HomeMy WebLinkAbout0528 COTUIT BAY DRIVE - Health 528 Cotuit Bay Dri
11055-040 Cotuit
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COMMONWEALTH OF MASSACHUSETTS
_ EXECUTIVE OFFICE OF ENVIRONMENTAL AFfAIRS, ,
DEPARTMENT OF ENVIRONMENTAL PROT CTION-
ASSESSORS MAP N0:
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PARCEL NO.
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TITLE 5 N
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASS SSMEATS
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SUBSURFACE SEWAGE DISPOSAL SYSTEM FO
PART A
CERTIFICATION
Property Address: 528 Cotuit Bay Drive
Cotuit, MA 02635
Owner's Name: Jim Bowser
Owner's Address:
Date of Inspection: June 4, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Need urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: June 8, 2004
The system inspector sha\submia copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 2004 i
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a.year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 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 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.
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 colifonn
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 1 d
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: 'Jim Bowser
Date of Inspection: .June 4, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,.for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
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 System:
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- I WPA)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: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on thesite has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 528 Cotuit Bay Drive `
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings.,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
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: Pumped in 2002-per 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
✓ 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)
Tight Tank Attach a copy of the DEP approval
Other(describe): '
Approximate age of all components,date installed(if known)and source of information:
Approximately 1975-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line_
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 18"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
Recommend pumping.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
i
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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 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 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 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
• Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The pit had Y ofwater on the bottom. The scum line was at the same level. There did not appear to be any signs offailure. The
bottom to grade was 9.5'. The cover was 2"below grade.
CESSPOOLS: None (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 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
• Page 10 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 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 feet. Locate where public water supply enters the building.
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10
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Page I I of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 Cotuit Bay Drive
Cotuit, MA
Owner: Jim Bowser
Date of Inspection: June 4, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to determine the 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:topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic maps and water contours maps, the maps were showing approximately 30'+/-to ground water at
this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report.
11
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
n �
a `
+ z .w TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 528 COTUIT BAY DR COTUIT,MA 02635 `- EVE®
Owner's Name: GEORGE RICE ,_
Owner's Address: 528 COTUIT BAY DR COTUIT, MA 02635 JUN 14 2002
Date of Inspection: 6/5/02 TOWN OF BARNSTABLE
HEALTH DEPT.
Name of Inspector: (please print) OHN GRACI
Company Name: SEPTIC INSPECTIONS _
Mailing Address: 3 1pia. BOX 2119 TEATICKET, MA.02536 Q,
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 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 a4i� maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section'151340zof Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally asses
Needs Fu Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �i'd< • Date: 6/5/02
The system inspector shall submi 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 twthe buyer, if applicable,and the approving authority.
t4
Notes and Comments r
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOM MEN D,,RAISING COVER TO LEACH PIT 3'.
****This report only describes contitions at the time of inspection and under the conditions of usual that lime.This
inspection does not address how the system will perform in the future under the same or different conditions of use.
F
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Page 2 of 1 I
,z
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
`+ PART A
CERTIFICATION (continued)
Property Address: 528 COTUIT BAY DR COTUIT,MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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.
`1
Comments:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOMMEND RAISING COVER TO LEACH PIT 3'.
B. System Conditionally Passes: '
_ 'des-ribed in the"Conditional Pass"section need to.be replaced or repaired. The system,
One or more system components as'`
upon completion of the replacerngnt ortrepair.Aas approved by the Board of Health,will pass.
.x• ii
Answer yes,no or not determinedr(Y,N,ND),in the for the following statements. If"not determined"please explain.
n/a 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 i
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
distribution box is leveled or replaced
ND explain: n/a 33
t .
`3
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 th'e Boa!rd of'Health):
1._:broken.pipe(s)are replaced
ql'#'obstruction is removed
l!11 `9'
ND explain: n/a
': is
Page 3 of 1 I
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 528 COTUIT BAY DR COTUIT,MA 02635
Owner: GEORGE RICE ,
Date of Inspection: 6/5/02 `,3
C. Further Evaluation is Required by,the Board of Health:
as.
_ 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.
,r ,
1. System will pass unless B`oa`rd 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 withih,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;Boarrd of Health(and Public Water Supplier,if any)determines that the
system is functioning in a m°anner that protects the public health,safety and environment:
The system has a septi&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 I 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.
s
_ 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 n/a
"This system passes-if the well'water6alysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate niirogen'is equal`to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attaA d�to this form.
; s
3. Other:
n/a ,
Tt"� s
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 528 COTUIT BAY DR'COTUIT,MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02
,i
D. System Failure Criteria applicable to.all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
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 c.
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 '/z 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 NO PUMPING INFORMATION.
_ X Any portion of the SAS,cesspool or privy is below high ground water 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 I of a public well.
X Any portion of a cesspool•or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fi-om 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;,foricoliform 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 for•►.-f, ,
,, t
(Yes/No)The system _fails:] 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
X the system is within 400 feet of a surface drinking water supply
t¢
X the system is within 200..feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—I WPA)or a mapped
Zone 11 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.
t95
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.
'f.
' �' a
Page 5 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE?SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
{.' CHECKLIST
Property Address: 528 COTUIT'BAY DR=COTUIT,MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02
Check if the following have been'done.,You'must indicate "yes"or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
A.
,.,
X _ Has the system received normal flows in the previous two week period`?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X _ Were as built plans of the,'system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelliii�g inspected for signs of sewage back up
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site'?
X _ 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 9
X _ Was the facility owner:(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?,
' a
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.'For ezampl'e,�a plan at the Board of Health.
X _ Determined in the field.(if any of the failure criteria related to Part Cis at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
t
Page 6 of I I j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-
.,f PART C
SYSTEM INFORMATION
Property Address: 528 COTUIT BAY DR COTUIT, MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02 r .
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):`;'T Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR°1'5.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does 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):NO,
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years,usage(gpd)): nK O u u I 0 Z 1000
Sump pump(yes or no): NO
Last date of occupancy: n/a l
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR'15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no),,NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a is
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: NO PUMPING INFORMATION
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons---'How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy ;s
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy,`of the IDEP approval
Other(describe): n/a
Approximate age of all components,dafe'installed(if known)and source of information:
APPROX 24 YRS BY OWNER {
Were sewage odors detected when arriving at the site(yes or no): NO
1
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE!SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 528 COTUIT BAY.DR COTUIT,MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02 Ij
BUILDING SEWER(locate on site plan) y:
Depth below grade: 20"
Materials of construct ion:._cast iron X40 PVC other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 14"
Material of construction: Xcon"c'refe metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age'corifirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 547411WA' 10""
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: 2"
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: 16"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERYaTWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate,on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top ofl outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, ui.let and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage;etc). :w
n/a
Page 8 of I I t
O
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 528 COTU1T BAY DR COTUIT, MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02 t
5
•t,
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a .5 I
Capacity: n/a gallons
Design Flow: n/a gallons/day , 1
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a.
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.):
n/a
PUMP CHAMBER: _(locate on site plan) E}
Pumps in working order(yes or no): NO ' t,
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
zt
s
r t
=; ,W
Page 9 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 528 COTUIT BAY DR COTUIT, MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02
SOIL ABSORPTION SYSTEM (SAS): 'X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a ;1 , leaching fields, number: n/a
n/a overflow cesspool, number:, n/a
n/a _ innovative/alternative system
Type/name of technology: n/a
S .
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF
FAILURE. RECOMMEND RAISING COVER 3'. BOTTOM IS AT 9'6".
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a j
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan) a,
Materials of construction: n/a'
Dimensions:n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
L.
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 528 COTUIT BAY DR COTUIT, MA 02635
Owner: GEORGE RICE
Date of Inspection: 6/5/02
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.
i
{
� s
Page I 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
4 SYSTEM INFORMATION(continued)
Property Address: 528 COTUIT,BAY DR COTUIT,MA 02635
Owner: GEORGE RICE tit
Date of Inspection: 6/5/02
SITE EXAM ,• �•
_Slope
_Surface water
_Check cellar
_Shallow wells =;,,
Estimated depth to ground water,12+feet~
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS dafabase-explain-,n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT. t
i
A.
-
l:1,iIS�liL, �eF
.4s
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street Boston,Ma. 02108 Jolui Gf,id
' D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
wILUAM F.wELD (508 564-6813
Governor �� A - 9
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO IN PART AF 4 ✓�
CERTIFICATION �'EivEO
T NOV 1 3 1999
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55PAR 40 L 24 Address of Owner:
Date of Inspection: 10/5198 (If different) TOBrNOFB=A"
Name of Inspector: JOHN GRACI THOMAS TRULOVE;BOX 155 IT1HDEpZ
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: A
lr
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria dented In Title V
Condition Passes code 310 CMR 16.303.My findings are of how the system is
Y performing at the time of the inspection.My Inspection does
_ Needs F th Evaluation By the Local Approving Authority not imply any warranty or guarantee of the longevity of the
Falls septic system and any of Its components useful life.
Inspector's Signature: Date: 19m198
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system i a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR 40 L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:10f5198
_ Sew.aQe backup or.breakout or hiah.static water level observed.in,the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following: _
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR 40 L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:101`5198
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART B
CHECLIST
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR4a L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:1015199
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR 40 L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:10f5198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3w g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yea
Seasonal use(yes or no): Yea
Water meter readings,if availabie:(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy: nfa
COMMERCIAL/INDUSTRIAL:
Type of establishment: nfa
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nfa
Last date of occupancy: nfa
OTHER:(Describe) We
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nfa
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nfa
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
SYSTEM IS 20 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no) No
- (revlaed04RA97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR 4O L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:1015198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 1'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le'6-•H5'7"W4•10"
Sludge depth:6"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness:V
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumpingnt-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: v 6--
Material of construction: cast iron 40 PVC_other(explain)
Distance from private water supply well or suction IIne:TOWN
Diameter: nla
gammljnts: (conditions of joints, venting,evidence of leakage, etc.)
(revised 04N27)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR40 L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:1015199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene_Other(explain)
Dimensions: Ufa
Capacity: r9a gallons
Design flow: rda gallons/day
Alarm level:_nfa Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nfa
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Ufa
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
UNABLE TO EXPOSE,n WAS UNDER PATIO
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)—Ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
nfa
(rev1eed=7)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 528 COTUIT BAY DR.COTUIT MAP 55 PAR 40 L 24
Owner: THOMAS TRULOVE;BOX 1550 COTUIT
Date of Inspection:1015199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits,number: 1000 GALLON OCTAGON LEACH PIT
leaching chambers, number:Na
leaching galleries, number: nla
leaching trenches, number,length: Na
leaching fields,number, dimensions:Na
overflow cesspool, number:n1a
Alternate system: Na Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE PIT HAD 6"OF WATER IN IT,AND HAS NOT BEEN MORE THAN 2.5'FULL:
CESSPOOLS:_
(locate on site plan)
Number and configuration: nla
Depth-top of liquid to inlet invert: Na
Depth of solids layer: Na
Depth of scum layer: n1a
Dimensions of cesspool: rda
Materials of construction: nla
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding; condition of vegetation, etc.)
Na "
PRIVY t
(locate on site plan)
Materials of construction: r9a Dimensions: Na
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
(revised 04117)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
528 COTUIT BAY DR.COTUIT MAP 55 PAR 40 L 24
THOMAS TRULOVE;BOX 1550 COTUIT
1015198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)'
(r 2i _— _1
A PA�,�
(revlaed04)Z7197) Pay ! of 10
s.
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
528 COTUIT BAY DR.COTUIT MAP 55 PAR 40 L 24
THOMAS TRULOVE;BOX 1550 COTUIT
1015199
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
_X— Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
i
0
(revised04)27197) page 10 of 10
i—
., TOWN OF BARNSTABLE
LOCr'►TIUN C�'� 84 SEWAGE #
VILLAGE COTU 1 ASSESSOR'S MAP& LOT SS O YO
INSTALLER'S NAME&PHONE NO. GOT
SEPTIC TANK CAPACITY f
LEACHING FACILITY: (type) �iT Ce X�� (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER TM Q OWSe��
PERMITDATE: 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 leac g facility) / Feet
Furnished by �/�' G CO.
A aAGk
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ao i ►
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...... FimB./ ...................
THE COMMONWEALTH
NWEALTH OF MASSACHU$ETTS
BOARD OF HEALTH.
............. ...........
Appliration for IMiposal Marks, Tou'ptiuirtion Vrrmit
Application is hereby made for a Permit to Construct or Repair an. Individual Sewage-Disposal
System at
J
....... ... .. ........ ...................................................
-------------------------------- ..........I-----------------
Kal�� Lot NO,
co .....
do
ner_� dress
..................
------------ ------- ................ . ... ................
Installer Address
Type of Building Size Lot
U ------- -- -----------Sq. feet
Dwelling—No. of Bedrooms--------------IRD.....................Expansion.Attic Garbage Grinder.
Other—Type of Building ------ No. Qf oersons-_------------------------ Showers Cafeteria
IOtherfixtures .... ..... ------------------------------------------------------------------------------------------
Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity./V4-gallons Length________________ Width-_::._._......_. Diameter____-._.--_-____ Depth--------_-----
t.
Disposal Trench—No. .................... Width-------------------- Total Length----- -- T �ghiA$ - --------- q..
h below inletA--- -----
Seepage Pit No..................... Diameter.......GP....... Dept Pi......... eacliin� ---------
Other Distribution box Dosing tank
Z
Percolation Test Results Performed by..___._.
.............................................. Date........... --------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
rZ4 Test-Pit.No. 2................minutesper inch Depth of Test Pit________.____.______*............. Depth to ground water-__-_.-.__-____-._-_----
;; ------- ..............
0 ......... -- ----- -- -—- --- ------------
Description of 1�oi........4-- '_!rt.... .........144.. 71--- .................114). ......... _11-- . - .... .
..................... ........... . . ..... .......
U .........................................................................................
7-----------------------------------------------------------------------------------------*-------*------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
. ........................................................I----------I------------------------------------------------------------------------------------------------------------------------------
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 iissued qbDthe boardDd-beall.th,.......
U 19 --------
--------- ---
.... .. ..
Id .......... .....
S* ------- ..... -------
tam Date
Application Approved By......
------------------------------- ---
Date
Application Disapproved for the following reasons:..................................................................................................------------
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.... --
at ----------
at
e
----------------------- -------------------------- --------------- -------
No......................... FEE..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_..._ . ..
ApplirFation for Bhiposal Worko T. mitrurtioat Prrattit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System af,p --- -� ---•-
.......
t ! �........ .....Address :--------------------F ------•--------------------- -- ------------------------------------------
-
or Lot No
...............................°.........-- ........----•---••--=••--- ..._...--•---•-------••••-
(/,,. .
Owner.� J YC ..� •........ s�(•.. ,%�• ��-
Installer Address / f1 f
Q Type of Building Size Lot...........`...._../_/.........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )'`
`-I Other—T e of Building _ No. of persons............................ Showers — Cafeteria
Other fixtures ...................................-_l-�_
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity. '...gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.....: ............ Totoottaall,l arch',g arr.- ;lfWs !t.
Seepage Pit No------_-------_-- Diameter......_`........ Depth below inlet. _......l-/l'ta" eac to -t ea-'_-._...._......�__sgq. it.
Z Other Distribution box ( ) Dosing tank ( ) 4_ HOC�' - •- /? - 71"
0-4 Percolation Test Results Performed by------- t: vy2r n!, .......................... Date----------------------------------------
I Test Pit No. 1................minutes per inch Depth of i/est Pit-------------------- Depth to ground water........................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit------------_....... Depth to ground water----.__________•_______.
-_-------------- - ----------------------------------Y-,-.
�DDescription of Soil-------- E' r l`st�.�t 1 �.-/� " = 1 Il' J ��
U — - 1/4o----- �A-4 � Wr —
---------------------------------------------------------
-------=-----------------------------
---------------------------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable.__----•___________________________________________•___-____-_-•__.___________--___.__.--.-----.
•-------------------------•••-•---•••••--•_.._..-•-•••-•-•--•-•-••-••••••--••••-•-----------•--•------•----------••....•-----•--•----•-••......--•--•-•••-•-•-••---•- .................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boarc�u*
"
Signed.------- !L±....,.--- -------- ................................
Date
Application Approved BY-----... .. ...... �f� //� c .`�F---- 'J!
0 T r Date
Application Disapproved for the following reasons,:................................................................................................................
•----•----••----•-----------------•---•-•-•-•-••------•---...---•-••----•------......•-••--•--------•----'-•------•-------------------•-------•------------•--•-•-•-•-•-----•--•-•-----••------------- =
Date
PermitNo....:..................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ..... ............OF.........v " .jrt;_Z_& 1t......:.......... ..
THIS IS TO CERTIFY, That t Individual Sewage Disposal System constructed ( '�'Or Repaired ( )
by ------I n- ------- ------------- ------- ---------------- ----------- --------•-
sdlYer
at �� / ---------
'
has be if�shalled in accordnce wtth fhe ovislOfis of Aiti e XI of The State SanitaCode as describ in the
application for Disposal Works Construction Pe mit No..-_�s _.__.__ .,� ......_.... dated.___�.:-../. .:..7.!_".............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector-------------------------------------------------------------•......-----------•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oF.............................. 1f'�'f�/�Lil /
NO.`......: �:,_``... � ........._ G;.G� FEE-----f-•�
Permission is hereby granted............ Z • _/' / !s'
to Construct ( ) or Repair ( ) an IC dt�l -Sewag I p sa Sy tem 1
at No. ------i)-------------.4 = ... JOB//1 ! 1 --- �-1 am_% , � �✓
0- reet
as shown on the application for Disposal Wor nstruction Permit No____ ______________ Dated..... .--1.r�w_-%.S __..._.
DATE........
FORM 1255. HOBBS & WARREN. INC.. PUBLISHERS VII
I
U®CATION 5EW4,CtE PERMIT UO.
1 _ �*--ASL _ _ _
VILLAGE -0--
1mST- LLE �5 UgE�6 A RE .SS
BUILD 5- .- ADDR SS� ----_
�- DQTE -PER"IT LSSUED '-
5
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1
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y.�-,o�,
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TOWN F BARMTABLE
' 11 SEWAGE #
iO LOCA.t N S2
VILLAGE ASSESSOR'S MAP & LOTSS�6
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (ty 1+ 4 (size) AC6
i
NO.OF BEDROOMS-
BUILDER OR OWNER. Q.Snit]
rlr�
PERMITDATE: COMPLIANCE DATE: /3
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 �(1 (aC
. bqW ,G
A N
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ERT
ARCHITECTS,INC.
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Aa�reT.•1B•Bamuarnemmam�e• wee
947 ROUTE 6A, UNIT 8 .
Z)o.� .�} N PO 80X 343
e YARMOUTHPORT, MA 02675
tel (508) 362-8883
fax (508) 362-4883
M BATH xww.cnTAROMCn.'cw
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E7Q3TINO SITTING AREA .'w f�•
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BEDROOM MOH -
EX3T. BA
CLOS RENOVATIONS
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MR-&MRS.TOM
o° MELIA
BEDEDaSTMROOM,
BEDROOM. L INSOROOOM . D
" S28 COTLTIT BAY ROAD
COTUIT,MA '
EXISTING FIRS FLOOR PLAN
Y � O PROPOSED CHANGES
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FOR FINIS o OR
s BE UMD
D.
FOR PEewmec aR wlsmucnaN
. - - - - - BIIN AN SIIlNAI AACIOTECM
9TANP AND 9GNANRE cmN
5'PEMRT SEry gT:'WII9IRIIC110H SEry
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E)US , '. - Am OFCIS�TEARRANCIEN TO,WOES %MM
- 111EREBY.ARE Mal BY AND RDAMN M TT -
t` SPAC CRAWL
... _ ^ .. ,. M UTMMO Bar AHOY PERSO O�OR w OR
POR my Pa WION NW.T M—MM PIG-
.. • - . '
. ,. PROJECT#: 100208 "
02.15.08
REVISIONS: 02 26 08 -
-
I ^/
'E E.P. E 'OPENING TO WASTET PIPE
CRAWL SPACE OODU
PERMIT SET: 02.28.08
UP
.. PROGRESS SET
' T PRICING SET:
' PROGRESS SET
EXISTING
PROPOSED
CRAWL SPACE
FINISHED
STEP UP BASEMENT
•
_ = = = = __ _ _ -___ _ _ ---------- -
----
- - ____ ________ _ _ REOISTRATION
• - .. .. ..
EXISITING
UNFINISHED 0
BASEMENT FURN. SOME 1/4'eP_B
e 'UNLESS OTHERWISE NOTED.
-
.4068 SHEET NO. -
TJ
WA7ERSPIPES ..
PROPOSED.
BASEMENT PLN.. .
- - m .SIZECLOSET AS NECESSARY TOTAL NUMBER OF SHEETS
IN SET
:. +.. ... _.. - .. THIS SHEET INVALID
PROPOSED'BASEMENT PLAN UNLESS ACCOMPANIED BY
. SCALE: 1/4 I1 O' I' A COMPLETE SET OF
.WORKING DRAWINGS
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