Cotuit Bay Dr.Cotuit Owner: Ed Molina • r Date of Inspection:10/M7 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g p•d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: z Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes ' Seasonal use(yes or no): Yesvaila Water meter readings, if able:(last two(2)year usage(gpd): nta Sump Pump(yes or no): No Last date of occupancy: summers COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) Nory Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: n/a Last date of occupancy: n/a OTHER: (Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: T System was last pumped 5 years ago_ System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system " Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 15 years with a new pit installed in 1990 Sewage odors detected when arriving at the site: (yes or no) No (revised 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 Cotuit Bay Dr.Cotuit Owner: Ed Molina Date of Inspection:10/2M7 SEPTIC TANK: X (locate on site plan) Depth below grade: 16' Material of construction:X concreate metal FRP_Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L t0'6"h 5'7'W 5'6" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25'. Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 0 How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP: (locate on site plan) > Depth below grade: nra Material of construction: _concrete metal_FRP_Polyethylene_other(explain) Dimensions: nla Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:nla Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping,�a Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) nla BUILDING SEWER: (Locate on site plan) Depth below grade: 2'4• Material of construction:_cast iron X 40 PVC other(explain)` Distance from private water supply well or suction linOow^ Diameter: 4•_ rrvamments:(conditions of joints,venting, evidence of leakage,etc.) (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 Cotuit Bay Dr.Cotuit Owner: Ed Molina Date of Inspection:10/W7 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal FRP_Polyethylene_other(explain) Dimensions: rda Capacity: n/a gallons Design flow: We gallons/day Alarm level:_n14 Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) We PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised( 127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 360 Cotuit Bay Dr.Cotuit Owner: Ed Molina Date of Inspection:10rV97 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: ' n/a Type: leaching pits,number: 2-1,000 gallon leach pit leaching chambers,number:n/a leaching galleries, number: n1a leaching trenches,number, length: n/a leaching fields, number, dimensions:n/a overflow cesspool,number:n/a Alternate system: n/a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) The overflows are structurally sound and functioning propedy.They both had V of water in them. CESSPOOLS:X (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert 1" Depth of solids layer: 0 Depth of scum layer. 1" Dimensions of cesspool: 4'x5' Materials of construction: block . Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Main cesspool and all components are structurally sound.Recommend pumping system every one year for maintenance. PRIVY:_ (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n/a (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 360 Cotuit Bay Dr.Cotuit : +' Ed Molina 10l2197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) f eA og �o Rqq 14 , NC 3K IL Cb . I (revised 04/27/97) page 9 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contlnued) 360 Cotuit Bay Dr.Cotuit Ed Molina 10/M7 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (MUST be completed) USGS Maps and Charts (revised 04/27/97) page 10 of 10 LOCATION SEWAGE PERMIT NO.� 3 L 6 &l,± 2Su A I VILLAGE ALL ER'S AME i ADDRESS 3UIL0ER OR OWNER DATE PERMIT ISSUED ` ., DATE COMPLIANCE ISSUED /o � � .� r � _ �� s � � . 9 �� TOWN OF-BARNSTABLE LOCATION6-(O CC")'TU &�IM(l 16 SEWAGE #— (-7 VILLAGE_ !C=,(t ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITYS�D LEACHING FACILITY:(type) 1tc 1' (size) loaa NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERCVAj DATE PERMIT ISSUED: p" L3 DATE 'COMPLIANCE ISSUED: � VARIANCE GRANTED: Yes No Xboo Gil q Lac P o -�