Loading...
HomeMy WebLinkAbout0187 CROCKERS NECK ROAD - Health 187 Crocker Neck Road Cotuit A= 019-034 - -- - — - - — -- - - - Dig-oay Commonwealth of Massachusetts 4V ED Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r c 187 Crockers Neck Road r Property Address I , Annette Hughes Owner Owner's Name 'y information is MA 02635 June 17, 2020 required for every Cotuit page. City/Town State Zip Code Date of Inspection e, r.•i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer,use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. 8 Conditionally Passes 3. 8 Needs Further Evaluation by the Local Approving Authority 4. 8 Fails June 19, 2020 Inspector s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 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: 2) System Conditionally Passes: rl One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" o the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfil tion or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is le s than 20 years old is available. Y N ND xplain below): t5insp.doc•rev.7f26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): L] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 8 Observation of sewage backup or bre out or high static water level in the distribution box due to broken or obstructed pipe(s)or du to a broken, settled or uneven distribution box. System will pass inspection if(with approval of oard of Health): broken pipe(s)are repla ed 8 Y ON ND(Explain below): obstruction is remov 8 Y ON ND(Explain below): distribution box i eveled or replaced Y Ej N 8 ND(Explain below): The system required pumping more than 4 tires a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval cif the Board of Health): broken pipe(s)are replaced 8 Y 8 N L] ND(Explain below): obstruction is removed 8 Y N © ND (Explain below): 3) Further Evaluation i/Requiby Board of Health: Conditions exist wr evaluation by the Board of Health in order to determine if the system is faili health, safety or the environment. a. System will p of Health determines in accordance with 310 CHAR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owners Name information is Cotuit MA 02635 June 17, 2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) Ej Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a ordering vegetated wetland or a salt marsh b. System will fail unless the Board of He Ith (and Public Water Supplier, if any) determines that the system is functionin in a manner that protects the public health, safety and environment: © The system has a septic tank and s I absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tr utary to a surface water supply. 8 The system has a septic tank an SAS and the SAS is within a Zone 1 of a public water supply. 8 The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. 8 The system has a septic tan and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup p well**. Method used to determine dis nce: **This system passes if the we water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates ab nt and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provid d that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) 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 1h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 8 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- - 10,000 gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:.To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No the syste is within 400 feet of a surface drinking water supply the Sys m is within 200 feet of a tributary to a surface drinking water supply the stem is located in a nitrogen sensitive area (Interim Wellhead Protection Ar, a—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26120 1 8 Title 5 official inspection Forth:Subsurface Sewage Disposal System•Page 5 of 18 l - 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Ln 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 i:f1�>���iliry�w��f( �� ® �i��f1t� if II)f�F�Atg ®wfl€�) p�yil@d 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: 0 Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 187 Crockers Neck Road Property Address Annette Hughes - Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN 11@w b@-$@d on 310 DMR 15:203 (for @x@mpl@ 110 gpd X.#@l 330 GPD Description: ' 1 Number of current residents: Does residence have a garbage grinder? 8 Yes ® No Does residence have a water treatment unit? Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) Laundry system inspected? Yes No Seasonal use? Yes No 2018= 52 GPD Water meter readings, if available (last 2 years usage(gpd)): 2019=68 GPD Detail: Sump pump? Yes ® No Current Last date of occupancy: Date t5insp.doc•rev.72612018 Title 5 Official Inspection Form:subsurface sewage Disposal system•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is required for every Cotuit MA 02635 June 17, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq. , etc.): Grease trap present? 8 Yes 8 No Water treatment unit present? 8 Yes No If yes, discharges t . Industrial waste holding tank resent? 8 Yes 8 No Non-sanitary waste discha ged to the Title 5 system? 8 Yes 8 No Water meter readings, i available: Last date of occupan y/use: Date Other(describe below): 3. Pumping Records: No previousrecords found Source of information: Was system pumped as part of the inspection? Yes 8 No 1000 If yes, volume pumped: gallons How was quantity pumped determined? Site tube on truck Maintenance Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is required for every Cotuit MA 02635 June 17, 2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool 0 Overflow cesspool 8 Privy 8 Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract 8 Tight tank. Attach a copy of the DEP approval. © Other(describe): Approximate age of all components, date installed (if known) and source of information: System installed 2/15/1992 Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate on site plan): 3 Depth below grade: feet Material of construction: cast iron 40 PVC 8 other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityfro`n n State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2.2 Depth below grade: feet Material of construction: concrete 8 metal ©fiberglass 8 polyethylene 8 other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 8 Yes E] No 8.5' x 4.5'x 5' 1000 gallons Dimensions: 6" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 8"at inlet, 4"at outlet Scum thickness 10" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" Dip tube and tape measure i How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Tank pumped and cleaned by Ready Rooter, Inc. after inspection.Recommend maintenance pumping every two years t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address - Annette Hughes Owner Owners Name information is Cotuit MA 02635 June 17, 2020 required for every Zip Code Date of Inspection page. City/Town State D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: 8 concrete U metal [7 fiberglass 8 polyethylene 8 other(explain): Dimensions: Scum thickness Distance from top of scum top of outlet tee or baffle Distance from bottom of cum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pum ng recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as rel ed to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade.- Material of construction: Fl concrete 8 metal fiberglass 8 polyethylene 8 other(explain): Dimensions: Capacity: , gallons Design Flow: g gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e, 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: © Yes No Alarm level: Alarm in working order: 8 Yes rj No Date of last pumping: Date Comments(condition of alarm and floats i ches, etc.): *Attach copy of current pumping contract(required). Is copy attached? Yes No 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): One inlet, one outlet. H-10 D133, 2.5' below grade. No high water staining over outlet invert. Riser installed to bring cover within 6"of grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is COtuit MA 02635 June 17, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes No* Alarms in working order: 8 Yes No* Comments (note condition of pump amber, condition of pumps and appurtenances, etc.): i * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: 3 infiltrators wl leaching chambers number: stone. leaching galleries number: Teaching trenches number, length: 8 leaching fields number, dimensions: — 8 overflow cesspool number: innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes - Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to locate and inspect units. No staning liquid at time of inspection. No sign of past hydraulic failure Units 3' below grade Clean dry stone around units at time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater in ow 8 Yes 8 No Comments(note conditio. of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is required for every Cotuit MA 02635 June 17, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: M hand-sketch in the area below drawing attached separately l Or�% QJ.1� l .N!3 � I I t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is Cotuit MA 02635 June 17, 2020 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 15. Site Exam: M Check Slope 8 Surface water 8 Check cellar Lj Shallow wells >5 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 1992 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database -explain: maps massgis state ma us/oliver.ph You must describe how you established the high ground water elevation: Test hole in 1992 to 120"found no ground water. Base of units 4.2' below grade. Accessed local ground water countours and topo mapping No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � - E _ 187 Crockers Neck Road Property Address Annette Hughes Owner Owner's Name information is required for every Cotuit MA 02635 June 17, 2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETT'S a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION I, TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY;ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A . .CERTIFICATION Property.Address: 187 Cmckeis Neck Road Cotuit,MA 02635 Owner's Name: Jaines Barger . : Owner's Address: ,. I Date of Inspection: May 23, 2012 Name of Inspector:(Please Print) Janzes 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 perfor ed based ommy �D training and experience in the proper function and maintenance of on site sewage disposal systems 4 I am a D.EP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: . 4 t ✓ Passes C itionally Passes N e s Further Evaluation by the Local"Approving Authority . F ils Inspector's Signature: Date: May 29,2012 The system inspector.shall su -t aI copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30.days of compl ng 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 atthe 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 n i Title 5 Inspection Fohn 6/15/2000 page 1 l Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 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 enfiltration 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 i Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. . 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James BarQei Date of Inspection: May 23, 2012 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%z 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 form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered alarge system the system must serve a facility with a design flow of 10,600 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to.any question in.Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a . significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 4 . Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 187 Crockers Neck Road Cotuit, MA Owner: James Barger Date of Inspection: May 23, 2012 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 the site 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: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): N/a 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: Unknown COMMERCIAL/INDUSTRIAL . Type of establishment: Design flow(based on 3l0 CMR 15.203): gpd . Basis of design flow(seats/persons/sq/ft 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 app. One year ago Was system pumped as part of the inspection(yes or 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: Date of installation 21611992 per as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) - Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 BUILDING SEWER(locate on site plan) y' 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: 22" 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 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30". 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: 10" 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.). The tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage: GREASE TRAP: None (locate on site plan) Depth below grade: } Material.of construction: concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top_of scum to,top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or,baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 Cockers Neck Road M Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 t Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 C rockers Neck Road Cotuit, MA Owner: James Barger Date of Inspection: May 23, 2012 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required). If SAS not located explain why: Type leaching pits,number; ✓ leaching chambers,number: 3-infiltrators with 2'stone per as built 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 infiltrators ivere dry and clean. There did not appear to be any signs of failure. 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 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters-the building. a 33 t� 3 3% a3 v3 yag ° 10 Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 15+/ 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 and water contours maps, the maps were showing approximately 15 +/-to ground water at this site. This report has been prepared only for the;septic system and components described herein. This septic system has been 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 f ture. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report andlor any components of the septic system which have not been located and inspected. - 11 TITLE V CALCULATION CHART COMPONENT 3 BEDROOMS 4 BEDROOMS 5 BEDROOMS 6 BEDROOMS SEPTIC TANK 1500 Gallons 1500 Gallons 1500 Gallons 1500 Gallons DISTRIBUTION BOX Distribution Box Distribution Box Distribution Box Distribution Box SOIL ABSORPTION SYSTEM: Cultec Recharger 330's 4 (334 GPD) 6 (471 GPD) 8 (606 GPD) 9 (674 GPD) [NOTE:5 are not enough [NOTE:7 are not Cultec Recharger 330's(with 2'stone surrounding SAS)• -provides only 401 GPD] enough-provides only 538 GPD] Cultec Recharger 330's(with 3'stone surrounding SAS) 3 (332 GPDI) 5 (490 GPD) [NOTE:4 6 (569 GPD) 8 (728 GPD) are not enough-provides [NOTE:7 are not enough only 411 GPD] -Only provides 650 GPD] High Capacity Infiltrators 4 (394 GPD) - _ 5(461 GPD) 7(598 GPD) 8(667 GPD) - H.C.Infiltrators(with 4'atone and 14 inches underneath) NOTE:6 are not enough,only [NOTE: 4'stone is not recommendeed,more infiltrator units are recommended) provides 530 GPD Infiltrator Maximizers 5(342 GPD) 7(457 GPD) [NOTE: 6 9(573 GPD) [NOTE:8 11(689 GPD)[NOTE:10 Infiltrators Maximizers(with 2 ft.stone surrounding SAS) are not enough,only 399 are not enough,only are not enough,only 631 GPD capacity] 515 GPD capacity] GPD capacity] Infiltrators Maximizers(with 3 ft.stone surrounding SAS) 4(357 GPD) 6(494 GPD) 7 (563 GPD) 9(700 GPD) [NOTE:5 are not enough, [NOTE:8 are not enough, only 426 GPD] only 632 GPD] Infiltrators Maximizers(with 4 ft.stone surrounding S.A.S.) 3(357 GPD) 5(516 GPD) 6 (595 GPD) 7(675 GPD) [NOTE: 4'stone is not recommended,more infiltrator units are recommended] [NOTE:4 are not enough,only provide3438 GPD] ` s' 500 Gallon Chambers 4 (395 GPD) 5 (477 GPD) 6 (560 GPD) 8 (724 GPD) [NOTE:7 500 Gallon Chambers/Drywells(with 2'Stone) [NOTE:3 are not enough, are not enough,only 642 only 312 GPD capacity] GPD capacity] 500 Gallon Chambers/Drywells(with 3'stone) 3 (384 GPDI) 4 (477 GPD) 5 (574 GPD) 6(669 GPD) 'I 500 Gallon Chambers/Drywells(with 4'stone) 2(355 GPD) 3(462 GPD) 4 (570 GPD) 5(677 GPD) [NOTE: 4'stone is NOT RECOMMENDED,more chambers are recommended] Flow Diffusors(with 2'stone surrounding SAS and 12"deep 4(343 GPD) 6(485 GPD) [NOTE:5 7(556 GPD) 9(698 GPD) [NOTE:8 stone on bottom) are not enough,only are not enough,only 627 provides 414 GPD] GPD] Flow Diffusors(with 3'stone surrounding SAS and 12"deep 3(340 GPD) 5(506 GPD) [Note:4 are 6(589 GPD) 7(671 GPD) stone on bottom) not enough, g ,only provide 423 GPD capacity) Leaching Trench 60' X 4'X 2' or(2) 80'X 4'X 2' or(2) (2)48'X 4'X 2' or (2)57' X 4' X 2' or 30'X 4'X 2' 40'X 4'X 2' (4)24' X 4'X 2' (4)28'X 4'X 2' Leaching Field 446 S.F. (330GPD) 595 S.F. 743 S.F. 892 S.F. ALL MINIMUM S.A.S.SIZE REQUIREMENTS LISTED ABOVE ARE BASED UPON TIJREE ASSUMPTIONS (1) No garbage grinder,(2)Class I Soil(0.74 GPD/S.F.),(3)No wetlands within 250 feet of S.A.S.and groundwater is greater than 14'below SAS J:CHARTITV COMMONWEALTH OF MASSACHUSETTS a EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS r` DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property.Address:" 187 2ocker� NeckRodd Cotuit MA 02635 Owner's Name: Janes Barger. �l'f Owner's Address: (J Date"of.inspection: May 23; 2012 Name of Inspector: (Please Print) JamesM Ford Company Name: JamesM: 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: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 010 CMR 15.006). The system:.. ✓ Passes. C n itionally Passes N e s Further Evaluation by the Local Approving Authority F ilsJ Inspector`s Signature: Date. May 29..2012 The system inspector shall su m't a copy ofithis inspection report to the Approving Authority(Board of Health or . DEP)within 30 days of compl ng this inspection. If the.system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and.the systemi 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.perforin in the future under the same or different conditions of use. Title 5 Inspection Fonn 6/15/2000 paged Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 G oclrei-s Neck Road Cotttit•MA Owner: James Barger' Date of Inspection: May 23, 2012 Inspection Summary: Clieck 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): f 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:. 187 Crockers Neck Road Cotuit.MA Owner: James Baigerr Date of Inspection: Mav 23: 2012 C. Further Evaluation is Required by tale 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 s 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 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. , a 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23, 2012 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%z 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 ceriified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails..The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flo gpd. w of 10,000 gpd to 15,000.. 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 `— — Y 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 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£ailed: 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: 187 Crockers Neck Road Cotuit,MA Owner: Janes Barger Date of Inspection: May 23, 2012 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 ronnal 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(arid occupants if different from owner)provided with infonnation 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 ✓ _ Existing information. For example,a plan at the Board of Health: I ✓ 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)]. t 5 1 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 187 Crockers Neck Road Cotuit,MA Owner: James Barger Date of Inspection: May 23 2012 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example:,110 gpd x#of bedrooms): 220 Number of current residents: . 0 Does residence have a garbage grinder(yes'or no): N/a 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(last2 years usage(gpd)): . Unavailable Sump Pump(yes or no): . No Last date of occupancy: Unkl7mvn COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq/ft 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: Puniyed app. One vem•ago Was system pumped as part of the inspection(yes or 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: Date of installation 21611992 per as-built curd Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION (continued) Property Address: 187 Crockers Neck Road Cotuit.MA _Owner•: Jaynes BarQei Date of Inspection: May 23, 2012 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: 22" 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 gala Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle: . 30" 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: 10" 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.). The tees were present. The liquid level was even with the outlet invert There did not appear to be any sighs of leakage GREASE TRAP: None (locate on site plan) . Depth below grade: Material of construction: ._concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Cotrunents(on pumping recommendations,inlet and.outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert;evidence of leakage,etc.): .` I 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: 187 Crockeri Neck Road Cotuit.MA Owner: _ James Barger Date of Inspection: May 23, 2012 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Evert 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.): d 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SIfSTEM INFORMATION (continued) Property Address: 187 Crockers Neck Road Cotuit.MA Owner: James Barter Date of Inspection: Mai;23 , 012 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type. leaching pits,number: ✓ leaching chambers,number: 3-hifiltrators with 2'stone per as built leaching.galleries, number: leachingarenches; number, length; - leaching fields, number; dimensions: overflow cesspool, number: Innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic g failure level Y of> ondin -d .a- p g, mp soil, condition.of vegetation, etc.). The infiltrators were drip and clean. 77tere did riot appear to be anLsigns of failure 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.lydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None locate on.site lat P. ) Materials of construction: t Dimensions: Depth of solids: Coments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 187 Crockers Neck.Road Cotuit,MA Owner: James Bai`Qer Date of Inspection: May 23, 2012 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benclunarks. Locate all wells within 100 feet. Locate where publicwater supply enters the building. 771 : ro 3 39 9.3 � � y 3� a.<7 ° f . 10 v Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: . 18.7 C rockers Neck Road Cotuit,MA Owner: Jmnes Barger Date of Inspection: May 23, 2012 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water IS+/- 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 inaps 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 and water•contours maps the nians were showing approximately 15 +/ to Qr ourid water at this site. This report has been prepared only for the septic system and components described herein. This septic system has beers inspected mid passed as of the date of'itrspection.This report is not h warraiuy or getaraiitee that the system will fcarctiorr properly in the f tture. There have been rto warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this iepor•t anal/or•any components of the septic system which have not been located and inspected;. 11 TOWN OF BARNSTABLE LOCATION 187 rea-CkW /llErk SEWAGE VILLAGE ' ajr ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. i (impy.S �oZB'��_rO SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 3 oArS7170?Ara-A ' a(size) NO. OF BEDROOMS 2 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER___jAMXJ DATE PERMIT ISSUED: IA119i�zl DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No j/ 3 � e i i psi cR6�KEnS AJ D 03 .... V .....D.......... I� .---- •• - -• - Fps..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH - TOWN-OF BARNSTABLE Appliratinn far, Bilivna1 Workii Tonntrnrtinn Vamit c - Application is hereby made for a Permit to Construct (,<J"or Repair (,,y an Individual Sewage Disposal Systemat: -e� ------••- •-•-- --------....•••............._...a.. .....�� /��. .. ...�f.. -- ... ---....--- .........--------------------...........-- Location-Address or Lot No. Owner Address ---------------------- ...---_..... Installer Address Q Type of Buildii Size Lot............:...............Sq. feet V Dwelling No. of Bedrooms.........&..............................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building No. of persons............................ Showers —Type g ---------------------------• P ( ) — Cafeteria ( ) QOther fixtures --------•--------------------=-•------------------------------- w Design Flow...........................................gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid*capacity. DOPgallons Length................ Width....--.----..... Diameter--.............. Depth................ x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-----------..--.-.-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.-----..........--.. Depth to ground water........-----.--....--.. 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 9 ------------------------------------------------•--------------•---------------•--------------.............................................................. 0 Description of Soil........................................................................................................................................................................ x U ------------------------------------------•----------------------------•-----------------......------------------------------------------------------------------------------------•--•----------------- x ----•----------------------------------------------------------------------------------------------------------------------------------------------- ------ . . r U Nature of Repairs or to ions—Answfr hen ap licable.......1DCID....---�A-------1A ---✓G...... 1--w-A........ // u °� 5 6 --------------------------------- --- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has been issued b the board of health. � p Signed 1 .....------ Date ApplicationApproved By ... ....... . . . . -- ............. . ................... ....... . .. .................................... ..-------------------- Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------- ............................................ ..... -- - Permit,N�. Issued-.. -....-�'.. ..._4................................... .......................Dare--.............._-_.....Date...... T J No...................... � -Fxs....��D.._ THE COMMONWEALTH OF MASSACHUSETTS -BOARD OF HEALTH TOWN>OF BARNSTABLE Appliration fnx'Disp-usttl Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( or Repair (fir an Individual Sewage Disposal System at: // . O � ..............._... ....11 ��och-�/Z_��rf� ��, .....---- �' Location-Address or Lot No. • ... . ............................ ............................................. .................•-.............................. Owner Address a O c P rZ; �?�.:?.t.C.3....................•-----.....-•-•- --•-•--•-•--...---•-------.....---..........................-•----.............---•--.......-•---- ............................. Installer Address Type of Building, Size Lot............................Sq. feet �-, Dwelling " No. of Bedrooms.........:R..............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building ............................ No. of persons..................._........ Showers ( ) — Cafeteria ( ) Otherfixtures ;=�x ; = f .............................................................. W Design Flow............................................gallons per person per day. Total-daily flow............................................gallons. WSeptic Tank—Liquid capacity.! OQgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ • •---•---------------------------•---------------.....--•---.........----.........---••--•-------•--................................. --------------.--------- O Description of Soil...............................................................................:........................................................................................ W rJ ----------------------- ---------------- ------------ ------------------------------- ------- -•------------ -••--------------------------- •--------- -............... ........ •--------••-----•---•------. ... W UNature of Repairs or terations—Answer hen applicable....__..?.q2._-...5 -p...:___�f yi G.....- -h[•k--_-_... Agreement: . The undersigned,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE`S of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. -/?/�� Signed ----- - - ----------------------`C ....-..-------------- --- Application Approved By ...- ... w _ ce ................................... .................................. Dace ..---- Application Disapproved for the following reasons- ....................................................................................------------------------------------------- ' �� Dare Permit No .. . ... ...................................... Issued Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CPr#ifirate of Complianre THIS IS TO CERTIFY, That the,Individual,Sewage.Disposal System constructed ( ) or Repaired ( ) by......................... -��-.............................. � ;� .......------. 1 .:'. .. .. U..I at ...... .. . . ......1... �8 , ... : :--...r D = 1.. ----------- ------------------------------------------ I!!- has been installed in accordance with the provisions of TITLES f he Sta e nvironmental Code as described in the application for Disposal Works Construction Permit No. ..--.. . -.....--.. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONST ED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......:. ="----- r----------------------------------------- --------- Inspector --------..........----......= -....---..--....---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE/I FEE��: D No....................lr..� --•---......... Uispsal� nrk Tnns#T/I uar-1. r mi# / , r �/ Permission is hereby granted 1 `�_ 1./�.v. .!_.!..�. ... to Construct �j or Repair an. ndivid a��'°�ewa e D• osal- Str et as shown on the application or Disposal Works Construction Per it�1o._ .. ...�.__. Date.6.___f . .----.------------t!...... Board of Health DATE............................. t••- ...Iq-.,.._. FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS AsBuilt Page 1 of 1 TO�/WN OF BARNSTABLE LOCATION /g 7 rtaC s_ff SEWAGE # 907 ' VILLAGE U/� ASSESSOR'S MAP & LOT IN NAME Sz PHONE NO. 1/S SEPTIC TANK CAPACITY /Gad _ LEACHING FACILITY:(type) 3 i/,f`l� rm b' �(size) NO.OF BEDROOMS-,_ PRIVATE WELLOR PUBLIC WATER BUILDER OR,OWNER - 1?4�'.S Ip DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: a VARIANCE GRANTED: Yes No (/ ay� t Z3 A3 31' i j CK66ks.b 1/ http://issgl2/intranet/propdata/prebuilt.aspx?mappar=019034&seq=1 5/2/2012