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HomeMy WebLinkAbout0202 CROCKERS NECK ROAD - Health FFi202 CrockerNeck Road Catiit ----- --- -- - -- - 019=020 l Cox TOWN OF BARNSTABLE LOCATION ZC Z(2roc}2crS Nkck RCL SEWAGE# 2015• Z44 VILLAGE 0y'1 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Q FCaya�i oJ� SEPTIC TANK CAPACITY �p `cpla�ccehcn-� OrJlu 1 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS OWNER Kp5cr�1 ;na S ,�uC'u PERMIT DATE: 47•Z 9• /S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A1- 3 1- zo Az- zt, A3 G3" 2Z M A t3 © ZO No. c26 6 �___� YY Fee /()®� •/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Misposar 6pstrm Construction i9ermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) [:]Complete System [Individual Components Location Address or Lot 7No. jt"� Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel LOZ CCets �2C.�c (z((�. ZO {$'yUt-=c Installer's Name,Address,and Tel.No. S•O$• y'Y7' 0 11S3 Designer's Name,Address,and Tel.No. EXCat/cdiOn 14 Tca_',,*crr`1 !.P7 F-ores , Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) __D 00L ot-Aw IN Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of `C Compliance has been issued by this Board of Health. S' ed Date `•]• 30� /S Application Approved by Date %5 Application Disapproved by Date for the following reason Permit No. Date Issued No. O Fee /o® ) / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes I' application for Misposal 6pstem Construction Permit Application for.a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System 2 Individual Components Location Address or Lot No. I�) ^ � e-�'u Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Z-OZ C,«Gkos �)Qc�_ R'Isr -Lom Croc.1--emrs k1scW R Installer's Name,Address,and Tel.N,o. S Og 77" �53 Designer's Name,Address,and Tel.No. i 9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Desijhf provided gpd Plan Date Number of sheets Revision Date Title 1. Size of Septic Tank I • Type of S.A.S. Description of Soil # ' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees fo-,ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 ofthe Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. { -`� Si ed Date `7 30 IS Application Approved by Date 7i Al y Application Disapproved by Date for the following reasons t Permit No. 2oi S Zy 4 Date Issued / Zo'5 ------------- =_.-_, _ ------ ---------- 0-6 THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓S Upgraded( ) Abandoned( )by X ca yn� i o._) at 7 OZ 0 r oc W c r has been constructed in accordance \ with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer ExCg,oa� i O,k Designer , #bedrooms AA Approved design flow gpd The issuance of this permit,shall not be construed as a guarantee that the system ill functiioon as signed. Date f ��, /�/ � Inspector 7� � - - - --_ --No.�iO�'7 �f�l., _ �. - _--�_ --� A•;=-=� k..-.- A-._-�.__--- _ __------ -----.--------- Fee "� /��'' ----F. v .. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposaf 6pstent Construction Permit 'l, `___,..Peiinission is hereby granted to Construct( ) Repair( ,1j Upgrade( ) Abandon( ) System located at . 2n? CC roc W r c-S n1 e e i< and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. r' Provided:Con truction must be completed within three years of the date of this permit. Date Zct '7,9 0`j Approved by - Fax Send Report JUL-29-201514:21 WED Fax Number • 15087906304 Name BARNST HEALTH Name/Number 917744137476 Page 1 Start Time JUL-29-2015 14:21 WED Elapsed Time 00'34" Mode STD ECM Results [O.K] Nu. Ale, Fce I Do THE COMMONWEALTH OF MASSACHUSETTS Rinomd in uornputer: PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS Yea Rpplitation for Disposal Opstem Consstruttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complctc System Individual ComponmLs I.ncation Address or Lot No. Owners Nome,Address,and Tel.No, Assessors Ma Parcel 2-02 Croce-et 15 3e6L tzk Robzri Kinq SbVr�-4 -zo c r Installer's Name,Address,and Tel.No. bolt•y7'T' Designer's Name,Address,and Tel.No. EA3mVsM4;0^ 14'reaSeery w F-c—rca Type of Building: Dwelling No.of Bodrooms _Lot Size sq.ft. Garbage Grinder( ) -Other 'type of Building - No.of Persons Showers( )Cnfehria( ) Other Fixtures_ Design AM(min.required) . Lard Design flew provided' '- - _ gpd Plan Dete -Numbcrol'Sheets Revision Date Title, Size of Septic Tank 'Type of S.A.S. -_ Description of soil Natnreofftepairsor Alteratiew(Answawhenapplirahle) .S300C 4001- 111 Date last inspected - - Agrecmvn t: The undersigned tppem in ensure the construction acid maintenance of the afore described on-site sewage disposal system in accordance with the provisions of ThIc 5 of the Environmental Code and not in place the system in operation until a Certificate ol, Compliance has been issued by this Hoard of Health. S ed Datc_ 30-/S Application Approved by ApplicatJon Disapproved by Date for thu following reason _ - ----- Permit No. 15 7-4q _ Dato Issued " /�•Y/7,e1� ---- ------------------------------------------ --- -------- -------------------- THE CCIMMQNWEALTH OF MASSACHUSETTS - BARNSTABLE,MASSACHUSETTS Certifitate of Compliance THfC DS'TT,1 t'.F.RTfFY,that the tT,-rite Rnwnge Disposal system(:anstructed( ) Repaired(-*") Upgraded( ) Abandoned( )by,f3_�u Q EYe-t,�4 ii 0 3 at 707 Cr=Rcr-s IJecK fit.--- ._.._has been constructed in accordance wilh the provisions of Tdlc 5 end the lot Disposal System Coasiruetion Permit No. y loud 7'�2e1/'1pl Iuushdler 8 ExCit/0.'�.1 P.0 - Dcsigacr _ . _.. __ #bedrooms A _ ----. . ,YI�Q1 Approved design flow AW gpd The issuance oi'this permit Shall not N construed as a guarantee that the system will function as designed. - Date Inspector .... ._ ....__.___.-----------__.__.._.____...__---------------------___—._.______._..__...... . xe. Z0E U� pee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Bisposal.Opstem Constrattion permit ` Permission is hereby&=red to Construct( ) Repair(V1 Upgrade( ) Abandon( ) Systemlocatedat 7-0-L CrrncKzre meet Pe4 c4 ;4 I t Town of Barnstable Barnstable Regulatory Services Department "' 't MASS • s/1RNSTAHLE, • O D 1639. Public Health Division .200 Main Street, Hyannis MA 02601 200� Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7 August 4, 2015 Robert E. kingsbury % Judith Lee Freeman 24 Driftwood Lane Plynouth, MA 02360-2094 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 202 Crockers Neck Road, Cotiut MA was last inspected on 7/2/2015 by Matthew F. Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally passes " under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution—box needs to be replaced. You are ordered to repair or replace the septic system within one (1) year from . the date you receive this notification.. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO C' �'" ° co Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\11 Evans St Ost May 2013.doc ��Try tom, Town of Barnstable i M i &UMSfABLE, p MASS Regulatory Services Department rf � Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-8624644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (brokedcover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: ven r Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 8/3/2015 Parcel Detail .. MASS. � Logged In As: Pa Ce i Monday, tua�.st 3 2015 Parcel Lcok�jo Pa rce I Info Parcel ID 019-020 Developer Lot LOT 153B�� � � Location 202 CROCKERS NECK ♦� Pri Frontage 000 Sec Road GUIMQUISSETT ROAD sec Frontage 150 �� village COTUIT Fire•District `COTUIT� Town sewer exists at this address No Y Road Index 0383 \` - Asbuilt Septic Scan: / 019020 1 Interactive Map Owner Info Owner KINGSBURY, ROBERT owner Co_ ,C/O JUDITH LEE FREEM� Streeti.24 DRIFTWOOD LANE 'Street2 city PLYMOUTH f State MA zip 02360-2094 Country Land Info Acres 0.31 use Single Fam MDL-01 zoning RF Nghbd�0106 I Topography ,Level Road !,Pa\oed Utilities Public Water,Gas,Septic , Location Construction Info Building 1 of 1 Year 1950 Root Gable/Hip J Ex Built Struct Wood g ,_ wall Shingle' Living 1272 Root As h/F GIs/Cmp J AC 'None Area C pover Type nt Bed Style Ranch Wall Drywall Rooms 3 Bedrooms Bath Int - ' • Model Residential Carpet Ba2 Full-0 Half Floor Rooms Grade BelowA\erage TYpe Hot Air Rooms 6 Rooms Heat stories 1 Story_ Fuel GasFoation MIXed J Gross 2138 Area Permit History Issue Date Purpose Permit# Amount Insp Date Comments 9/1/1995 New Roof 10662 $1,200 1/15/1996 12:00:00 AM CO RE-ROO 9/1/1986 Addition B29970 $52,400 1/15/1989 12:00:00 AM COADD'N http://issq l2riintranet/propdata/ParcelDetail.aspx?ID=669 1/3 Commonwealth of Massachusetts �P �l / 010 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1710 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Na 'e informatifor every on is required Cotuit Ma 02635 :.. 7-2-15 page. City(rown State Zip Code Date of Inspection ND .. 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. Imng out forms A. General Information filling out forms on the computer, use only the tab 1. Inspector: [ key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation _ I Company Name VQ 14 Teaberry Lane Company Address / Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-2-15 Ins ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owners Name information is required for every Cotuit -Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a,complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F rm 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is Cotuit Ma 02635 7-2-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced. ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): System is in working order but d-box is in poor condition and must be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M �t 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of"a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection C. Checklist - Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013- 36,000gallons 2014-33,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-date of last pump unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ L Title 5 ®fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.' 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon ` Sludge depth: 6„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time. Tank should be pumped every two years to prolong life of system. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. CitylTown State Zip Code Date,of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete El,metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 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.): At time of inspection D-box was in poor condition nad must be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road 1 Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 (6'x6') ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit had a stain line 1'6" below invert. Cesspools (cesspool must be pumped as part of;inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commol wealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert.Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or.benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately ti t � A iS 3s 3 1-�l - 'ZO �Z- 13H ' CCOGkecS ¢ ROApL 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 L f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Z Check cellar ® Shallow wells. Estimated depth to high ground water: Gw 10" feeee t a 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: sept-22-1986 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Crockers Neck Road Property Address Robert Kingsbury Owner Owner's Name information is required for every Cotuit Ma 02635 7-2-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information- Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 0217011858 OW112001 Commonwealth of Massachusetts Form 4--System Pumping Record i' Massachusetts System Pumping Record System Owner System Location Kingbury Robert Primary Home 202 Crockers ?deck R3 202 Crockers Neck Rd Cotuit, MA, 02635 Cotuit, HA, 02635 • (508)-420-1479 x {506)-420-1479 x Kingbury Robert I Type: Emergenc Routine Cesspool: No Yes Septic Tank: No Yes ��4 Date of Pumping: Quantity Pumped: Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: A"� Date: Pumper Signature: Condition of System/Othe Comments r� 5`2--4 50 Dep Approved Form-12/07/95 �-l �c�t 5 i 1� � r� � - 10 �3 LOCATION SEWAGE PERMIT NO. oa0 VILLAGE C0Ty r INSTA LLER'S NAME A ADDRESS R U I L D E OR OWNER DATE PERMIT ISSUED I - `fib DATE COMPLIANCE ISSUEDh r , @@ _ � - —1 �het* �� �� , , .; _. �� �v N '� i� tl Ju'` � ��� �� ,� ���-� � J '= 5 ,ASSESSORS MAP NO: 4 `1 THE COMMONWEALTH OF MASSACHUSETTS OAR® OF HEALTH OF, .......................................................................................... firaatioaa for Biopooal Workii Toaaotrurtioaa ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal .............at: ... at ... ............. � �"�" �.... �' tYl 1.1 Location- dd sn r Lot No. ....................... ....................................................----- Ow r Address W Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- . W Design Flow......: atD....................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter____-_-...__-___ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No. -�._.. Diam r._. _ ----------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (L.) ` Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a ,.� 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------------------------ a ----------------------------- .....•........................ •-• ..................--------•---••----------•--------------•-----------------•-•---.----------._---- ODescription of Soil...........----------------------�--------------•-•-------------------...---------------------------------------------------------------- -------_.._........_.. x W ------•---••----------------••...----••--------- --•----•---.........•-•--•••----•----...--•-••-••---..... . ------ ---...---•------•-......-----••------•------------------ U r Nature of Re ai s or Alterations nsA PP —A er when a licable__o.��1. .(a!:C'i 6.)0c_�n+.... .. ^_� C -------- ------------------------ -- - - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TILT:. . p 5 of the State Sanitary Code—The undersigned further agrees not to place the system iin,� operation until a Certificate of Compliance ha been issued by the board of h alth. ........ ... ...............................7,.­,.......... Application Approved By.....- -�.. ... ..... ......................• ..... E...... ... Date Application Disapproved for the following reasons----------------------------•----•-----------------------------•---------------------.--------•------••-•----- -••-••-•-•••--•------•-------•-•-•--•...---------•---•----------•-----•--•---•--••-••----•-•-----•---••-•---•-•---------•--------•-•--------------•-••••--•------•--•----••-----•---------•----•------•- Date Permit No........ ....- --� f'..��_ Issued....................................................... Date t� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i 0 F � - Appliration for Disposal Works Tonstrnrtion rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . .. Location-rdd ss or Lot b�Yo. aw er �.. } �iAddressO ------- ------•------------ -.--...... --.-----•-- - ------•---------------.-...--- -•••--------. .._ .--------- - ... ------------------------------------------------••. •... lInstaler f Address UType of Building 1 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aI Other—Type of Building ............................ No. of persons............................ Showers ( )'`— Cafeteria Other fixtures d --------------------------------------------------------- w Design Flow.......�L?.t;?_/7....................gallons per person per day. Total daily flow__._........._..........._..................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No. s ----- Diam�e ._. 1�........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (1,.�''L� F osing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_____-___-_------_-__. fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... W' ........--------------------•••-•---•-•.......•-----•-----..._..--------•................_..-•-•----••••••••-•--•---•--.....------•-•-............-----•-•-• ODescription of Soil........ . ...............•----•-----------•--------------- -----------•-•--------------•--•-----•-----------------------------•--•........ x U •-•-••---•--.._..•-•----•-----------•----•-----•-•---••-••-•--••••---•--•-------•...........................•••----•-•........----•----•----••-•......--•----•-----•--•----•----•-•-----••------------- w _ U Nature of Re airs or Alterations—Answer when applicable_ _ 1��t_C,_. k� ... .5�� �._-....... -----------------•-- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of TT I a:p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the board of health. Date Application Approved By....... �.� _. ., C � at- .................•-•---•---•• ------ Application Disapproved for the following reasons:.............................................................................................................._ --------------------------------------------•-----••------------.............-•--•--•--••....--•-••-•••----•---•----.._.....-••-•--•--_.._........•-••••---•-•......•.................................. Date Permit No._......` _._�' ---••--•--•- ...l .__. Issued.. ----- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD JOF HEALTH ..... v .. .........OF........... Qrrfifiratr of Tomplianrr THIS I�- `U CEli{T�IFY� T1�at1 the individual Sewa Disposal Syste c st lcted �) or epaired ( } by = -:}...._ ......... . -------------- IrEst�ller - �^ ( tr; has been installed in accordance with the provisions of T'L 71E. 7 of The State Sanitary Code a descr' ed in the application for Disposal Works Construction Permit No.... [�!s dated---------� ,7 tom, �------•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM f 1 L CTION SATISFACTORY. DATE...`..-...y. ........ ................................................ Inspector..12.2..------------------..._...----------------------....-•-•--.....-------•-- t � F{ THE COMMONWEALTH OF MASSACHUSETTS -�?-`- BOARD OF HEALTH .............�.�. ". FEE... ? ... iu ofin, Workii Tonstrudinift Plermit r-y's_ Permission is hereby granted - . ---•--.. --............... .. ................... ... .... . to Construct ( ) or Repair ) an In ividual Sewage Dis- tem at No...... .._. ._. ......•••--• a- IL.�L�?c�G'�C.....----• ......L -•-9r-= - r j .................•---•---- -•--------..._..---....-- Street _,.,... as shown on the application for Disposal Works Construction Permit jn.�.a�-3_Dated , �._...� j. -------------------------------------------•......---• !/f �( Board of Health DATE---l-�•----.........{ /....-----•------------....v..................-------•---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • 4. i i _. • I Iv ' Y /7- , \ ,T y lilt 1 C. i ZI a -p,sr 1 p s II' QeX li taco CSgv- / �G O Sync MP Z07 ,B ` Qta b�� 27a0 y7y /71 /3 a8 Z S4 r-7= ¢ 17/. /3 ' T LOCATION SCALE . .�.��; 30'.... DATE S 22/78C PLAN REFERENCE OF E D V Al RD s . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . E. �ELLEY No. 26100 11✓ F, 'pfCt$iE Q 1 CERTIFY THAT THEE 57i,A/G 8u/GPiNG ( � %� i�� �� SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON; DATE SE'�l 1 Z REGISTERED LAND SURVEY