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HomeMy WebLinkAbout0437 COTUIT BAY DRIVE - Health 437 Cotuit:l3ay=Drive C otuit - -- - A = =055 = 048 a f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 437 Cotuit Bay Drive C Property Address Caso A Owner's Name Cotuit ✓ MA 02635 7/1/16 Cityrrown State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 614 /1:�a0 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 r Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/1/16 Inspec or's Signa ure 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. 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any.failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 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: n/a ❑ Observation of sewage backup or break out or high,static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 437 Cotuit Bay Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a 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 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. 437 Cotuit Bay Drive-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.):1 ❑ 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: n/a 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 ❑ ® 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 of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 437 Cotuit Bay Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM ,. 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑. the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® 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)] Y 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 437 Cotuit Bay Drive Property Address Caso Owner's Name. Cotuit MA 02635 7/1/16 Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 2 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 Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 6 weeks a yr perowner Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 437 Cotuit Bay Drive-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 CityrFown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 3 yrs ago per owner 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): Approximate age of all components, date installed (if known)and source of information: 2005 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): . 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Covers raised to 12"of grade, irrigation line at edge of outlet cover If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -----------=-------------------------------------------------------------------------------------------------------------- Dimensions: 1500g Sludge depth:' 2" 11 Distance from top of sludge to bottom of outlet tee or baffle ' >12 Scum thickness ' + ' trace-1/2" >21, Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >21, How were dimensions determined? Measured 437 Cotuit Bay Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 Cityrrown 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): n/a Dimensions: Scum thickness T Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: p Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): n/a 437 Cotuit Bay Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 437 Cotuit Bay Drive Property Address ¢ Caso Owner's Name Cotuit MA 02635 7/1/16 Cityrrown State ,. Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): n/a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): D-Box 3' below grade, cover raised to 12", very good condition, use caution there is an irrigation line directly over the cover, electric line is within a couple feet of box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 437 Cotuit Bay Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit, MA 02635 7/1/16 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits; number: ® leaching chambers number: 6 in ❑ leaching galleries number: ❑ leaching trenches a 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.): Infiltrators were video inspected and are damp at this time, top of chabers 3'6" below grade, no indication of past backup, entire system in excellent condition 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 City(rown - State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer- Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): n/a 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M °'r 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. A -4 � • • Ll 437 Cotuit Bay Drive•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 437 Cotuit Bay Drive Property Address Caso Owner's Name Cotuit MA 02635 7/1/16 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: per elevation of home • r x , 437 Cotuit Bay Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i I °1005�50 No. r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for X ow5al *pztem Cun5tructiun Permit � Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No.437 %+(L (, Owner's Name,Address and Tel.No. Assessor's Map/Parcel55' �A N �.4s o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 9 <3 0 779 — fs9 1 Type of Building: Dwelling No.of Bedrooms 5� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .55® gallons per day. Calculated daily flow 66 ,3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta)Cgde and not to place the system in operation until a Certifi- cate of Compliance has been issupoby this B Health. f ,v_� Signe Date �'"v /70 Application Approved by m Date Application Disapproved fcrthe following r s s Permit No. Date Issued No. Fee V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Mizponl *p5tem Cun.5truction Permit " Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components i Location Address or Lot No.437 Cb t(t t D(% Owner's Name,Address and Tel.No. EA N CAS O Assessor's Map/Parcel ss Installer's Name,Address,and Tel.No. ` Designer's Name,Address and Tel.No. R41,V G'Q__Q1Uf J W- 50 778 -,- FsctI�j Type of Building: , Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons.)- Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 66 ,3 gallons: Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: -y The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment C de and not to place the system in operation until a Certifi- cate of Compliance has been issu Eby this Bo of Health. Si gne 44w, t!_ Date v Application Approved by cn' Date Application Disapproved for the/ r�ns P Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS + `�. Certificate of Compliance y ~ THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(V )Repaired( )Upgraded( ) Aba don�etd( )b; bra ce" - at �I / LD d J ✓l '� has been constructed i accordance x with the provisions of Title 5 and theYr Disposal System Construction Permit No O a 5c`3 dated /0�� 5 Installer NO Designer _ 10 stalle C� �S The issuance of tt„ s rmit h 11 not be construed as a guarantee that a system will nctio signed. Date Inspe or r ` '�-< � Fee No. i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS AA Migoe;al *p5tem Construction Permit Permission is hereby granted to Construct -Repair/( )U q!t( )Abandon ) System located at 410 t /, �C y j and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date .f this pe t. , Date:_. ►� Approved by • I own of Barnstable' oF�, , yP` ti� Regulatory Services Thomas F. Geiler,Director.,., • SARNSTABLE• Public Health Division AFFD NIA'C Thomas McKean,Director, 200 Main Street,Hyannis,MA MR, Office:,508-862-4644 Fax: 508-790-6304 Installer &Desi:lner Certification Form - Date: 3/10/0 6 Designer: BSC GroiP• In c .. Installer:alley: �Rvc e: H 0.0 0..1 � 1e f Address: r ss: 657 Main' Street Unit "6. Address: ���or,d $k W: Yarmouth, MA02673 d1ew���e , 14. �dG55� On // — / =05 s-,,e siCr was issued apermit to install a 'woos_ 5-03 (date) (installer) septic system at 43 7 cotL i t Bay_,Dr i v based on'a design drawn by (address) BSC Group, Inc. dated September 9 ,° 20.0.5. ^' (designer) I certify that the septic system referenced above was'installed substantially according to the design, which may.include minor approved changes-such,as lateral relocation of the distribution box and/or septic tank. x I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical'relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. 1N OF,9.. MARK CIVIL (Installer's Signature) No.45937 � lsTP� `��SJONAIfis ' (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. , Q:He Certification Form ECO-TECH YIA t 2 PARCEL 10 Environmental www.eco-tech.us LOT THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 437 Cotuit Bay Drive Cotuit Owner's Name: Mary Alice Coughlin Owner's Address: 437 Cotuit Bay Drive C Cotuit ,MA 02648 Date of Inspection: April 28, 2004 l Name of Inspector: (Please Print) David D. Coughanowr,R.S. tj Company Name: Eco-Tech Environmental > Mailing Address: 43 Triangle Circle Sandwich,MA 02563 ca Telephone Number: (508)364-0894 CU cn r-- cn rn 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 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: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature �` CAS'"�-- Date: Ape l I -412 / 20 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 Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 437 Comit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28,2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no,or not determined(Y,N,or 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 breakout or high static water level 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 Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain 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 ND explain 2 f Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28, 2004 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 and 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 by 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 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 437 Cotuit Bay Drive , Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28,2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes" or"no"to each of the following for all inspections: 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 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 X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of 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 1 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.(This system passes if the well water analysis, performed by 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) No (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 following: (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-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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28, 2004 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks?, Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? n/a Were as built plans of the stem obtained and examined? the were not available as N/A p system � Y ) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeladin the SAS. located on site? Y _ Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X Existing information.For example,Plan at the Board of Health. Y _ 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 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd(425 gpd leaching provided) Number of current residents 1 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two-year's usage(gpd): 551 gpd(irrigation system in use) Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: 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: System last pumped summer 2002(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank,distriliutien box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternate 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) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age: 24+years Design Plan approved 10/23/79(BOH permit#692) Were sewage odors detected when arriving at the site: (yes or no) no 6 f • Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28,2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:_cast iron X 40 PVC other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_ SEPTIC TANK:Yes (locate on site plan) Depth below grade: 15 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle: 28 in Scum thickness: 2 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 13 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended every 2 years. Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out. GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 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: 437 Cotuit Bay Drive Cotuit Owner: Mn Alice Coughlin Date of Inspection: April 28,2004 TIGHT OR HOLDING TANK: none (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/day Alarm present(yes or no):_ Alarm level: Alarm in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: none (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) PUMP CHAMBER: none (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 i Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin . Date of Inspection: April 28,2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located, explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries,number _leaching trenches, number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching pit appeared unsaturated.No evidence of surface ponding,breakout,lush vegetation or other evidence of hydraulic failure was observed. Leach pit contained 18 inches of effluent in a 6 foot pit. CESSPOOLS: none (cesspool must be pumped at time 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 or no): Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: none (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.): 9 y Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28,2004 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'(Locate where public water supply enters the building) LEACH O PIT S TRAP DOOR LOCATIONS n SEPTIC TANK 0 Z B A B C I 7.5 ft 8.5 ft 2 5.5 ft 10 ft EXISTING # 437 3 42.5 ft 26 ft DWELLING W Z J W 3 I COTUIT BAY DRIVE NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 437 Cotuit Bay Drive Cotuit Owner: Mary Alice Coughlin Date of Inspection: April 28, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 25+ feet Please indicate(check)all methods used to determine high 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 local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Barnstable GIS department records indicate that property is over 25 feet above groundwater table. 11 No.._......lB.. _ - .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 01 0 /..F '1.. ......OF......�al.�!�.............-.................................................... Allp irFation for_ Disposal Wjarkfi Towitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: ` 1 i b 11 .................... ..... ....... ... ........_........___.................... ._._.. ..._..........................._..._. ..Lo• tion-Address r Lot o. Owner Addres. � .................................................. •-----••. _ .1�' .............................................. Installer Address Type of Building Size Lot...�lq,.a".`f.....Sq. fe t U Dwelling—No. of Bedrooms.........M.............................Expansion Attic ( ) Garbage Grinder (� ) Other—T e of Building ... No. of ersons-------S----_----------- Showers — Cafeteria Other fixtures .... ---5►---'A�*. w Design Flow............-.t.......................gallons per person per day. Total daily flow-------------- ....................gallons. WSeptic Tank—Liquid capacityJ50.0_gallons Length._/0--..... Width....1. ------ Diameter................ Depth...�!_.4'.� x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-________-----•-----sq. ft. Seepage Pit No.......I........ Diameter........X_ Depth below inlet.......(jr.......... Total leaching area.:e? !P.......sq. ft. Z Other Distribution box (&,I Dosing t { ( ) ~' Percolation Test Results Performed by........ d►�s.._�c �-!_��.•........................... Date....C: ."12'z q Test Pit No. 1... .y..._.-minutes per inch Depth of Test Pit-------V?. .... Depth to ground water________________________ fs, Test Pit No. 2---) ?.....minutes per inch Depth of Test Pit.......tZL,.... Depth to ground water....."-------------- a o- D Description of Soil.......... �_._ a 5 x w U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------_.................................. ---------------------------------------------------------------•--------------------........__•••••••----••••••---------••...---•••••--••••••-------••-••••-•-••••-•-••••-•--•--•-•••....•••-••---•••••. Agreement: The undersigned agrees to install the aforedescri ed Indivi al Sewage Disposal System in accordance.with the provisions of TILL LE 5 of the State Sanitary Cod The un r igned further agrees not to place the system in operation until a Certificate of Compliance has bee is ed by the o rd of alth. / Date c� Application Approved By.... '------ . _U44 ...................................... -.----1 d'a3� --------- Date Application Disapproved for the following reasons:.................................................................................••-•--•._......•••••........... .......................................-----------------------------------------------------------•--..... Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA TH �!..........OF............ .. ........... . wrtifirFate of TontpliFanrr THIS IS T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ��.�............ .-------•------•-.-----------•.-...---------- by........ -- //,V� ...... has been installed in accordance with the provisions of T;1 //`�� of The 4ate Sanitary Code as described in the application for Disposal Works Construction Permit No. lz_.�%Z dated.-- Q a �7`�`--------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................•-••-•----•.......--------•--.. Inspector.................................................................................... ......... ....7_1� FEE".............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ------------7- .....OF...... ..........__............................................ Appliration for Bispoiial 10ork� Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at .................................................... .................................................................................................. Location-T�Tress or Lot No. ...................................................................................7............ .................................................................................................. Owner Address ......................................................................................... ....... .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ......................................................................................_............................................................. Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width.........._...__ Diameter._.___........_. Depth.....__.._..._.. Disposal Trench—No..................... Width.................... Total Length................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.___--_--___-__---_. Depth below inlet.............._..... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.._................. Depth to ground water--______-__-____----___. (i Test Pit No. 2................minutes per inch Depth of Test Pit_.__._......_....... Depth to ground water........._.._......._.__ -----------------------------------------------------------------------*.......*...*"........*--------------------------*------------------------------------- 0 Description of Soil........................................................................................................................................................................ -------------------------­-------------------*------------------------- ......................*---------- ----------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------*----------*---*---------*------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install 'the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ne4..................................................................................... ................................ ApplicationApproved By.*.- ...................................... ..... .......-------------- ........ Date ;:APPlieatio Disapproved for the following reasons:................................................................................................................ ................................................................. ..................................................................................................................................... Date Permh. ........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA �.16 lit... . .. . ..... ............... ...........OF....... ............................... up rdifiratr of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by-------xV_atv . .....A............ ........­.... ...t Ll Int� 4i . ....................................................... has been instilled in accordance with the provisions of T?IIL of The Zate Sanitary Code as described in the % ��-L ...............application for Disposal Works Construction Permit No. 9 _------_------....... dated----114--- ----- 'THE I5S41UANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEMIVILL FUNCTION SATISFACTORY. DATE. Inspector..::........................................;� ......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD �F H,EAW, H/ OF..........) ... ........ ................................ N .......... ..... ......... J...................4. — ..1>49 FEE .................... fit Permission is hereby granted---.'.---at . ....... ............................................................:...:::-------- to .. Cons,trusit or �(epair ( )/n In ivi al Sewa D s t7 at No.. C ...................................................... Street as shown on the application for Disposal Works Construction erjH%' No/-, .2J_?71 Dated..P - --------- -------------------------------------- Board oID4 DATE.... 1—..f..................................................... FORM 1,255bHOBBS & WARREN, INC.. PUBLISHERS • �t�t_Es t✓L1.Mt t_.� - '� '�SY�2lJOM � t 25. . ,:u C-aA�bAl. � (�►�Lt�.1t.».SL !� =ram - .t t tb 3 Z.,�'t-i C. 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FOVNDAT1ON5"0`JJQ t 1C.1't:c�l..l �t;�.vlr'L.•(5 v,/'►'1'1-t Tt t; I t�� Ltt-it= L_O T 80 A.1.1� ��'r L3��•.C� �:C 4 c.�1��.M�:•+••tT� o�_ . �c''~a c:: . - -TO w Q Gt" 13 A.1Z►�15 T A.$t•-•S r � O`T U fT �A'{G C..?�-10 VA'tG t.A,�.tC� 5U _Ila`f0�` �IC�T LA�,C'� U�.3 AN USTEi•..'V1l,.l.0 O, 1kt;�S`,,. 11.t�;('�?:J:✓Lf:_►•�;' .���=�ltw.�" ;�. ��1-t1::: c3_�`�-,r�.t`�� �+-tOFJI� A;Nt�tit l.:n.t�..i YC � h�.r tics ��r�r,ci.1'-c� is►`m TOWN OF BARNSTABLE �G LOCATION 7 3 SEWAGE # VILLAGE C6TZ-,T ASSESSOR'S MAP & LOT S/y9 INSTALLER'S NAME&PHONE NO.�• R CC✓!/dJu" — "cScTo�g { SEPTIC TANK CAPACITY �504 . "r� Id X LEACHING FACILITY: (type) T ga e✓ (size) ' NO.OF BEDROOMS BUILDER OR 0OWNE^R e PERMITDATE: II /' 0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 4'1 ,b„ a A� 73 l 4„ g1a V T 7 35" B , gs 60%'► f' 08S. I certify to the best of my best AS- BUILT" LOCUS INFORMATION professional knowledge, information and belief that the Septic System BLDG TIES DESCRIPTION INVERT CURRENT OWNER: THOMAS F. COUGHLIN TR. As-Built conforms with the plan A B ELEVATIONS approved by the Barnstable Board TITLE REFERENCE: BOOK 10235, PAGE 342 of Health. 1. ® HOUSE 89.31 PLAN REFERENCE: BOOK 292, PAGE 27 2. 10.3' 26.7' IN TANK 89.20 3. 17.2' 20.3' OUT TANK 88.98 ASSESSORS MAP: 55 4. 46.3' 34.1' IN "D" BOX 88.64 PARCEL: 48 OUT "D" BOX 88.46 ZONING DISTRICT: RF 5. 46.6' W.9' INTO CHAMBER 87.95 SETBACKS: FRONT 30' 6. 51.7' 42.3' INTO CHAMBER 87.88 SIDE 15' 7. 72.8' 60.3' END CHAMBER REAR 15 Professional Engineer Date 8. 28.1' 32.1' END CHAMBER MINIMUM LOT SIZE: 87,120 S.F. NO GROUNDWATER ENCOUNTERED ® 80.00 EXISTING LOT AREA: 43,836tS.F. ��HOF&*A�9 OVERLAY DISTRICT: ZONE II q�'� MARK D. cyG FEMA FLOOD ZONE "C" AS SHOWN ON 0 CIVIL � CIVIL ZONE DISTRICT: PANEL #250001 0018 D 937 DATED 7/2/92 FQ EP AS- BUILT N/F S '° SEPTIC COTUIT BAY SHORES ASSOCIATION INC. PLAN ASSESSORS MAP 55 - PARCEL #437 COTUIT BAY DRIVE S , COTUIT CB/DH M ASSACH U SETTS FND i N/F 00 THOMAS F. COUGHLIN TR. ASSESSORS MAP 55 BENCH MARK PARCEL 48 y SHED TOP OF CONCRETE BOUND 43,836±S.F. LARCH 9. ZOOG ELEV.=81.89 (ASSUMED DATUM) REVISIONS: i� NO. DATE DESC. EXIST. c1q ECK - FUTURE POOL v - BULKHEAD PORCH 0., - 16'x16' ci - 2 STORY STOOP 5 BEDROOM 19.1' c014 - WOOD FRAME - HOUSE #437 A 21' t� O 1500 GAL 4 - TOF=92.73 A/C 0.2 SEPTIC TANK bc0 Q UNITS OIL 21 0 (A / FILLERS 3 N 8 �12'x53' S.A.S = Ste` B ELE.METER GARAGE � 0 / \ F 5 N/F PREPARED FOR: ELIZABETH A. NARDONE °) � \ 4 6 ASSESSORS MAP 55 DEAN CASO "D" BOX PARCEL 51 145 OLD LANCASER ROAD 1 GRAVEL \ SUDBURY, MA DRIVEWAY 01776 7 (800) 990-7283 x 214 rn rn a � N � Soy Z F BSAGROUP c n 70 �o IP GAS -v GATE FND 657 Main Street, Unit 6 W. Yarmouth Massachusetts m UTILITY BOXES 0 02673 508 778 8919 -- - a 0 CB DH �' 25 0 ��- © 2006 The BSC Group-Norwell, Inc. FND A\rr TIPPED EDGE OF SCALE: 1" = 20' ONO 0 2.5 5 10 MEMRS _ R i?ISO 2 0 10 20 40 Fm 00 .-L-25 CB OF PA G0 EDP PROJ. MGR.. C. FIELD FIELD: D. G. / J. MaC. CALC./DESIGN: P. HAGIST DRAWN: P. HAGIST co O00 CB CHECK: M. DIBB _ _ G FILE: 8863-AB co co DWG. NO: 5648-02 \ SHEET 1 OF 1 JOB. NO: 4-8863.00 i