HomeMy WebLinkAbout0490 COTUIT BAY DRIVE - Health 490 C®tust Bay Drive -----�
COtu it
'055.034
cam\ Commonwealth of Massachusetts A96-�s-' o s q
fn Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
,Owner Owner's Na
Enformation is Cotuit Ma 9/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. Inspector Information 614r 1�e
filling out forms
on the computer,
use only the tab Chad Hathaway
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections-All Cape Septic and Survey
use the return Company Name
key.
Company Address
Forestdale Ma 02644
City/Town State Zip Code
r � 774 274 2581 12866
Telephone Number License Number
,1k 6 i -ems ' v u -UN
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection.; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
9/9/2020
Inspector Ignature Date
The system inspector shall su it a copy of this inspection report to the Approving Authority(Board
of Health or DEP)wit ' days of completing this inspection. If the system has a design flow of
10,000 gpd or.greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4 o i' 90 C tut Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don't's can be found at town health dept or mass.gov
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is Cotuit _ Ma 9/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
C broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system. is failing to protect public health, safety or the environment.
a. 'System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for everyotuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis-must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El Static liquid level in the distribution box above outlet invert due to an overloaded
® or clogged SAS or cesspool
99 P
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
r
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous.two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1,
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. CitylTown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
1s laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t,gnsp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is
required for every Cotuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: pumped june 2019 owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for everyotuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ 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:
tank older Dbox and leach 2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: ee
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain).
Distance from private water supply well or suction line: 26'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
none
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
f
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gal
If tank is metal, list age:
years-
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'6"x5'6"
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness less then 1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined?
tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump every 2-3 years under normal use. outlet tee has filter reccomened cleaning filter every 6
months to prevent possiable clogged filter and over loaded tank. tees in place. risers in place no
major decay visable
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
rn - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�a
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.).
7. Grease Trap (locate on site plan):
Depth below grade: feet
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: 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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
l5 nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dbox in good condition with light scaling of concrete. normal for Dbox 16 years old. Dbox is solid with
no cracks or leaks riser in place
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑. Yes ❑. No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and-appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System.(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
„ l 490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is
.required for every Cotuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
25'x13'x2' leahing bed with 2 500 gal leach chambers. riser in place. 3"of water in bottom of chamber
clean sidewalls over current level. leaching in good condtion
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5 nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I�
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 15 of 18
I
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
b GkGL
/ O
O 9(\Yka3)r t n Coup—r 2vcTy
3 � '
62
t ,
R 3 - �' C00-' 63- !D
IDr11 C'cwQs� ve d5
t5Ensp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
!P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for everyotuit Ma 9/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 30'
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:
el. area of septic per GIS maps 44' low in direct area 10' bottom of SAS 5' below grade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Perry
Owner Owner's Name
information is C
required for every otuit Ma 9/9/2020
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I
Commonwealth of Massachusetts.
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 490 Cotuit Bay Drive ...
Property Address 4
Robert Grady '
L-4
Owner Owner's Name �tr�
information is required for every COtUIt Ma 02635 8-14-17
page. City/Town State Zip Code Date of Inspection
1*5
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gttfoy
use the return key. Name of Inspector
i
B&B Excavation
Company Name
374 Route 130
Company Address
Sandwich Ma 02563
Cityrrown State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
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
8-14-17
Inspector's Signature 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.
� Us
tSins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Di os�al stem•Pa e 1 of 17
P 9 P 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17 `
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:.
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments: f-
System was in working order at time of inspection.
B) System Conditionally Passes:
El One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass. ,
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
_ I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 490 Cotuit Bay Drive
Property Address
Robert Grady _
Owner Owner's game
information is required for every Cotuit Ma 02635 8-14-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times'a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N• ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
L
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. City/Town a State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
.more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
r
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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is Cotuit Ma 02635 8-14-17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required-pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: ,
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of 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.
❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El ® The system is a cesspool serving.a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or.more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No f
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ El 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.
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
M Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. 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?
a ® 'Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from'owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(Actual) 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of,bedrooms): 349gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit GSM Bay Drive '-
Property Address
Robert Grady
Owner Owner's Name
information is Cotuit Ma 02635 8-14-17
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
. s
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (9P ))�
Detail:
2016-55,000gallons 2015-27,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: July 315`Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
,t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 A 8-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
ti
Pumping Records:
Source of information: Owner- last pumped 6 months ago
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)
El Innovative/Alternative technology. Attach a copy of the'current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval:
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2004 per COC
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan)`
Depth below grade: 2
feet
Material of construction: -
® concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) , ❑ Yes ❑ No
Dimensions: 1500gallons
Sludge depth: 3
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is
required for every Cotuit Ma 02635 8-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 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 15"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in
need of pumping at this time but should be pumped every two years for maintenance.
Grease Trap(locate on site plan):
Depth below grade: - NA
feet
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: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
490 Cotuit Bay Drive
Property Address -
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle
condition structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass . ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: - gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No.
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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 was in working order at time of inspection with no sign of past backup or carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: F ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
4
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
=:5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is Cotuit Ma 02635 8-14-17
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)'
Type:
❑ leaching pits number:
® leaching chambers number: (2) 500 gallons
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching was in working order at time of inspection. No high staining, damp soils or lush vegetation
were present. Chambers were dry when viewed.;
Cesspools (cesspool.must be pumped.as part of inspection) (locate on site plan):
Number and configuration NA
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
i
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan): .
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 490 Cotuit Bay Drive
M
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
,where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
REAR I
•
Rear garage
Al-25,6"
A2-62'
A3.74'4"
B1-39'
82-54't"
133-59,6,'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
N
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°w 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. 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: No GW @ 16'
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: 8-4-04pate
❑ 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:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w 490 Cotuit Bay Drive
Property Address
Robert Grady
Owner Owner's Name
information is required for every Cotuit Ma 02635 8-14-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
iL
TOWN OF BARNSTABLE
LOCATION � �n/[,/% � oiff t/6 SEWAGE #
VILLAGE_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. At� 0gli c�
`!SEPTIC TANK CAPACITY ��a(4S� f /570 i%4
LEACHING FACILITY: (type)42 Sb�C16►f (size) �.S i V>-
NO.'OF BEDROOMS?
BUIL6ER OR OWNER
PERMTTDATE: °I O t. COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
-on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A3�
i` 63-e
r,
3
� l
.t
No. L O Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPrtcation for Mioonl *paem Construction Permit
Application for a Permit to Construct( , )Repair( pgrade( )Abandon( ) []Complete System El Individual Components
Location Address or Lot No. 4/90 ,U(, !f ¢� O�y�e�lr�s e,9Oddreress&nd Tel.No.
Assessor's Map/Parcel ��` " .�l 4(10 _ cr
Installer's Name,AddrAs&#'eCAN`+O Designer's Name,Address and Tel.No.
350 Main Street 0i43 Cn-1 .
W. Yarmouth, MA 02673 g$$ -36(4
Type of Building:
Dwelling No.of Bedrooms_—3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow .3 gallons per day. Calculated daily flow d gallons.
Plan Date Ig Iq _ Number of sheets Revision Date N
Title
Size of Septic Tank /�DD FX%t�%ems Type of S.A.S. .Sao S
Description of Soil {_/` �lAi'I
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 E ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by is o of ealth.
Signed Date 018
Application Approved by Date
Application Disapproved for the following reasons
` Permit No. � �� Date Issued
d" ; «,tI 7101 Fee /4no
THECOMMONWEALTH OF MASSACHUSETTS Entered in computer
Yes
PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLE} MASSACHUSETTS
Application for ;)igpozal *p5tem Construction Permit
Application for a-Permit to Construct( . )Repair( pgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. ner's Name, dress d Tel.No.
u be/+ ellA c K (;
Assessor's Map/Parcel ��—_ r C�`�V p ✓i{- 13 a-y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
688 -360
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other TI pe of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow -� 9 gallons per day. Calculated daily flow gallons.
Plan Date 87 -773 Number of sheets Revision Date
Title
Size of Septic Tank /SOO �,t %s<�• s Type of S.A.S. SQ D S
Description of Soil
Nam•
Nature of Repairs or Alterations(Answer when applicable) 4 r /'14
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 E ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue�bys of ealth.
Signed {,d .l Date 9 !`/
Application Approved by Date T l��"
Application Disapproved for the following reasons
� 1
i
Permit No. C 1 Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (&- Upgraded( )
Aban oned( a by e-/ G)
at 90 d�u�1' d AV, �� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. uo q'S I�' dated�l °I/V
Installer Designer
The issuance of this nermilt 4hall not be construed as a guarantee that the sy to ill f`nc�tion as dde�gnnedl.
Date 1 1 I 'Inspector t.�-�Y kw.
--------------------------Fee lCIO
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,~ MASSACHUSETTS
Digozal *p�tern Congtruction Permit
Permission is hereby granted to Cons t( ),Repair( Upgrade( )Abandon
System located at �� . �4 ,�`-
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 Pe completed within three years of the date f this permi .
Date: / '/ 0 Approved byyZ
Town of Barnstable
oFtHE r o Regulatory Services
Thomas F. Geiler,Director
MAW. Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer: 4�/j � �SZ7 9 Installer: 4"/W
T d
Address: aZs63 Address:
On - 5=U Q • pg)eq-A160 was issued a permit to install a
(date) (installer)
septic system at -#11579P CvTlJi� 6q � vr' based on a design drawn by
• ��S� SS o�1 (address �2'�p SS �{�cE2 ��
�zJ2Y �y dated
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.
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 P<, ns. PI r
certified as-built by designer to follow. �-�N OF Mass
q
R E
Cn
. 1140
( staller's Signature 9 •p. o
\ GISTS
'9qN/TAR\
(Designer's.Signature)` (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNS ABLE 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.
p. Q: Health/Septic/Designer Certification Form
c�
TOWN OF BARNSTABLE L
• LOCATION 1�' �� �tS�[�/s% � �✓�f�� SEWAGE IV
VILLAGE COTS/% ASSESSOR'S MAP.& LOT I sF.+A
INSTALLER'S NAME&PHONE NO. —?-7r',)
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type),:2- 67.1mri'd —VjjA-4S (size)
• NO.OF BEDROOMS J
BUILDER OR OWNER
PERMIT DATE: 6`1 O t.I if COMPLIANCE DATE: A'.�-'OY
Separation Distance Between the:
Maximum Adjusted GroundwateT'Iable and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility` (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
02"
OF
Viz,
7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...'. ........... .OF......... .:........................................
i
Appliratiuu -fur Dhipwial Works C onMrurtiou' prruiit L,/
Application is hereby made for a Permit to Construct (\/) et'—�r ( ) an Individual Sewage Disposal
System at: ( 1-
0-6 {�
�. TV i Jl� ( k'i��L 6 oi'.. Z� �Ur'f 1 Aa� IJAi�'�. '� tJl�T"
• '7" 1
------------------------------- . --------...-----•-- ---- -
l !��=---VGLFG J oca 1✓!'� �eS `v....................... L— MCJc.-.1 r��`f^c,.or v���. VACA � vl..�7(,�F—�,
Oyvner tidress p� A �
Installer Address
UType of Buildin Size Lot.....Zg4- ......Sq. feet
jp,Dwelling—No. of Bedrooms_____________ _________________________Expansion Attic (w®) Garbage Grinder (�o)
a4 Other—Type of Building .:____ -ittteN_-_--__-- No. of persons........ -............... Showers Cafeteria ( )
a' Other fixtures ---------------- ----------------
w Design Flow-----------5V.........................gallons per person per day. Total daily flow........30P--------------------------gallons.
WSeptic T utk—Liquid capacityJAPP.gallons Length................ Width................ Diameter........_. ..... Depth--.._____--.----
x Disposal Trench—No- -------------------- Width-------------------- Total Length-----------_........ Total leaching area------------- ......sq. ft.
Seepage Pit No.AOd C%____ Diameter.................... Depth below``inlet.................. TNW,01�-
]tits area.--_-.----..---._.sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 0 i -R - 11"A,T-7G
aPercolation Test Results Performed by----------------------------------------,............-.................... Date---------------.........................
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water...._---_----_-._--. --
rXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-._.---______-.__-__..
..............V , r-------•-------•-- ---
O Description of Soil O ...._. d _... _.......1'-t - �i� `"� - 3- ' �a" ... . ----
x
w
UNature of Repairs or Alterations—Answer when applicable..-.:.......... --------------------------------------------------------------------------------
-----------------------•-------•-•--•----------....---------•--------.....•---------•-•••----•-.....------ --------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code— The undersigned fur r agrees not to place the system in
operation until a Certificate of Compliance has been issueADI
he oar of e th
Si new " - �. .....
.....................
Date
Application Approved By-----... . t;,((rk1L1 ,. ------------------- '-1.2 7 ----------
(/ Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•-----------------•-
--------------------------------
Date
PermitNo.......................................................... Issued........................................................
Date
��
J
No.......kl- .......--- FE�.......:.�.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................oF....... 'S t/.d 44' ..............................................
Appliration -for Ui.ipoottl Workii Tomitrurtioo Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Loca' n-Address � or of -o. •.
d:--G�c.�........----.�o�rr� ---------------------------- 7. It R, s �a: ..-. vK �,e ........
�- Ow er ,'/Address /
............ F4. ��?.N ,Z �ot�e___� .` �(64 ToaIS e�q
.........• -- ...... ----- •.•-••-
Installer Address
Q Type of Building Ir Size Lot......z� ......Sq. fee
Dwelling-4,Ko. of Bedrooms--------------------------------------------Expansion Attic Qt(b) Garbage Grinder (
Other—Type of Building //��-- �!4Mr, p �- Showers ( Zj — Cafeteria ( )
C>i YP g -J�--------------------- No. of er�oll5------------•----.._._......
Q' Other fixtures ---------------- -------------- - -
W Design Flow...._.___...5.............................gallons per person per day. Total daily flow..........��P---___-_.-_____---_.....gallons.
WSeptic Tank—Liquid capacitVIOP!2gallons Length................ Width................ Diameter---------------- Depth._-___.__.-.--.
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..__l_009?..... Diameter.................... Depth below inlet.................... Total lea liitl area..--- ............sq. ft.
z Other Distribution box ( ) Dosing tank ( ) p /✓ ,�' dYe 76
Percolation Test Results Performed by-------........................................... .............................. Date........................................
a
a Test Pit No. 1................minutes per Inch Depth of Test Pit-------------------- Depth to ground water-..___._-.-____.__--_..-
fl, Test Pit No. 2................minutes per inch Depth of Test Pit....._...-..._-.-.-. Depth to ground water................--------
(Yi .-----------•---•-----------------------
Description of Soil O ------ � .---- +� `� -------- --- —-------------------------------- - ----------
�4 f----------------------------------------------------------•--------------------------------------------------------------..--------•--------.._...-----------
w
VNature of Repairs or Alterations—Answer when applicable.-._...........................................................................................-
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the b rd f a
` ` 3��r " 5
Sig ed ----�!.-. --------------------
------- -----------------
D
Application Approved By------- -- - -------1 __u/1�S- '✓ .'.�r' 7
Date
Application Disapproved for the following reasons:--•------------•----------------•-----------------•-----••----•-•-------------------•---..-------------••-------
---•--•.......................... ...........•-------------
Date
PermitNo----------------........................................ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
f
BOARD OF HEALTH
. .................oF......../7Ai TA0�14...........................................
mprrtifiratr of f1.1oluphaurr
THIS IS TO CE."CIFY, That the Individual Sewage Disposal System constructed (}�) or Repaired ( )
r .. ---------------------------- -- . ------------------------------------------------ ------------------------------
p 0 i?l ��Y bie N ............... Insctaller�_
at.---•---- .-!_.(_�..........C? ' ................ ` —'.E_..� 4_fJ..(. .[..f
has been installed in accordance with the provisions of Af. X of The State Sanitary Code as d_ i- ed in the
application for Disposal Works Construction Permit No------------------ ................. dated...-.. .. ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRAJE ,-AS �GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SA ISFACTORY.DATE................ �...-------------��---...._..-----------�.... Inspector-------------------------- -.....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
77
cr� ......... .............OF..........'J.�+ 5 ��� ...................................... u-r�
No......................... FEE-----..............----
�i� o tti rk , TToo rurtiou Vrrmit
_ ti�
Permission Is hereby granted _ ��' { u •---------------------•-------...--•------------...--•--...................-----
to Construct (�O or Repair ( ) an Ind vidual Sewage Disposal System
at No.••---4q/--------�V?�.!"......& ..------4J�i_!/ ............Ctt0_Tcs< f
- -------------------•----------------.....---...------------•-•-----•-••-•--•-.....
Street
as shown on the application for Disposal Works Construction,Irmit o.. U� .. Dated_.3_-�_�_��.�.............
--------------------------------
Board of Heat
DATE-------------------------------------------------••---•-• ---------------------- Board
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L 0� �17!0 f� �=-�LJ � }fSEWAGE . PERMIT N O..
VILLAGE
,T,Al l l C R'S bl✓��'A ME & ADDRESS
B UP E R 01 OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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'+:av+rVe"`",.`B: :, ': ..,-a+Y'P+r>: ►r+47«r....,?bY+kasw..xrza.^aww+; �+:x.°eamKrAl+ w ..ws+.'4q'aLe '^:.un .. _ -. .... _. 'sgs»^a: :.. .... .. ..
M WON
iZ T\
{ �
STANDARD\
A D
D NOT
ES ES
\ \ I) THIS PLAN IS FOR THE INSTALLATION OF A ,SEPTIC SYSTEM.
2) ALL INSTALLATION PROCEDURES AND MAT%'RL4LS SHALL CONFORM TO 310 CMR 15.000, THE STATE ENVIRONMENTAL CODE,
\ \ TITLE 5, AND THE TOWN OF _�3 �. _ SUBSURFACE DISPOSAL REGULATIONS.
G���,� �\ \ 3) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE OF A VAILABLE PROPERTY INFORMATION WITH RECORDED DEEDS
NIP,\ \\ OR ZONING REGULATIONS.
\ \ 4) TOWN WATER DOES MW SERVICE THIS PROPERTY
King- -
•
5) THERE ARE NO EXISTING WELLS WITHIN 200' OF THE PROPOSED SOIL ABSORPTION SYSTEM.
Map 55 Pcl 33 0 91 e0' \ \ 6
) ALL COVERS OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 6 " 01, FIN/SPIEL? GRADE '
7) ALL SYSTEM COMPONENTS SHALL REMAIN ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY
IN, UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTERFERE WITH THE PERFORMANCE AC
b CESS,, INSPECTION
PUMPING OR REPAIR.
8) NO DRIVEWAY, PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION
71'56'01 _ Y\\ \\ SYSTEM, EXCEPT WHEN VENTING HAS BEEN PRO VIDED.
N TBM EL - 100.00 \
Top of Foundation \ \ 9) SEPTIC TANKS, GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES 'SHALL BE PLACED ON A 6 STONE BASE
fi \ \ \ TO ENSURE STABILITY AND PRL VENT SETTLING.
Pump and fill
Existing OUTLET DISTRIBUTION IJNES SHALL REMAIN LEVEL FOR A MINIMUM
. �l \_. - \ \ 10)
OF THE FIRST TWO FEET OF.THEIR LENGTH.�1
existing \ \@� g pit as 1,5OO Oral \ \ 11) ALL SYSTEM COMPONENTS STfAI,L BE CAPABLE OF WITHSTANDING H 10 LOADING UNLESS' THHL Y ARE '
CT t'P Ti i/P5" \ \ \ \ UNDER OR WITHIN 10
required P
S— Tank
\ \ \ \ OF DRIVEWAYS OR PARKING OR TURNING AREAS, IN WHICH CASE H-20 COMPONENTS SHAL L BE USED.
12) ALL BUILDING SEWER LINES SHALL HA VE AN INNER DlAb1ETER OF 4" AND SHALL B --
E CAST-IRON OR SCHEDULE 40 PVC
r ►�O 1 \ \ \ \ \ 13) THE DEPTH OF THE TOP OF ALL SYSTEM COAfPONEN "
AMAN.DA
� �
TS SHALL NOT EXCEED 36 UNLESS VENTING HAS BEEN PRO VMED.
\ \ 14 IN THE AREAS OF "CA NATION, EXISTING GRADES SHALL BE REESTABLIS
Ise) R = 75.00 ` / � - - -� �- \ � \ \ )
7� HFD UNLL SS 110TI,D 11 S PR0I�OSI,71 CON7'O URS.
CO UI�'1 10
t \
L = 68.00 � a a <U \
\ \ X .� \ \ Lz) IF sOI1S A.R6' ENCOUNTERED DURING THE EXCA NATION OF THE SOIL ABSORPTION SYSTEM THAT DIFFER NOTABLY FROM
THE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDI
i Proposed Sa ve exrsting \ \ 16 1�G
p \
„ . - C? \ ) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTILITIES.
� OSe 8 Ines
;
' �42 6'f \
01•0
�1 ; , V m I DEEP OBSERVATION
DESIGN DAB A
HOLE L0
Test Hole #1
\ \
(,)_ :..:.,. Test Ply \ Number_ of Bedrooms. .�� n ,
2
5 \
,0 Tel, sadl soil sou 1
Loco tlon \ Dp�th rt to �;
\ _ ( ) riaon T zt Color C
_ \ Garb e - s
. \ a Grinder. ::... usD
,-
\ \ d r
PROPOSED LEACHING FACILITYJ Desi n Flow o o� Lo _ .�a,� EN s o -
f
, \ r 110 dal/BR/Dayx Number of BR — L�c u� : ,' U MEYERCn
A � Two 500 Gal cone eharnbers ,..g \ \ o . _ ( ) �3,r� � -�,� .r�s,��
No. 1140 .
(or similar with 4 stone \ o Septic Tank. , `�" U �32 �3,b 'Gorsc 2`s�-�
f � � rc:..akr• F�- �� GIST,
( Total Dim 25 x 13 ) \ - �o � = Des' n ,. r s
l " ~- - - - - - - - ( T Flow x 200�) C n t 5 T d o ��� d-sr(: Aw o r nt-4 n�o �'�d� c ^+ r �
` - Leaching Area: -z�(
—. _ Deep Obe Hole.Date: � I `�1 G 4 .
Gc'�V-e 'tr/ 2 ,�? s`s� 9 S ide wa ll:
T U G<// .�) 'rot ✓f 1 .S�f `9e$ 4 4 Soil sse fir`� t•�_
Witnessed
/ 7,
Pere Rate: _ S M I N l f �o d
NIF (2 5idewalls x _ Ft x Ft +
--- � ' Soil Survey Description: CARVER
1571.3` Geologic Material: OUTWASH
- _ Oche (2 Endwalls x !2..Qj�1—F'�' x -Ft) Depth to standing linter. NA
_ Depth to Weeping hater: NA
Ma 55 PC] 39 .
N/ r .88 P Bottom: 3 2 O .? Depth to Mottllng(Color): NA F
j' L� c� Eat Seasonal High Gl� NA C1; MSS
O i i+ 2 5 USGS Observation Well NA
Robinson }f. ----Ft t 2. ) t j^y
—Ft [ ` r-� Data of Last Measurement NAoD'JVAf?C�
�lJTn g �� Comments: /< A.
Ilia 55 Pcl 35 �l Long Term Acceptance Rate (LTAR): 0. 74 > STONE p �U ���� 3 ?� � �3 a
{�
Leaching Area Design Capacity �. 1 No. 280so'; � h t�C� -� .�
�
C. 4,
(Side/wall Area + Bottom Area x LTAR Fss G IS TVR
5
TOP OF
FO UNDATION
EL r o p t o D Raise co to hin 6 of
finish grade all risers as needed :. ..
- • ��-5 N.G. GROUND SURFACE ELLc-'10 -_2__
t > r
GROUND SURFACE PROJECT LOCATION
" MIN
4. N ST A l_ OUTLET PIPE LEVEL ,
? FIRST TWD FEET 2'2' N VEVT REQUIRED ASSESSORS MAP Jt` LO%
rj
( 9<P�F 2"MV--3"MAX TOP EL
MIN 2' LAYER DOUBLE WASHED
AIN
INVERT EL lis'- 1/2- STONE 9 I 3 T -- APPLICANT.'
A INSTALL / . G' �`y EFFECT_'VE
INVERT EL �` `
GAS BAFFLE �' SIDEWALL `�
w �F B" MNA BASE
INVERT ELF INVERT EL !
Proposed G l 3 �U�v r 0 CI G �--. (�
INVERT EL �QNC. 3/4 - i i/2 DOUBLE PA i4l
`D — Box C t.�n^-.� *:,� g �r' <, t r + �4�' WASHED STONE �.
TNVERT EL PREP14RED BY
j _ �-x r �� '� ! '.�.r s;-1-1 �-•� „ �`,�•ot,�� C�J--{l� xY�-�o''� Z-�� 5,�{ _ �� � %
L C ram,, 1
r�l l Pal� �•!1 1 U I
/r t Lal .S'epdic Tank BOTTOM EL �� � o`e c
d, 13uy. 17ZO
- .. .EL 130TT0/!✓J OF TFST NOTE �* Ea�I� ��� , � -' S/},hfQ6+l1tGf0� MA
r — ( �d Gt c� vla.-c-e�-
soy- ��a-3�r9
� ,
II
� s M.t��C-'
v� rt o , 3 l 5� S�tG�r' �► o �'