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0112 CRAWFORD ROAD - Health
LA = Crawford-Road r P 05 048 I 4� SEWAGE INSPECTIONS p �� LOCATION III. f Q-C-A � )I DATE e I L VILLAGE l d7'fC9 %V AS ESSOR'S MAP & LOT O S / •INSPECT0R L f- n SEPTIC TANK CAPACITY bQ 0 LEACHING FACILITY: (type) LjP (sizc) In 00 NO. OF BEDROOMS S BUILDER OR OWNER i YIMr' I►1�C A OWNER MAILING ADDRESS C;o y a l f �G a r 2� �)b FEB 0 8 2005 TOWN OF BARNSTABLE DATE 1/1 4/0 5 HEALTH DEPT. PROPERTY ADDRESS 112 Caaw�oad Road p b LOT llaz,3 02635 - On the above date, their+WIC system at the address above was inspected. This system consists of the following: 1., 1- 1000 ga-e.eon zept.ic tank.. 2., 1-Dizt2.i9ut.i0n Sox. 3.� 1- 1000 Ga ion ieach.ing /?it with' 2' stone a�� aaound. Based on inspection, I certify the following conditions: 4., 7h-i.z .ins a t.itie dive hept.ic zyztem., (78 code) 5.,7he 6ept•ic hyztem jh in /2ao/z•ea wo2k.ing onde2 at the /z2e�sen't time. 6.,7he 'wa,6te watea .in ieach.ing /tit wa,3 50" ge-Row ,invelz i/2e at the time o� .inh/zect.ion,' SIGNATURE Name: Robert A. Paolini Company: Jose- P Macomber & Son Inc Address: P. O. Box 66• Centerville Mass 02632 Phone: 508-775.3338 or 608-775-6412 A' `-JGSEPM P. MACOMBER & SON;: INCW Tanks-Cesspools-l.eachfields Pumped &•..Installed Town Sewer-Conneetlons P.O. Box 66 Centerville, MA.02632-0066 775.3335 775.6412 .l �•\ COMMONVMALTH OF MASSACHUSETTS •I RC NTAL AFFAIRS XECU'�• • •OF�Tt;E OF E 1\fM'� E IVE , DEPARTMENT OF +1V10INTA1,PROTECTION A t TITLE 5 OFFICIAL INSPE•CTIQN FOB ASSESSMENTS SUBSURFACE SEWAGE•DISPOSAL SYSTEM FORM PART•A e .CERTIFICAThON Property Address: 1 1 Z Cauw;eo/zct' Road Co._u it ma,3,6 Owner's Name: Richaacl Mc.Do aa.ecl Own.ef'sAddress- .same Date of Inspection: 7/1 4/0 5 � NaMe of Inspector: (please Company Name: ?: P,AaeomAe,-t• & .&n 1-40, Mailing•Addt'ess: en �zvx e, as a. 02¢3Z Telephone Number: 5 0.8—7 7 5:373 8 CERTWXTION STATEMEN'£ . I certify that have personally inspected the sewage disposal.systetn,at this address and that'the.informationreported below is true.,accurate and complete as of the time of the inspection.'The inspection was performed based on ny training and experience in-the proper funetion and maintenance of on Bite sewage disposal systems.I am a DEP approved system inspector pursuant tb�Saction:1S:340.of•Title 5(314)CMR•1S:•009j The system: XXXFasses -Conditionally Passes Needs Further Evaluation.by the Local Approving Authority ail Inspector's Si attire: Date:• The system inspector shall submit a copy of this inspection•reporfto the-Approving Authority•(Bow of Health or DEP)within 30 days of completing this inspection.If the systepi is a.phaarcd sym 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 tashe.system ownm and copies soutto*p buyer;if i4pplicable,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 ftkture under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION F0I-I-NOTTORVOLIJNTAR�Y ASSESS.MV"NTS- SUBSURk'ACE SEWAGE.DISPOSAL' SYSTEM.INSPECTYON.FORM. ' . PARTA CERTIFICATION(continued) Property Address: 112 C2awdo2d Road Cota it Ma Owner: Richaa c ono Zd Date orinspection: 1/14/0 5 Inspection SAI matt': Check AX; -,D or.E/ALWAY Gcomplete-alI of Section A. System Passes: NO I have not found any information which indieates ih2tany 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: Septic zy,6tem .ih .in Naope2. woak.ing oadea at the p2ezent -time-, B. System Conditionally Passes: N 0 One or more system components.as described in.the"Conditional.Pass"-section need t0 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. N0 • The septic tank is metal and over 20 years oid*or the septic-tank(whether metal.or:not)istatructurally unsound,exhibits substantial..infiltrataan or exfiltration.or.tankmfailure:is unminent: System will pass inapection ifthe existing tank is replaced with'a complying septic tanlc.as appr©ved 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: NO 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 brokers;settled-or uneven distribution box:.System will pass inapection.if(with approval of Board of Health)' broken.pipe(s)are replaced. . obiftdtioti is removed ` distrilSiifori box is leveled or teplaced ND explain: v. v NO 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 pipes)are replaced obstruction is removed ND explain: Page 3 of 11 OF°FFICIA.L]E FECT.ION FORM-NOT IOR Y-OL•UNFA RY ASSES-SMENTS SUBS1tW ACE SEW-.A E D.ISPOSA L S•YSTEM Ir1SPtCTI6N.-fORM PART°A.. . 'CERT-MCAM0N(6oritinued)' : Property Address: 1 1 Z C2acv 707 u.it (�a Owner:..Richa2d (�c[7oan�d Date of Inspection: C. Further Evaluation-is Required by the Board of Health: NO Conditions.exist whichsequirefurther.•evaluation•by.theBoard:of,Health;m•order.:to.,ddteniine if-the system- is failing to protect public-health)safety or thb environment. 1. System will pass unless Board-of.Hoal.tb determineskin aecordagl a with 310.CMR 15:30 1 .b that the system is-not functioning tn.a•mapner which WRl•protect public health,safety.arril the..en,ctrotrnrent: rz ocssspool or privy is.within,50 feet of asurface water n oo 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 mariner that protests theprtblic Health,safety and environment: no The system has a septic tank and soil absorption'system-(SA-S).:and the SAS is within 100 fe.et-of a surface-water supply or•.tributary to asurface water-supply. n o The system-has-a.septic tank and SAS and the,SAS is!within a Zone 1 of a••public water supply. no The system has a septic tank and,SAS:and-the SAS is withimSO feet of a private water,supply well. no The system has a septic tank and SAS and the•SAS is less than 100 feet.but 50 feet or:rriore fcotu a private water supply well" Method-used to determine distance• **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the iv.ell_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 bo attached to this form. Y 3, Other; Page 4 of 11 OFFICiAL•INSPECTIO•N'FORM-NOTTOR;YOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL;SYSTEM INSPECTIOMFOORM PART A CERTIFICATION(contit=4) Property Address:1 12 C a a w f o z d 'R o a d Cotu.it Ma Owner:R icha zd (' 6Dana. d Date of Inspection: 1 `5. D. System Failure Criteria applicable to all systems:. You must indicate"yes".or"n6"to.eaclz.ofthe:fpllowiAg,for a11 inspections: Yes No _ . X Backup.ofsewag6:into••fatthy.:or.systeift*eQmponentdue•_to�overloaded:orelogged•SAS,.or.cesspool _ X'Discharge:or-ponding of effluent to the.s&&ce.6f the.ground or...suxface:waters due to:anbverloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or —' cesspool ' X Liquid depth in-cesspool is less thank"below invert or available volume is less than'A-day flow X Required pumping more-than-4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below High ground water elevation. _ X Aziy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water-supply. X Any portion:ofa•cesspool•or.privy isvithin•a:Zone!I.,of-&•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.eesspool-orprivy 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 pollutionjrom:1bot.facflity and:thg 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•niust be attaehed.to this form.] NO .(Yes/Nto)•The system fa,_lls..I•have determined that one onmore.of:the:above.failure:oriteria exist as described in 310 CMR 15.303,therefore the.syster.n%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 4he:system znust.serve.adaeility with a design flow of 10;000 gpd to 15f000. 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). Y .. yes no _ X the-system is within 400'feet of a surface drinking-water supply — X the system.is within 20U feet of a tributary.to a surface drinking water supply X. the:system is located in a nitrogen sensitive areas(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 Seciion 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 OFFICI•AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �i�$SURFACESEWAGE DISPOSAL SYSTEM INSPEC`I ON FORM PART I! CHECKLIST Property Address:1 12 C1vaw&1td Road Cotuit Na Owner:Richaad (7c[7orzaid Date of Inspection: _ U-14/0 5 Check if the following have been done You must indicate"yes"or"no"as to each.of the foi low ing: Yes No X Pumping information was prdvided'by the Owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks.? 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 4-inspection? X Were as built plans of the system'obtained and examined?(If they were not available:hote ass N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out?. X . — Were all system components,-including 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? X _ Was.the facility owner(and occupants if Ofer�ent from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and locatiot3 of tb� Soil Absorption System(AS).on'the site.has been determined based on: Yes no X Existing information:For example,a plan at the Board of.Health. _ X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance . is unacceptable) [310 CNN 15.302(3)(b)] 5 r Page 6 of 11 OFFICIAL. NSPECTI0NI::FF}RM'-NOT FOR VOLUNTARY ASSESSMENTS SUBS ACE S19-WAGE DISPOSAL SYSTEM INSPECTIOL.�I:FORM PART.0 SYSTEM INFOR ATIONI Property Address: 112 Caaw1o2d /toad o u.i.t IM Owner: i2.icha2d McDonald Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desip): ,:3 Number of bedrooms.(actual): 3 DP.SIGN`:flow•based on'310 C1G&11 .203':(for exa4le:-110 gpd z#-6f bedrooms):3-X l-.10=3 3 0G%>D Number of current residents: .: 2 Does.,residence have a garbage grinder oyes or nod; o Is laundry on a separate sewage.system•(yes or.no):.rz o [if yes separate insp.q;tion required] Laundry system inspected(yes or no): no 2 0 0 3= 10 eJ f Seasonal use:(yes or no): n o P ater meter readings,if available(last 2 years usage(gpd)): 2 0 0 4- (a o00 M ��< W g� Sump pum (yes or no): n o Last date o�occupancy: 122 e 3 e n t COMMERCI�USTRIA-L Type of es tab J} nt: Design flow.(W on 310 CMR 15103):. N4 gpd- ow(seats/persons/sgft,etc Basis.of doot Grease trap�present(yes or no);N4 Industrial waste holding tank present•(yes or no):N� Non-sanitary waste discharged to the Title 5 system-(yes or no):N Water..meter readings,if available: NA Last date of occupancy/use: . NA OTHER(describe):. NR GENERAL INFQRN!(ATION Pumping Records Source of information: a int 12ump 3127103 a. l Macom. e2 Was system pumped as part of the inspection(yes or no): N0 If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for.p..umping: TYPE OF SYSTEM , X Septic tank,distribution box,soil absorption system - . —Single cesspool —Overflow cesspool —Privy v _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 IjEP.approval _Other(describe): Aproximate age of all components,date installed(if known)and source of information: f9 yeats o i d Were sewage odors detected when arriving at the site(yes or no): no i f Page 7 of 11 e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_112 C2 a uif o�zd Road -Cozuzz 7----- Owner:R-ichaad rlcDoaa ed Date of Inspection: 1/14/0 5 A M \ BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private.water supply well or-suction line: I()0 f-1-�— Comments(on condition of joints,venting,evidence of leakage,etc.): _ao into ate t iaht Venfted thaQuc,/h house vent No evid'enee V eeakage. SEPTIC TANK:_(locate on site plan) Depth below grade: 21" Material of Construction: .X 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: 5 ' 8"h i.gh/4' 10"w-ide/8' 6"$ong Sludge depth: t 2 a c e Distance from top of sludge to bottom of outlet tee or baffle: t 2 a c e Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: t�z a c e Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined; m e a z u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle con(ition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): /jump .tank eve2u 2 to 3 ueaaz , Iniet 9 outjet tees ate in � hounr/ No vv-ic/ nce 01 .Peakage GREASE TRAP:NO (locate on site plan) Depth belotv.grade: Material of construction:_concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or-baffle: Date of last pumping: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage.,etc.): G,zeahe taa/z zs not 22ezent , TWA Wnrm An;mnnn 7 Page 8 of 1 I OFFICIAL jN-S-PECI'ION FORM-NOT FOR VOLUNTARY ASSESSMENTS 5F 9W.RF;A,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property kddress:l 12 Crtaw and Rd., Owner,,- I?icha&d 1�rtagan LJ Date of Inspection: 1/1 4/0 5 TIGHT or FOLDING TANK: no (tank must be pumped at time of inspe`ction)(locate on site plan) Depth below grade: rta Material of construction: concrete. _ metal fiberglass___polyethylene other(explain). na Dimensions: rza Capacity: rta .gallons Design Flow: na gallons/day Alarm present(yes or no): na Alarm level: na Alarm In working.order(yes or no): Date of last pumping: na Co 4nts(condition of ai.arm and float switches,etc,): f'.ght o2 hoiding .tanks not /22ezent.� DISTRIBUTION BOX: ye'6 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no Comments(note if box is level and distribution.to outlets equal, any evidence of solids carryover, any evidence of le a e into or ut of b x, etc.) Yo tz �eve�.•No evidence o� zoetdz ca/tzyove2.•No evidence 2,� Pvrikri��o �nfn nn nub p� Dg)g �3nX hrIA nnn Pnfnn,-iP - PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or.no): na Alarms in working order(yes or no): na Comments(note condition of pump chamber,condition of pumps and appurtenances, ett.): l um/2 chamge2 not �2e�ent Y ,® J 8 Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SEWAGE DISPOSAL SYS'I'.EM INSPECTION FORM SUBSURFACE PART C SYSTEM INFORMATION(continued) Property Address: 1 9 2 C2aw-�o2d Rd.' C�if, Na Owner:.?i r h i n rl /'1 i o n d Date of Inspection: 9 /9 4/ 5 SOIL ABSORPTION SYSTEM(SAS):y e-3.(locate on site plan,excavation not required) If SAS not located explain why: Type y e h leaching pits,number: 1 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.): h deic �a�.Qu2e.,Vegeta-Uon a/�Rea2h Sandy ho��. No evidence o� y2auh one a 2un ao .' no2maz.�Leac in y 124- az o ? _ CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) na Number and configuration: Depth—top of liquid to inlet invert: n a Depth of solids layer: na Depth of scum layer: na Dimensions of cesspool: na Materials of construction: a Indication of groundwater. inflow(yes or no):na Comments(note condition of soil,signs of hydraulic failure,level of,ponding,condition of vegetation,etc.): Ce3-3 oo.-h not aezent.- PRIVY:n o (locate on site plan) Materials of construction: na Dimensions: na Depth of solids: na Comments(note condition of soil,signs of hydraulic failure,level of onding,condition of vegetation,etc,): la iv not 2e�ent. 9 e Page 10 of 11 PECTION.FOR—. NOT,,FOR••?VOLUNTARY..ASSESSMENTS —. OFFICIAL-IN. AGEMISP.OSAL SYSTEM�.INSPECTION:FORM SISIF'ACE PART C - SY,STEM'INEORMAT'I.ON(continued)' Property. Address:112 Claw&,zd Rd.,,_ o TUTT.t (Fa.� Owna-Richaa McDonaid R Date of Inspection: 4 SKETCH OF SEWAGIE•DISPOSAL SYSTEM ' e a sketch of the sewage disposal system including ties to at least two su p lr een rs the building. ���ur Provid benchtn�arks.Locate all wells within }00 feet.Locate where public pP.Y 0 WAG v 10 Page 11 of 11 OFFI .AL CI INSPECTION FORM=NOT FOR VOLUNTAxC ION FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP PART C SYSTEM INFORMATION(continued) Property Address: 112 C2cw"'o2d Rd.' Owner: ' • ` - - P1 r jl n n rz,e d r Date of Inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells s j: Estimated depth to gro und watery feet Please indicate•(check)all methods used to determine the high ground water elevation: n oob�ed from system design plans on recorn -If checked,date hole within 1 0 feet of of SASj 1� viewed: Ll ,observed site(abutting property/observatlo �hChecked with local Board of Health-explain: a,6 u caacl u hChecked with local excavators,installers-(attach documentation) "Accessed USGSdatabase=explain: h��� •�own B¢2nh�a��e•'ma•'uh �—. You must describe how you established odel high g2 u1d water elevation: used;Gahert & Miller m used•USGS observation w 1 used• Technical — wa er a eva ions. VX Leaching Pit =t Groundwater: Feet Below Bottom:of Pit 14i&h Groundwater Adjustment 1.8 ft per r&irnpteLMethc d Therefore,the.vertical•separation distance between the bottom of the lead ing pit and the adjusted groundwater table is feet: • tit p:r•rrnnr rrc+•r��Tr '�� 'r' ��r�T.• T• Tm�= per_ BOARD. OF IIEALTII 1 'I'UWN OF 9I)I)9I1[�FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMmm- PART D� CERTIFICATION ...�;.+�T...-::•-ea+s nrr++•r..'rrr�t+rrr+ra'TT+'Try.. -TYPE OR PRINT CIrEAR41'- PROPERTY INSPECTEDd STREET ADDRESS ASSESSORS MAP , DL,O_CK'-AND PARCEL # 1C�'1��' 1 a ►C,� 1'1 OWNER' S NAME -I PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME 5 1 1 [u e4J DC) + ADDRESS � To or ity state LIP COMPANY ADD �t. COMPANY TELEPHONE 1 ? � 5 �j�j U FAX 0' R R � r CERTIFICATION STATEMENT at I certify that I have personally inspected s rue ,. accurate, and sewage dispos�l ysterrl this address and a at tirhe��of ,inspection .e information rTherted inspection was performed and any omplete as of the ti recommendations regarding upgrade , thentrooperefunctionrepair and maintenance ofon- with my training and- experience in P site sewage disposal systems . „ ; ,I,,„t, Check one: Systeui PASSED The inspection which I have conducted has adequately protectinformation - wliich indicates that. the system fails to health or the envirotament as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this, form . System FAILED* The inspection which I have con 1rcted has found that the system fails to Protect the Public health and 'the environmedtonn PART oCdanFAILURE ce with Title 5 , 310 CMR 15 , 303 , and as specific Y CRITERIA of this inspection form . r ' Date j Inspector Signature copy of this certification must be provided to the OWNER] thenUYER e a pl ioable ) and the BOARD OP' HEALTlI„one whe r P FAILED, the owner or operator es wowed ortre ui,redm * If the inspection unless al.lo .e q within one year of the date of the inspection, otherwise as provided in 3110 CHR 15 . 306 , partd.doc • H3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION m F 7 e` i p�M SVev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION rnrn Property Address: 112 CRAWFORD ROAD COTUIT, MA 02635 Owner's Name: DEBORAH TOTTEN Owner's Address: 112 CRAWFORD ROAD COTUIT, MA 02635 Date of Inspection: 9/19/01 Name of Inspector: (please print) ,t#'; JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the intbrmation 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 DEI'approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Further aluation by the Local Approving Authority Fails Inspector's Signature: / Date: 9/4/01 The system inspector shall submit 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 1, SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG TIIE SYSTEM'S USEFUL LIFE. , ""'Phis report only describes conditions at the time of inspection and under the Collditlom of use n( (hill tI111C.1,1113 inspection does not address how the system will perform in the future under the same or different conditions of use. Tilly Form (rl C1,1000 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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. Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. 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 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 n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a r Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/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 n/a. 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 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the 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 X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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? 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 dwelling inspected for signs of se wage 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example, a plan at the Board of Health. X _ 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: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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: 0 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)): n/a Sump pump(yes or no): NO Last date of occupancy: 8/16/01 COMMERCIALIINDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,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 OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a 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 _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): n/a Approximate age of all components,date installed(if known)and source of information: 1985 Were sewage odors detected when arriving at the site(yes or no): NO Pagb 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 BUILDING SEWER(locate on site plan) Depth below grade: 66" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply 1 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: 60" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" 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: 17" 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.): THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO 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 of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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 Capacity: n/a gallons Design Flow: n/a gallons/day 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: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE p q i 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.): DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.DID NOT EXPOSE.BURIED TOO DEEP. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,NEVER MORE THAN 2 FOOT IN PIT..BOTTOM IS AT 11 FEET 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 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) 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 4 Pabe 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT, MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 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. P q I Al A� I A13 A ST c � � 1� g6 q 1� G� � CA 34a C b LIj CG L1I r in Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR M PART C SYSTEM INFORMATION(continued) Property Address: 112 CRAWFORD ROAD COTUIT,MA 02635 Owner: DEBORAH TOTTEN Date of Inspection: 9/19/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 13 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 database-explain: n/a You must describe how you established the high ground water elevation: FOUND NO WATER AT 13+FEET.TESTED BY AUGER 11 L O CAT ION #vv:s ' /�C;k S E W A 6 E PERMIT NO. L6 -r 4 : f-oP,S� z > VILLAGE co7ul -T INSTA LLER'S NAME i ADDRESS \ FP-PrN J,I B UILDE R OR OWN ER 2 tv� G S F)ANE Go-N�z2,GT(o� DATE PERMIT ISSUED 0 DAT E COMPLIANCE ISSUED 10 _ SC-) _ �� ,�. ,- i b 5 D �6 � � 3 � r � 6�i x �' � r` 39' � fi .i � 9q � S 7' I No.._.. ......� Fss.. ............... Qfl5' 0 9 `a' THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF _FLEAI-TH /.O IN�1..................OF..-. r hJ. .J ... Applir�a#inn for Eliipnsttl Works C�nnitrnrttnn ranfit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at ... .............................................� .4r.ss7[Q . f �f? ..._............-----------•-•---.... --- ---�-- �c............................. Location-Address or Lot No. o. ........................................................ .. Owner �— A Installer Address Type of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms-.-._._ .............................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures .----••--•----•-••-------•---.... . W Design Flow............: .....................gallons per person per day. Total daily flow..........�3 P..................... WSeptic Tank—Liquid capacity Ae!5tgallons . Length..E�Z!."Width.=!?� Diameter................ Depth s.j!�-.0 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../.......... Diameter./z_'=_4*'.. Depth below inlet..4:."_a....... Total leaching area..7!�_?......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by-_ ��'1°_'!�...16F f' d�!"!'� _______________ ------------- ,a Test Pit No. 1..... .......minutes per inch Depth of Test Pitt�L'_.4.._... Depth to ground water-__!✓g.H ...__. Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ -------------------------------------------•----••-------------....-•--------------•-•-•--...__.._........................................................... 0 Description of Soil..... Z.4`_.._...L st_ _./�!l��e ........................... /z.,, �. 4/F !/tr �'.zs `�'`` ...........---•-•------ •----........................................................... i......................................... .........N_._......._ ...._........ �./ !Cl.... � i W •-•-•----•-•----------------••••--•---••---- ' y U Nature of Repairs or Alterations—Answer when applicable.............................. ............................... ...... . . ��.. �1=-• ................... ......... Agreement: G, The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys em in acco ance with the provisions of TI'L LZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certifi to of Compliance has been issued by the board of hea Signed ....... ;ll.�- 6 . �. --------- Ap i ion Approve By........................ - ------• .......--- 9/1 .t • -------•- ..............----•-------------•Date - - -- APplieation Disapproved for the following reasons:------•--------------••-------•----•-----------------.....--------------------•--......._...-••--•----------- ..----•------------------------•------------•-••••---•-------...•••••---------•-.......•------•---•-------••••--•-•••---•--••-•--•-----•••-••---------•-•-----•-•-•---------••--•--•••......---•-•-•--- Date PermitNo......................................................... Issued_....................................................... Date No........................ Fss ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 7—o I/V/-/............................. ...... .... Aopliraffo&for Disposal Works Tonstrurtion rumit Application is hereby made for a Pe_�imit to Construct (X) or Repair an Individual S6wage Disposal System at: `17 A/ .............................................................................................. ............................................................... ........... Location-Address or Lot No. . ................................................................................................ Owner Address .................................................................................................. .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..........�3............................Expansion Attic Garbage Grinder �4 ....... PLI Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures ....................................................................................................................................................... Design Flow________._._....!�r5 ....................gall'ons per person per day. Total daily flow----------- ....................gallons.- 9 Septic Tank—Liquid capacity/L��e�egallons Length.J.7.-�Z��. Diameter________________ Depth. W -------------- Z Disposal Trench—No_.................... Width____._.__._.__._.__. Total Length.____.______.____.__ Total leaching area....................sq. ft. Seepage Pit No._._.___/---------- Depth below Total leaching area__76=3......sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by--Z� Z 71--------------- - ........................... - 'Test Pit No. 1......e�...._._minutes per inch Depth of Test Depth to g' rou_n'-d'water_ c,.�-----�. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.______...____._:__,.::' ........................................................................... ................................................................................. 0 Description of Soil------- ...... -----------.......f-/ -4............................................Z..........................................I................... ..........................................................................................._ ......................................................... U Z .................................................. �X<..... .............................................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...................................................................................................................................................................................................... Agreement: The .undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation u 'til Certificpte of Compliance has been issued by the board of health. . Ir Signed.],......... ..................... ...... A li Ion Approve nBy................................. ...... .... .. .............. Date App Ication Disapproved for the following reasons_________ ____.............................................................................................. .................................................................................................................................................................................................-------- Date PermitNo......................................................... IssuedL.............................. ------------Date THE COMMONWEALTH OF MASSACHUSETTS .:,...BOARD OF HEALTH .........................................0 F..................................................................................... M.F.Wrtifiratr of Tomplianu THIS IS TO CERTIF ; That the .�e�dividual Sewage f.sposal System constructed or Repaired ... .. .. ............ ........... by-------------------------------------------- . ....... ....... ............... 4 sballer '444 at... .....�t�.Z.......&. ..... .. ....... ........... I -?-----------------------*,-**---------------------------------- -------------------------------- has been installed in accordance h the provisions of TITLE 5 of The_,�We Sanitary Code a/descr�_o__��_.1bed�ke- application for Disposal Works Construction Permit No...... ............ dated--------- If 4 ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... .. .............. ..... ....... ............... .... ........................... Inspector--------- ...................r.—.. THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 HEALTH ............... 0 F......... ........................ .... .... ........ No..... :.__.._. 0..... 5 3 FEE. Disposal Works 01.111ustrurtion Vvrrutit Permission is hereby granted________________ ......kA??_Rk.-S............................................................................ to Construct ( or Repair an Individual Sew Disp al System at No.............�•66 .. T 0 fu l .. .................... ......................................... ...... Street as shown on the application for Disposal Works Construction Permit No....._...........!!Fbated.....1 ................................................... ...... ... ........ Board H DATE-------------- .................................... FORM 1255 HO ES & WARREN. INC., PUBLISHERS.HERS 7 # PROJECT TITLE �1 !y � d 1 t { r � , 4' y iL i.Y t _ � v PREPA Riro FOR , 3u N v4j c a v __ �Gy t�r s c P� Stowe Devim•PreWdent �G _._ "The F.xdmme*is BaUdIng" -. $20 Mein Street Cotuit,MA•508-420.1340 _. e-mail:cenlraiconsburttonto(�gmail com 1 Websit0:vw +.centraicapecanstruction.com SCALE 7 DATE P DWG NO. c DESIGNS u� CHECK E' DRAWN JOB N0. S>9 ET OF ttf` PROJECT TITLE 01, If Mae 4--c-n OP; ..J:4 t4 quo,".°_ . �--F�I� _� .�� r� A R' s . - : PREPAREDFOR -..- 03 . j Central Co won Company, Inc. , Steve Devlin•President "The Excitement is Bullding" - �; _ _,_�._...__�r-ITT820 _.___ ,__ _- — — _ _ _�_V. .____.__ I Main Street•Cotuit,MA-508-420-1340 - - e-mail:contralconstrucoonco@gmall.com — �— -- � Website:wwrw.centroicapeconstruction.com ! f SCALE P 0 t TI — --- — r-- nb �~ DATE 6`t DWG NO . f { - - - -. DESIGN � ` CHECK DRAWN JOB NO. SHEET OF' ,. LOCUS DATA ' ' ` / / _ \ SCHOOL ;STREET CURRENT OWNER ANNE L. LOT 46 N CT z / / PLAN REFERENCE 223-39 / �o a z Ln DEED REFERENCE- 22363-120 M i ZONING DISTRICT RF / Q' / �\ �\ \ sR'' Locus SETBACKS 30' FRONT / 0 , \ sy Locus MAP 15' SIDE / / ` \ �L NOT TO SCALE: �s 1.5 REAR EXISTING Soy, 14-0129-CPP DRIVEWAY h' FLOOD _ZONE "X" 7-16-14 O/ / �' ry 25001 CO7521 J / 0 / O:/ EXISTING L ASSESSORS MAP 005 / / I GARAGE PARCEL 048 / 21,862f &F. OVERLAY DISTRICT AP/RPOD/SWEP LOT AREA 21,862f S.F. / : EXISTING DECK / J/ TO BE REMOVED _ - - CERTIFIED EXISTING PROOSED P L O T PLAN / j i DWELLING / NEWP118'x20' r �, # 112 C R A WF O R D R D / 8- - - ADDITION COTU IT, MASS EXISTING / LEACHING PIT DATE: OCTOBER 17, 2014 .01 OWNER/APPLICANT: AN N E L. DON 0`VA N PROPOSED NEW 14'x19'. DECK .204 COLUMBIA HEIGHTS APT #5B BROOKLYN , NY 11201 ~' SHEET 1 . OF 1 r� PREPARED BY: =3EDv'�Ro EAS SURVEY m INC. i NF �S,• �s . SIG 141 R T. 6 A Sj FSs o N 0 20 30 40 SANDWICH , MA 02563 CONCRETE PH. (508) 888-3619 l l FOUND CELL (508) 527-3600 /0 L 0 T, 4 8 TYPj GRAPHIC SCALE: EAS.SURVEY@YAHOO.COM 1 INCH = 20 FEET I............IIIIiIIIIIIIIIIitIIIIIIIIitIIIIIIS IIIIIIIIItIIIIT,IIIIItIIIIttIIIIIItI6RA GE 0 V,IIRADE- IIlIIIIIIIIItII��,-,LEA CHIM. 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