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HomeMy WebLinkAbout0031 EASTWOOD LANE - Health 31 Eastwood Lane Cotuit A= 121-142 - - k E. I I� +fit i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown State Zip Code Date of Inspection 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: A. General Information When filling out forms on the /�((""ll V✓I U computer,use 1. Inspector: only the tab key to move your Scott Campbell cursor-do not Name of Inspector use the return key. Cardinal Company Name 32 Ridgetop Rd. Company Address Cotuit Ma 02635 City/Town State Zip Code 508-420-1295 S1388 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 ins�ction was performed based on my training and experience in the proper function and maintenance-ef on:�*e sewage disposal systems. I am a DEP approved system inspector pursuant to;Section 1%340 Title 5(310 CMR 15.000).The system: M Q ® Passes ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority J.�J76 C4 6/16/2011 Inspector's igna re 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. II Lt �4 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys m•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is Cotuit Ma 02635 6/16/2011 required for every page. Citylrown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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): ❑ 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•11/10 - 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 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. City/Town 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 '/z day flow t5ins-11110 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 G'M 31 Eastwood Lane Property Address Catherine Alder Owner owner's Name information is required for Cotuit Ma 02635 6/16/2011 every 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- ❑ El The ❑ ® 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•11/10 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 31 Eastwood Lane Property Address Catherine Alder Owner Owners Name information is required for Cotuit Ma 02635 6/16/2011 every 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 I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 31 Eastwood Lane Property Address Catherine Alder Owner Owners Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d yes 9 ( y 9 (gP ))� Detail: 2009=24,000 gallons 2010=25,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 2011 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown 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: 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978 town of Barnstable information on file at the board of health Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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): 9„ 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: Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. City/Town 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 2' Scum thickness 2'3" Distance from top of scum to top of outlet tee or baffle 41' Distance from bottom of.scum to bottom of outlet tee or baffle 27„ How were dimensions determined? sludge stick, tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank needs to be pumped. Inlet and outlet tees in place at time of inspection. Tank at proper working height at time of inspection. No evidence of leakage into or out of tank at time of inspection. 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown 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 ❑ 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•11/10 Title 5 Official Inspection Foam: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 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): Box working properly at time of inspection. Small amount of solids carryover into box at time of inspection.No evidence of solids carryover to leach pit. No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-11/10 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 �M s 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Course sand. NO signs of hydraulic failure, no ponding or damp soil,normal vegetation. (grass) 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 E Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Citylrown 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•11/10 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every page. Cityrrown 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 o 3a I I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 ' 6/16/2011 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 13+ feet 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: 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: Excavation at time of inspection back side of leach pit Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 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 31 Eastwood Lane Property Address Catherine Alder Owner Owner's Name information is required for Cotuit Ma 02635 6/16/2011 every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 commonwealth of Massachusetts 0 0' 2 Title 5 Official Ins . pectoon Form � Not for Voluntary Assessments � Subsurface Sewage Disposal System Form , t�3 Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated W1512000.Inspection forms may not be altered In anyway, A. Certification Important�ngr. v u out 1. Property Information: farms on the cmrprter,use f h Z'o 05 Ct 1 i✓.�t Q� I -only the tab key �Address� o h e-z rt. to move your so curr-do not Na. use the retum key. 071 !T t e'l C Q S r Address } rrr5 Gtyl1 own sh" Zip Code Date of Inspection: Date 2. ins ctor. ; " __ k /4 f 3 Nacne Pf Ir"ector M me UomeM Ad� A s i' r-� a ( Mate Code TeN)hwm Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,ac6rate and complete as of the time of the inspection.The i inspection was performed based on my training and experience In the proper function and maintenance of orr site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15-W-of - Title 5(310 CMR 15.000).The system: 0 '"tee ; D Conditionally Passes p Fails _4 a S ❑ s u r uation by ice Local Approving Authority 4 Y �evt '"f""i' ( f Of Health or i a s� it a copy of this inspection o the pro Authority(guard DEP)within 30 d of completing this inspection.If the system is a shared system or has a design flow of 10,00o or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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'Ume.This Inspection does not address how the system will perform in the future under the same or different conditions of use. i Mup.doc-11=04 7rtle 5 Official Wapeeim Form:Subsurface Sewage Disposal Systern. Page 1 of 16 I commonwealth of Massachusefts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form i A. Certification (cons) 0eb CL A.1,0Q, Address own �-- � zo� z hi � � A e o—I ,�J� Name I Oahe of n Inspection Summa ry-Check A,B,C,D or E/ahmys complete all of Section D i A)` System Passes: D-100have 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: j E Bj conditionally Passes: ❑'One or mo system components as described in the"Conditional Pass"section need to be replaced or aired.The system,upon completion of the replacement or repair,as approved by the Board of H th,will pass. Answer yes,no or not ermined(Y,N.ND)in the[]for the following statements,If"not determined,"please expla ;The septic tank is metal an ver 20 years old'or the sep tic tank(whether metal or not)Is structurally unsound,exhibits stantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the 'sting tank is replaced with a complying septic tank as approved by the Board of Health. ; A metal se ptic tank will pass inspection if 's structurally sound,not leaking and if a Certificate Of Compliance indicating that the tank is less 20 years old is available. ND Explain: i i J I i t5'ffwp-dDC•1 MON Tie 5 Otftaat froWictim Form Subsurface Sewage Disposal System. i Page 2 of 16 I i i - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cons) L—h o� ri P address �R ` ) State zip Cate OwWs Name �— Date of tnsp 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 obs cted pipe(s)or due to a broken,settled or uneven distribution box System will Pass inspection ff approval of Board of Health): i [� broken pipe(s) replaced �l1� ❑ obstruction is remov } a ❑ distribution box is leveled or laced ND Explain: f 4 { E ❑ The system required pumping more than 4 times a year due to broken or obstruded i stem will ass in P ems)'The SY p inspection if(with approval of the Board of Health): (� broken pipe(s)are replaced obstruction is removed ND Explain: 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 tl a environment. 1f, System will pass unless Board of Health determines In accordance with 310 CMR V-3030)(b)that the system is not functioning in a man er which will protect public health, safety and the environment: ��Cesspool or privy is within 50 feet of a surface water rj i U Cesspool or privy is within 50 feet of a bordering vegetated wetland a salt marsh MaV.doc•11/2004 { Title 5 CMtdal I nspection Fomr.Subsurface sewage Disposal system Pape 3 of 16 Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Substitface Sewage Disposal System Form i A. Certification (c(Int.) �/ L ems/ w®o /0,4 lr l sla zip Code A owrii!rs mama Date of inspecion C) Further uation is Required by the Board of Hel alth(conty i 12. System wi ii unless the Board of Health(and Public water Supplier,if any) determines that system is functioning in a manner that protects the public health, safety and enviro ent: ❑ The system h a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a ce water supply or 'butary to a surface water supply. ❑ The system has a se p' tank a d SAS and the SAS Is within a Zone 1 of a public water supply. i 1 10 The system has a septic tank d SAS and the SAS is within 50 feet of a private water j supply well. i I i jE1 The system has aseptic tank and SAS d the SAS is less than 100 feet but 50 feet or fmore from a private water supply well'*. Method used to determine distance: G _ *`This system pa if the wen wafter analysis,performed at a DEP certfied laboratory,for �coft" bacteria an olatrle organic compounds indicates that the well is free from pollution from that facility and the p ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no oth failure criteria are triggered.A copy of the analysis must be attached to this form. . Other. �1 I I i j ; Wvzp.doc•1112004 r Title 5 Otgc ial nvedion Form:Subanfaoe a obposw Syam- i Page 4 of 16 4 • i Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form i A. Certification (�) � / J � T— �''�r�f S t l — state, o nun e o he--IOwf�e i s Nam Date of Ins ecttor► i D)System Failure Criteria Applicable to All systems: You must Indicate"Yes"or"No"to each of the following for all Inspections: Yes No Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool i 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 lox above outlet invert due to an overloaded or dogged SAS or cesspool Liquid depth in cesspool is Tess than 6"below invert or available volume Is less 0 than%day flow I Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).Number of times!pumped: E ❑ Any portion of the SAS,cesspool orpmry 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. 4 [) i Any portion of a cesspool or privy is"in a Zone 1 of a public well. j Any portion of a cesspool or privy is within 50 feet of a private water supply j Weil. j :0 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 i laboratory,for coliform bacteria and volatile organic compounds Indicates that the well is frees from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No The system fails.I have determined that one or more of the above failure D 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. i t5hrsp.doc 11/20D4 Title 5 Official inspector Form:Subsurface Sma e 9 Disposal SW. j Page 5 of 16 i i i i I Commonwealth of Massachusetts .Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) Address o,?(oas' l )) S ly zo cue I J r ( O!'1 �1� !J _ O cJ� OW-Ws Name Date)of Irmpede on i h E)! Large Syste : To be considered a large system the system must serve a facility with a design flow of 1 00 gpd to 15,000 gpd. i For large systems, must indicate either'Yee •'ne to each of the following,in addition th the questions in Section YES NO '© i ❑ ❑ the s is within 400 feet of a surface drinking water supply ❑ the s em is 200 feet of a tri system �butaty to a surface drinking water_supply ❑ the system is 1 in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a pped Zone If!,of a public water supply well If you have answered fires'to arty question in E the system is considered a significant threat, or answered'fires"in Section D above the large em has failed.The owner or operator of any large system considered a significant threat under or failed under Section D shall upgrade the system in accordance watt 310 CMR 15.304.The syst owner should contact the appropriate regional office of the Department. L%tsp.doc•i mmm Title 5 Ofda)Inspection Form:Subsurface Sewage Disposal System page 6of16 Comrrronwealth of Massachusetts Title 5 ®facial Inspection Form Not for Voluntary/Assessments Subsurface Sewage Disposal System Form B. Checklist J �� ��l state y t s- p r�Coal s Name Date of Check if the following have been done.You must Indicate"yes'or"nor 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 nom-raI flows in the previous two week period? 0 Have large volumes of water been introduced to the system recently or as part of i this inspection? ❑ Were as built plans of the system obtained and examined?(if they were not available note as WA) ❑ 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(3)(b)] Misp.doc•1112oo4 We 5 OMcIW rnspeCODrt Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subst'rface Sewage Disposal System Form I C. System Information �- i 00 w s� 6-?J-�- A7JPCode =i1yL>t1rto e� .�� w 0 ov owners name Date of kafecuofi E Residentlal Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): ? DESIGN flow based on 310 CMR 15203(for example:110 gpd x#of bedrooms): `� I Number of current residents: Does s residence have a garbage grinder? ❑ Yes [�/,No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes-V No Laundry system inspected? EYes ❑ No Seasonal use? XYes ❑ No Water meter readings.if available(last 2 years usage(gpd)): c� — Sum p pump? ❑ Yes Or No Last date of occupancy: e a CoMmerciallIndustrial Flow C ditions: Type of Establishment: I Deem flow(based on 310 CMR 1520 Gdbm per day WPM Basis of design flaw(seats/personsJsq it..etc. Grease trap present? ❑ Yes ❑ No iV Industrial waste holding tank present? ❑ Yes ❑ No i Nort sanitary waste discharged to the Title 5 system? [I Yes ❑ No Water meter readings,if available: Last date of occupancy/use: D ata Other(describe): MnV.dac^1 V2004 Title 5 Odal Irapecom From:Subsurface sewage Dbpwa Syswm Page a of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont) rStateZhcone Oumers Fume Date of inspeoon General information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ YesNo i If yes,volume pumped: sue$ i How was quantity pumped determined? i Reason for pumping: Type of System: Septic tank,distribution box,soil absorption system [Q Single cesspool El Overflow cesspool P Shared system(yes or no)(if yes.attach previous inspection records,if any) 0 Innovative/Alternative technology_Attach a copy of the current operation and maintenance contract(to be obtained from system owner) [1 Tight tank Attach a copy of the DEP approval. p Other(describe): Approximate age of all components,dale installed(if(mown)and source of information: v Were sewage odors detected when arriving at the site? ❑ Yes kNo t5insp.doc•11/2004 Tile 5 MUM Inspection Form:Subsurface Sewage D61xnW system- Page 9of16 Commonwealth of Massachusetts Title 5 Official- Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (corn.) 71 own Slated Zo Code O*WV V / s Name Date of hr436cuon Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC r(explain): Distance from private water supply well or:evidence on feet Comments(on condition of joints,venting, of lea e,etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: crate ❑metal D fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of 0 yes 0 No certificate) /o o Dimensions: —T 3 Sludge depth: f/z. Distance from top of sludge to bottom of outlet tee or baffle / 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 3 How:were dimensions determined? `-e"`�/� e t5kisp.doc-1 UMM We 5 teal Inspection Farm:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) —�"?/ r- 4 o d- /-Y:3 ix) Q- P //fj f S oa 63j- Ckawn �� State Z�Code owifees Name Date of r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity. liquid levels as mated to outlet invert, of leakage,etc.).ce rVIA 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 fast pumping: Date Comments(on pumping datkms,inlet qnd outlet tee or baffle condition,structural integrity, liquid levels as related to outlet i evidi a leakage,etc.): Tight or Holding Tank(tank must be pumped at time Inspection)(locate on site plan). - Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): L%WPAOC•111a Ttte 5 O dal Inspection Form:Subsurface Sewage D System Page 11 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cons 3- 1 �r�St ctcSyc7 �i��� mate ap coft s Name Date of Tight or Holding Tank(cont) Dimensions: Capacity. gaDom /� Design Flow: - ganons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in order. ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Distribution Box(if present must be opened)(locate on s" plan): Depth of liquid level above outlet invert Comments(note if box Is level and distribution to outlets equal,any evidence of solids carryover,any evid of leakage into or out of box,etc.): a � �, Pump Chamber(locate on site plan). Pumps in working order. 00 ❑ Yes ❑ No Alamo in working order_ ❑ Yes ❑ No nspactim Form:subsurface sewage Dwposd systm Page 12 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) _ �S 0 PrdWrly C2a�Jj state/sue Zip code va J l J e-, 1 ` f' t e-J2 0 V er's Name Date of Inspeel n Comments(note co '�ofpump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: leachinge pits number. 0 teaching chambers number. El leaching galleries number: El leaching trenches number,length: 0 leaching fields number,dimensions: [) overflow cesspool number. Q innovative/aitemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): t� r t5rnsp.doc-11/2OD4 Title 5 Official Inspection Form_Subsurface Sewage Disposal System- Page 13 of 16 commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System informon (cor t) P CVfrn /J e State /J` /J Code s Name Dale of! Cesspools(cesspool must be pumped as part of Inspection)pocate 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 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, dition of vegetation, etc.): .doc�11 t5insp /2004 Trfie 5 Offiaal lnspec§Dn Form:Subsurface Sewage Disposal system Page 14of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) / o /v� /W-05s l31 ,,4 zip sate coae s Name Date��(�� •J/y ofl Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system inducting ties to at least two permanent reference landmarks or benchmarks.Locate all wLlnfie� Lute where public water supply enters the building. 9Q �nc IC � 5� l3 CLgL-- I� ( C-1> 3 3 a-C> L q S o 3 _- 3 � r s r � t5aosp.doc•1 irzoat True 5 Official }nspeaion Form Subsurface Sewage Disposaj system- Page 15 of 16 Commonwealth of Massachusetts File 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Oopj (W0 ( LIB e Property Address _ 6� 63s, Ci !ro n ' tY State Zip Code Owner's-Name Date of hnspeption Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 30 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: ` Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked w. cal Board althin: � of� K Checked with local excavators, installers-(attach documentation) ]� Accessed USGS database-explain: You must describe how you established the high ground water elevation: r Y041—ibit S oq /L %i-24 t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 OF TyFAT COTUIT ctT#EX �efxztxt[ext# * FIRE DISTRICT ro 1926 �, 4300 FALMOUTH ROAD, P.O. BOX 451 JUV( COTUIT, MASS. 02635 PHONE 508-428-2687 FAX 508-428-7517 copy IA . C { Town of Barnstable OFtHE 1p� o Regulatory Services snArsrnBM ; Thomas F. Geiler, Director 9� i AM � A�FD3�p Public Health Division Thomas McKean, Director, 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspections.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR7AUG � 004, MAP' ',.�.._.�.-�-_--,--F.-��, PARCEL. ;� ® 2' STABLE LOT � uPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 31 Eastwood Road Cotuit, MA 02635 Owner's Name: Dan Kadar Owner's Address: Date of Inspection: August 9, 2004 Name of Inspector: (Please Print) James M. Ford Company n a Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai s Inspector's Signature: Date: August 12, 2004 The system inspector shall suti 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. I Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated,below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 I 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.J No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• ' F 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: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on,the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on 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)]. I 5 Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 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): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown-years ago COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sqft,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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool - Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 1113178-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: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line_ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) - Depth below grade: To grade 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: 0" 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: 14" 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.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. r 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 I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: A ujzwt 9, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons .Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (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.): The D-box was level. No solids were present. 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.): I 8 • Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000ga1.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The leach pit was dry and clean. No scum line was present. The bottom to grade was 9'. 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 , D Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building, I I. ay o 3 y y So 31 ' 10 . e Page 1 1 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 Eastwood Road Cotuit, MA Owner: Dan Kadar Date of Inspection: August 9, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40 +/- 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: Checked with local excavators, installers-(attach documentation) ✓ Accessed USGS database-explain: Topographic and water contours maps You must describe how you established the high ground water elevation: Using USGS topographic maps and water contours maps, the maps were showing approximately 40'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 _ � f i L O C T 10 S E G E IT NO. VILLAGE INST LA'S N AV E AD RESS ---------------------- 0 U It OR':..- ONfN-ER _... DA T E P ERMIT I S S U E D DATE COMPLIANCE ISSUED � � - 9 � y 3i 50. i I i 1 E TOWN -F Bpp STABLE LOCATION �ISTWw� I� SEWAGE # _ I VILLAGE C p 1 V t ASSESSOR'S MAP & LOT-n . IC3 '— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY pOTM I LEACHING FACILITY: (type) (a (size) NO.OF BEDROOMS BUILDER OR OWNER 8q r PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facili ty (If any-wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching�acility) (' Feet Furnished by 1/IS'pC19 , J Y'0� i I O 3 a ► ao y 3 3 g ao y so 31 R TOWN QF BARNSTABLE LOC '.TON� ASr(WW '`�• SEWAGE # VILLAGE C a l V t ASSESSOR'S MAP & LOT'6LS'®3 '- INSTALLER'S NAME&PHONE NO. `SEPTIC TANK CAPACITY CIPU p LEACHING FACILITY: (type) 0-TF 60x( (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 acility) Feet Furnished by 1^S000U�1 J �0� / 1 y 331 ' ao So 31 L 0 C/A ,, S E G E I T NO. VILLAGE LP Q93 " INST.. LEIt"S - N E AD RESS e - i DATE PERMIT ISSUED - DATE COMPLIANCE ISSUED � . � - '�� x • I Si �� No........ s 1 Fsi&.......Ir............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 09 s�� ,Z _----....OF........_...... YYI....s......................................... FT Appliratinn -fur Bi,ipuiittl Works Tnnitrnrtinn Prrmit Application is her by or made for a Permit to Construct (_ Repair ( ) an Individual Sewage Disposal �p System at: ,ye 3•i ® J e .................................... - Location-Address or Lot No. W ( Owner Address Installer Address Q Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms__._. _________________ _____________Expansion ttic It Garbage Grinder ® aOther—Type of Building ............................ No. of persons------ Showers ( ) — Cafeteria ( ) Q' Other fixtures Q ------------------------------------------------------------------------------------------------------------------ W Design Flow............. ____________________gallons per person per day. Total daily flow...............g'._Q..0..............gallons. P4 Septic Tank—Liquid capacit-QQC-gallons Length---------------- Width..............-. Diameter................ Depth................ xDisposal Trench—No- -------------------- Width-------------------- Total Length__-_-__-____---___- Total leaching area_.--.--.__--_-__--sq. ft. Seepage Pit No-------- ---------- Diameter..e__,)(,?.__.. Depth below inlet-------------------- Total leaching area.___.-.-._--.-_-__sq. ft. z Other Distribution box Dosing to ( ) v /; C,19", y,�' 77 P � a Percolation Test Results Performed by........ .-d�---Gt.GYP ....................... 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_.._-.-..---.-_--_-_-_ P4 ---------a---- ---------------- 4-i-.` -'.-�-'.-.-._-�--.----`-�----�------~--=---------,a-----/------------••----------•- _ ----• ------•--- - - --•---------- --- Description of Soil ` o. U Nature of Repairs or Alterations—Answer when applicable.---------------------------------------------------------------------------------------------- -----------------------------------------------------------•-----------•-------------------•---•--•---•----------------••----------•-----•------..-------------------•--------•---------------------- Agreement: The undersigned'agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. D Application Approved By------------ .....��' !f=�,��. �t. . . ----•--•------ � s Date Application Disapproved for the following reasons:--•------------------------------------------------------------------------------------------------------------- . -----------------------------------------------------•------------------------------------------------•-••••--••-----......•----•---------------••-•---- .......................... ,it Date PermitNo......................................................... Issued--------- ----- Date No......................... ............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... _ _ . .............OF......................................................................................... Appliration -fur Ui Voiial Workii C owitrurtion Prruid Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at < Lo anon ress or Lot.No. W ,I'��O��caner Address .. L,rt IP Installer Address UType of Building Size Lot.---_---_-----------------Sq. feet Dwelling—No. of Bedrooms...__ ------------------------------------Expansion �' Garbage Grinder Wb a Other—Type of Building ----------------- p ( ) ( ) _.___..__.. No. of persons _________ Showers — Cafeteria a' Other fixtures ------------------------------- - - W Design Flow............. '"` ________.__...._.__gallons per person per day. Total daily flow.........:...... :Q_0-__....---.--.gallons. WSeptic Tank—Liquid capacit/ (gallons Length................ Width................ Diameter---------------- Depth-.-.---_-.----- x Disposal Trench—No--------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No........1---------- Diameter_. .A_ .... 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 "Pest Pit.................... Depth to ground water-..-_-._-.---.--.----- 1:1q Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-..-..--..-..--__---- t� •--•------------------------•-•- ---------------------------------------- -------••--------•-----•--------------------------------- ODescription of Soil------------------------------------------------•-------•----•--•-----•--•--•------------------------------------------•------- ----------------------- •--------------- x W VNature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------. -------------- -----------------------------------------------------------------------------------------•• •----------------------------------------- ------------------------------------------------- Agreement The undersigned agrees to install the.aforedescribed,:Individual Sewage Disposal System in accordance with the provisions-of Article XI:of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. ; Application Approved By.- :_._-:_ Date Application Disapproved for the following reasons:-------•------------------------•--------- ...............------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (.!i! :............OF.....................f.„1..� ..'.! 'r�. C �............ Trrtifiratr of 0,11mlifittnre THIS ISO�ERTIJU, That the Indiy.,Wual Sewage Disposal System constructed or Repaired ( ) by....................-- -------¢' a..... j � ------------------------ aI I tiller at C ._.. L_ � -. ...-•-•--•------••-----•------------------ PS has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------------------------------........... Inspector.................................................................................... THE HUSET OF COMMONWEALTH A L MASSACHUSETTS TS -- -+-� BOARD OF HEALTH No. -W.1... C ✓...... ... OF........... � � 1� ll ' ................ FEE........................jark tn� tr�trti t rrmit Permission is.hereby granted------ -- ,-Cl ' ''.? -- 6�1 --- to Construct P,�) or Repair ( ) an Indd'vidual Sewage Di posal System atN ...ICZ7... ?Q. . ................. ............ro._Klz�l--------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No..................... Dated--------...------------------------------- -------------------------------------------------------------- --------------------------------•••------ ` _ / Board of Health DATE I f ---------------------------- -- FORM 1255 HOBBS & WARREN. INC.. 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