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Home My WebLink About0078 CURTIS ROAD - Health 78 CURTIS RD , COTUIT 000A 047= 1 1 No. Fee BOARD OF HEALTH TOWN OF BARNSTABLE 0[pprtcatiou jor Yell Cougtructiou Permit Application is hereby made for a permit to Construct(e, Alter( ), or Repair( ) an individual well at: 7? C w rT Rd (.oT T Location-Address Assessors Map and Parcel :oN E M o r e ce,.-T;s /?J coT;T m (k . Owner Address D e a)-v ca-iu to c II /b 8 D e g"0 SS Rcl Mas 44 e< /'!u Installer-Driller of Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well f L) Capacity Purpose of Well 47'o go a N41 Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certifi to of Co=been issued by the Board of Health. Signed Y 2 1 lJ/ ate .. Application Approved By 7/,0 `I Date Application Disapproved for the following reasons: I n �q� Date Permit No. V"`v A Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(•< .Altered( ), or Repaired( ) by Oea•uiS SCapjwf l/ Installer at n cuo-Ts /?j cbrut� has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Wel)rrot tion Regulation as described in the application for Well Construction Permit No.V/10- 02,--? Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector Y� No. � Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pplication for Yell construction 'Permit Application is hereby made for a permit to Construct(P', Alter( ), or Repair( ) an individual well at: sue+ Location-Address Assessors Map and Parcel 1( e� F,:,wFMore '78< Cu✓ / iis ILL c�T60 4 (7A Owner Address// �Ehjn� ,rj �Cvn.) ruc 7b� �e �/o$.S Vic! avtC,shjo ('< /yI . Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well y P l) Capacity Purpose of Well �7io Au Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance//has been issued by the Board of Health. Signed y/,)� Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. i�'� rUG� Issued Y • Date t -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH '+ TOWN OF BARNSTABLE Certificate of Compliance j THIS IS TO CERTIFY,that the individual well Constructed(-); Altered( ), or Repaired( )' by e n ? y9,7 SC01,j,,' /✓ Installer at f u r TS ri j C�7u- , has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No*laI a? Dated V1 301 2 r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Construction Permit No. Z'��r Fee Permission is hereby granted to new N i S SC u �� l Installer to Construct(r);^ Alter( ); or Repair( an individual well'at: No. 7R C u/T/S Ca7viT Street as shown on the application for a Well Construction Permit No. �! � �i- Dated J Date 30�2" Approved By ` >f l.nT l 3 6.16' O t� N 8511 31" E / d LOT 16 ' o � a / 1 'i o; 4. 2 / 5 0 co p00 \R = 130.00' � o 22 L = 16. 79' CD / RES.. Z011W "RF" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.' "C" Bank Use Only TOWN: _COTUIT _ _ --- -- REGISTRY OWNER: DENISE_M___KELLY----------------------- DEED REF: _ 9495�253-----------___BUYER: _KENIVTH_B_.__& J0 ' V _FIIVIVE'llIOIZE_ _____ ________ DATE: -1 1��00-__-__r-___-___- PLAN REF: 475_4____ _ SCALE:1"= 50___FT. I HEREBY CERTIFY TO YYASHINGTORj AILTUAL BANK NA. # _____ _--THAT THE BUILDING $''� y YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS VAULCONSULTANTS SHOWN AND THAT ITS POSITION DOES _ __ CONFORM kv y TO THE ZONING LAW SETBACK REQUIREMENTS OF THE Na 32MM 143 ROUTE 149 TOWN OF _ BARNSTABLE-------------AND THAT MARSTONS MILLS, MA. 02648 IT DOES_NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD � AREA AS SHOWN ON THE H.U.D. MAP DATED_8�19/85 _ � � TEL: 42 Co .unit —Panel 250001 0015 C FAX: 420--55553 __ __ _____ THIS PLAN NOT MADE FROM AN INSTRUMENT 28244 CB PAUL A. MERITH , PLS SURVEY NOT TO BE USED FOR FENCES, ETC. 'F BARNSTABLE -LOCATION SEWAGE # Q j ATI LAGE �. !"� ASSESSOR'S MAP & LOT � 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACI�NG FACILITY: (type) (size) -NO.OF BEDROOMS_&� BLUDER OR OWNS PERMITDATE: DO COMPLIANCE DATE: — Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells_ exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r. J � _.s /7 /� G u _ �'� i �-� �- !3 i �� . No. 7 V o— `l Z, Fee o / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for loiopogar *ps�tem Cott.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System KIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 6( 0 a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. . 0--ctA ee-- 5134-0 P-(,\C� i S k aL,% S 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 U gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank 1avt-z— Type of S.A.S. r S O �rvc`Z Description of Soil Nature of Repairs or Alterations(Answer when applicable) .ST � � S '� 'k- � 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 Certifi- cate of Compliance has been issued hylbis2pard.o alth. M Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. "vim Date Issued _ No. ',""a Z, Fee ` ' Entered in computer: THE COMMONWE�►�.�I�-OF MASSACHUSETTS YeS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Miquar *rwm, Construction Vermit - Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 6 C(0 I b�, ob( C 1/��. q t- 11 V 1 y� Yl'l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0-C A f�;c .SA C_ 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 �?` U gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank /- Type of S.A.S. <c t r ?'G Description of Soil: Nature of Repairs or Alterations(Answer when a plicable) STAR kocv Date last inspected: Agreement: y 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 Certifi- cate of Compliance has been issued b t oard oLL461th. j Signed' - Date I-D V-0V Application Approved by Date Application Disapproved for the following reasons Permit No. gdru -0te Date Issued /" Z'57- o-O --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,_that the On-site Sewage Disposal System Constructed( )Repaired( V11upgraded Abandoned( )by - a— S rC at G `� o 1 `rU iT_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZOT-V . q Z- dated // Installer Designer ^ �, The issuance of this permitishall ndbe construed as a guarantee that the system will function as d s'igne4. ,,// {{ ,,�J Date /A r/i? �I Inspector � ��11 A � 4/ .� / '!��'Vf�`,` �J -------------�-; -----------ram--,-Y—r�----- ee THE COMMONWEALTH OF MASSACHUSETTS t~t PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Mooat *pOtem Con5truction Vermit Permission is hereby granted to Construct( )Repair( [J r de( )Abandon( ) System located at Z j rrT c S c> r—r'7 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by r 1/669 NOTICE: This Form Is To Fie Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby ce:tuy that the application for disposal works construction permit signed by me dated j. -- -DO concerning the property located at J T G y t (fp meets all of the following criteria: v • The failed system is canner ed to a residential dwelling only. T"nere are no commercial or business uses associated with the dwelling,. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. / There are no wetlands within 100 feet of the proposed septic system There are no private wells within 1.50 feet of the proposed septic system There is no increase in flow and/or change in use proposed C./There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the ma.cimum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable) r/ if the S.A.S. will be located with'_50 fee;of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum.adjusted groundwater table elevation Please complete the following: C� A) Too of Ground Surface Elevation(using GIS information) ` a B) G.W. Elevation — - J V : [he.vt�-'(. Eugh G.W. Adjustment . D 1F EREN CE BETWEEN A and B SIGNED : �j;;�� DATE: ` 1-11-k-00 [Sketch proposed plan of system on backj. q:hcatth Colder.c-t G O --� 'lt-s/`.vw�S r _ .� MOF AI BARNSTABLE n i LOCATION SEWAGE # 1 NTILLAG ASSESSOR'S MAP &LOT 010 ®Jvoo/ INSTALLER'S NAME&PHONE NO. — SEPTIC TANK.CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNS PERMITDATE: DO COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of.Leaching Facility Feet. Private Water Supply Well and Leaching Facility..(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet i Furnished by 77 l ° I ,J . . .. ..... ............. COMMONWEALTH OF MASSACHUSETTS ik EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 78 CURTIS RD. COTUIT MAP 40 PAR 107-001 Name of Owner GEORGE KELLEY Address of Owner: 16 HILLDALE RD.S.WEYMOUTH MA.02190 (belo Date of Inspection: 12/22/99Name of Inspector:(Please Print)JOHN GRACII am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)Company Name: nla 2 8 �999Mailing Address: nla Telephone Number: nlaOFBARNSTABLE EALTH DEFTCERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information repe,accurate"./ �to and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper functi& and maintenance of on-site sewage disposal systems.The system: _ Passes The inpection is based on criteria defined in Title V X Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Furthirlva, ation By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:12/27/99 The System Inspector sha a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM CONDITIONALLY PASSES TITLE V INSPECTION. THE SEPTIC TANK IS BROKEN AND NEEDS TO BE REPLACED.THE LEACH PIT NEEDS A NEW 24"COVER. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 INSPECTION SUMMARY: Check A, 6, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: n/a B. SYSTEM CONDITIONALLY PASSES: y69,11 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. Indicate yes,no or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Itai The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection,or the se tic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration or tank failure is imminen. e sys em wi pass Inspec ion i e exis ing sep is ank is replace_wi a complying septic tank as approved by the Board of Hem nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n1a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed revised 9/2198 Page 2 of 11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. f 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply.well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER n& revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) . J Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Wa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22199 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa..(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth.in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped»1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 ; Owner: GEORGE KELLEY Date of Inspection:12/22/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 FLOW CONDITIONS RESIDENTIAL' Design flow:AN g.p.d./bedroom , Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: IV Number of current residents:2 Garbage grinder(yes or no):�152 Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):�LQ Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: nLa COM MERCIALANDUSTRIAL Type of establishment: nLa Design flow: nLa gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):JNQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nLa Last date of occupancy: Wa OTHER: (Describe) Wa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa- gallons Reason for pumping: a& TYPE OF SYSTEM X Septic tankidistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: 1991 Sewage odors detected when arriving at the site:(yes or no): �LQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 BUILDING SEWER: (Locate on site plan) Depth below grade: iL Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 8" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): XG nLa Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3". Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: i How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK IS BROKEN AND NEEDS TO BE REPLACED GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) DAL Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle n(a Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and.outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nla 4 revised 9/2/98 Page 7 of 11 SUBSURFACE SEWrAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 TIGHT OR HOLDING TANK: MQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: n& gallons Design flow: nLa gallons/day Alarm present: N_Q Alarm level:jV& Alarm in working order:Yes_No NQ Date of previous pumping: nta Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: ' (note condition of pump chamber,condition of pumps and appurtenances.etc.) D& revised 9/2/98 Page 8 of 11 C• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jiLa leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nla overflow cesspool,number: nLa Alternative system: Wa Name of Technology: jiLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT NEEDS A NEW 24"COVER THE PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT,AND IS FUNCTIONING PROPERLY. CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: nta Depth of solids layer: nLa Depth of scum layer. nLa Dimensions of cesspool: Wit Materials of construction: nLa Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)*a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla r revised 9/2/98 Page 9 of 11 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 4,) e A ne ` 0� L AD 3` 6A ya `L revised 9/2/98 Page 10 of 11 ' t • .. M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 CURTIS RD.COTUIT MAP 40 PAR 107-001 Owner: GEORGE KELLEY Date of Inspection:12/22/99 NRCS Report name: nta Soil Type: n1a Typical depth to groundwater: n/a USGS Date website visited: nia Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated.Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11