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HomeMy WebLinkAbout0060 EATON COURT - Health 60 EATON COURT Cotu it I' i f ,p J.M. OREILLY & AsSOCIATES, C-7 PROFESSIONAL ENGINEERING,LAND SURVEYING & ENVIRONMENTAL SERVICES Site Development•Property Line• Subdivision•Sanitary• Land Court•Fnvironmental Permitting C> N3 September 25, 2020 Job#8727 Thomas McKean Barnstable Board of Health 200 Main Street - Hyannis, MA 02601 Re: 60 Eaton Court Assessor's Map 055, Parcel 016 Cotuit, MA Tuleika -Owner Dear Mr. McKean: As per the requirement of the Massachusetts State Sanitary Code 310 CMR 15.021(3), J.M. O'REILLY & ASSOCIATES, INC. has conducted an on-site inspection of the newly installed sewage disposal system at the above referenced property. At the time of our inspection on 9/25/2020, the system installation had been completed with the exception of backfilling and final grading. Our observations were limited to the top of the Soil Absorption System (S.A.S.), the observation manholes for both the septic tank and distribution box and the soil conditions above the S.A.S. Soil conditions around and below the S.A.S. were not observed. Based on our observations, the sewage system was installed within substantial compliance with the approved plan completed by J.M O'REILLY & ASSOCIATES, INC. dated 9/9/2020,as filed in your office. This letter represents J.M. O'REILLY &ASSOCIATE'S inspection prior to backfill. No warranties or guarantees are expressed or implied for the future operation of this system. Please contact my office directly with any questions, comments or for any additional information you may need. Very Truly Yours, J.M. O'REILLY&ASSOCIATES., INC. Robert F. Reedy, T Civil Engineer cc: Client John M. O'Reilly, P.E., P.L.S. 1573 MAIN STREET,P.O.Box 1773,BREWSTER,NIA o2631 • PHONE: (508) 896-66o1 • FAx: (508) 896-6602 WWW.JMORF.ILLYASSOC.COM f S= 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ryl a 60 Eaton Court Rd IU Property Address ; Viktar Tuleika ' Owner Owner's Na a -k information is required for every Cotuit MA 02635 8-31-2018 _0 page. City/Town State Zip Code Date of Inspection t=F44h �4y1 • IaMk Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector:' key to move your cursor-do not David J. Burnie use the return Name of Inspector key. Northeast Construction Company Name Po Box 3250 32 Sara Ann Rd. Company Address raw Brewster MA 02631 City/Town State Zip Code 508-896-7713 S1 386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection..The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-31-2018 Inspector's Signature Z Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments *. 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. City/Town 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: This house has been vacant for several years, the septic tank was about 8" below the outlet invert. We filled the tank and checked it 48 hrs later and found the tank at normal working level. The distribution box was at normal level and the leaching pit was dry. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El 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.doc•rev.6/16 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 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. Cityfrown 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: 1 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form In Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is Cotuit MA 02635 8-31-2018 required for 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. ❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet Any P P Y from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 UTTiciai inspection orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit ' MA 02635 8-31-2018 page. City/Town 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? ❑ 0 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)1 D. System Information Residential Flow Conditions: e 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): 550gpd 1978 code t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. City/Town State Zip Code Date of Inspection D. System Information Description:. 1000 gallon septic tank, distribution box and leaching pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d house vaccant 9 ( Y 9 (gp ))� Detail: Vacant Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r; 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Eaton Court Rd V Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: plan dated 3/4/1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): All ok as to what we could view. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) The tank level was 8" below the outlet invert. We filled the tank and came back 48 hours and the tank was still at normal level. This property has been vacant for several years. 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: l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Ida Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Eaton Court Rd V Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 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 30 +� Scum thickness 2-4" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? tape and estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank should be pumped for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 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.): . The tank is now at normal level and the baffels are in place.The tank should be pumped for maintenance. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Eaton Court Rd Property Address . Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. City/Town 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 normal level. 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.): Normall level, no carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Located and found dry. t5ins.doc-rev.6116 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 60 Eaton Court Rd ,u Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 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.): Leaching pit found dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):, Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M0 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of V Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. City/Town State Zip Code Date of Inspection D. System Information' (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ® drawing attached separately t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 AsBuilt Page 1 of 2 L0CATIO EWAGE PERMIT NO. VILLA E INS.TA LIE NIS NAME A ADDRESS BUILDER OR OWN DATE PERMIT ISSUEDNk 8 �� 'kDATE COMPLIANCE ISSUED 4 f r� l ` 7 ...::.:.... . .. http://issgl2/intranet/propdata/prebuilt.aspx?m4ppar-05 50 j 6&sed 1 8/29/2018 L' C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is required for every Cotuit MA 02635 8-31-2018 page. Cityfrown 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: 14.80' per plan. 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: Plan on file BHD dated 3/4/1982 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file BHD date 3/4/1982 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how 9 you established the high round water elevation: Y 9 Plan on file BHD, test hole to 12' and note on plan to excavate to elevation 87.0 at time of installation. COC issued on 8/20/82 This is a dry test hole at 14.80' below grade. The bottom of the leaching pit is ar elevation 87.0. This allows a seperation of a minimum of 4'between the bottom of the leaching pit and the bottom of the test hole. f Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 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 ,L 60 Eaton Court Rd Property Address Viktar Tuleika Owner Owner's Name information is Cotuit MA 02635 8-31-2018 required for 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LO CAT IO SEWAGE PERMIT NO. VILLA E INSTA LLER'S NAME i ADDRESS B U I L D E R OR OWN DATE PERMIT ISSUED4- �� �DAT E COMPLIANCE ISSUED .O ,� ��� ;� �� r � � d� ► , A�, �" / !' l / / /%1L ^--� - __ _ - J No..... a-�/03 � Fxs.........) .............. THE COMMONWEALer OF MASSACHUSETTS BOAR® OF HEALTH ..............0 �4. '' Try i. ...........--- Appliration for Uiipoa al Worko Tonttrurtion Orrmit Application is hereby made for a Permit to Construct V or Repair ( ) an Individual Sewage Disposal System at: _ L at'o -A e or Lot No. w — Address � r. �....� .. ... .��.._. .� ��-�'../��:....�R. .rJ..r�.-1. Installer Address �, 5 ev_1'e_a' Type of Building Size Lote �,r,____Sq. feet Dwelling—No. of Bedrooms..........�...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ......�.`./ k?...'_.__ No. of persons........4� ............... Showers ( ) — Cafeteria ( ) P' Other fixtures .---•----•----••--•--........-•-•---------------•-------•-------------...........--•-----•--•----•---•------•--•-----------•--.....-----....--------- d w Design FIow..................................--..........gallons per person per day. Total daily flow........ ...................gallo . 1:4 Septic Tank—Liquid capacity/ gallons Len -. ._ Width-_-5"Z�....- Diameter--.- Depth..... ....... Disposal Trench—No..................... Width. . .._. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......./.......... Diameterf' Depth below inlet..4.''.......... Total leaching area..................sq. ft. z Other Distribution box ( ) Dos' g tank ( ) '-' Percolation Test Results Performed .eAKj.-.--.. ! ��'`�.� `� . Date. . © C_ Test Pit No. L ...--._ .--. minutes per inch Depth of Test Pit �S ........ Depth to ground water..,/­­­V­`__--- rs, Test Pit No. 2.4�'a- minutes per inch Depth of Test .._ .... Depth to ground water..lyy.!�:..74: a' ------------ --------------------------------------------------•--.......------•---------•-----•-.......---•--------•---------...................------•-•-- O Description of Soil...-- �r � ............•----G-�--.-.--.--�-----------------------------------------------•---------._.._.......---• w UNature 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 TL iTTE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een ssued by the bo d ea th. Signed......... -• -------• ----------- ............................... Date ApplicationApproved By•-•-•--••--••-•---•-----••-----•--.• •--•------- . .......................- ................ ........................-............... Date Application Disapproved for the following reasons:-----•-----------•-------------------------------------•--------------------•--•----------------------•••....--- ---------------------------------•••---•-.....--••••-••-------••••--•-•-•--------...•--•-------...-•----•---•••-•...•-•----••-••-----•----------------•--•-•------------••...••---•-----•••------•...--- Date P q- Permit No. Issu �'2► k�.. �_.... No......................... FE$..........................._. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH"' ..............o .n -1,��.: .... ApplirFa#ion for Diipn,a al Works Toxw1rurtiun Prrutit ~ Application is hereby made for a Permit to Construct or Repair ( ' ) an Individual Sewage Disposal System at: _ ow!!�-< % ` .,-/ <f 7"-./ -ETC✓/�'� --••- _--.-J• -•-......•. ..... ...3.....<................ ....... ••. --•-•..--... .................._._....-• -•-- •-•----•----•...................-•---......... i mf a :�A f s er or Lot No. -� •. ................•-- .... .... -•-•-•......----......._.............................._..._ ..._.......••--•••••••----•.....•-••••....-•-•••-- ........•-•--................................. Owner Address - -----------------------------.......................Z................................. ----------------_...._................. Installer g Address Type of Building Size Lott�r�_ _ ....Sq. feet U Dwelling—No. of :Bedrooms...........-:5..........................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—Type of Building .__..1-...J ...... No. of persons........��.............. Showers ( ) — Cafeteria ( ) Other fixture"s- -----------------------••---•--• -41 W Design Flow................`..........._..._....__gallons per person per day. Total daily flow....... . ...................gallons. I s� 9Septic Tank—Liquid capacit &n=..gallons �Length-4/. _......-._ Width..-�._-..... Diameter................ Depth..... Disposal Trench—No..................... Width- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......./........... Diameter '././_ j Depth below inlet..4.............. Total leaching area..................sq. ft. Other Distribution box ( ) Dosi g tank ( ) Percolation Test Results Performed _ _ "~' !...................................... Date... ,.a Test Pit No. 1---..........-minutes per inch Depth of Test Pit,/-. C/........ Depth to ground water_.,. /`r.*......... (i, Test Pit No. 2.g::�-_z--minutes per inch Depth of Test Depth to ground •---•-•---------------------------------------•-•••-•••...........•••------.............••••---•--....••••-•••••••-•-•--•...----••............-•...•--....•. O Description of Soil...�.��__-�`/ �/...`M.:. - .__-170 / � -------..-----•--••----_.. ... . •----•--•---•--•••••---------•••--•••-------•••------------•......------•.....-•-••---•- U --------•-•-•••- .......................................................... UW ........................................................................................................................................................................................................ Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..--•--------------------------------------•••--..... Agreement: The ttridersigned agrees to install the for cls� ibed Individual Sewge Disposal System,in accordance with the provisions of TTTI E 5 of the State Sanitar Cod — Th d er aree�not to lace the system in p g' � g p Y operation until a Certificate of Compliance has been e fPoa of h Signed...... --------•-- ...................... -`................................... ................................ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons--------------•----------------------------------------------•---------------•--•------------•--•......••...... ••-------•...-•...........:....•-----••-------•-----.........-•-••••••-------•----...----•------•........---•-•-----•-•••-••--•-••••-••. .------•-•--•.............................. --•--•----• Date Permit No......................................................... Issued...+ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH •� 4'` Cs'�.'..............OF, �. s l / ......f......./ C9rrfifirab of f��aut��i�tnrr THl >;S T Y That the Individual Sewage Disposal System constructed (V) or Repaired ( ) by.............. ... .••. at..................................................................................................................................................................................................... has been installed in accordance with the provisions of T�qa.,-,,-50 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 SATISFFA TO DATE.......... . Y. = -•-----------•--•Inspector THE COMMONWEALTH OF MASSACHUSETTS ,•... BOARD OF HEALTH ����.; . fin �-!S �lb ., , ................ .. oF... . :................................................... 3 S No......................... FEE........................ Permission is �t��r�r� rn�k� #rltr�uv�n Prutif ebY g ........................(ed ..- .......... to Constuct ( i) e�151al S aD is o syAX,1,;, atNo................................................................................................................................................................................................ Street as shown on the application for Disposal Works Constr t _._...___._ .__. •.................................... DATE---------------- ............................... . Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS V71, m -' - .t`." + ' i 'i'l 47 '� ► cam ,, #�• — . r9D 4 �C3 P :" +Yi',A/� / ,•�"Q++i •••, -```�� 47 � """ �.�1�S 1g f�C-. ., _ t _ t lo7'? cr1'r �ij j -a✓F... - r,a �`'1r / "�+.� / t" '"--`•� I Sr.=J t } e. //• Q� h1�9�/h'O� �S � G O!/��S 'T o ,B,�` .e}v/G y-' To GU i rti/�/ Ay6Ae •�..'. �Vc ScN �o __3 M��. .or rc.�-,!%t�'%.r7" E'G�v�C �o" �a=��'•�.E�9.STo..rE' ,� r/�: . ITC/�//T N�✓ / �� + ` /oo /�vvEer� po. �4 G�9� _oA/ /•vt�EQr` .S� !PIS /NEE � � UT d' . �� �Io / ivvE,e> s ErpT�c T�Ar� n o„ /A✓ _4Z.4e ' Yvf,",SVMP . G}O '..pp �P' �V p.a �� 'k �I� °:Q /D� G'.9.2B'gG� I"'-'—.35^ ----� �-/�� '•'; �� 0. Q�?: EG�v .cso-rror�.c. /A/ G r T' .Q � r � O •� 0 0 �����• P R O f l LE OF /a'a•. SANITARY DI SPOSAL SYSTEM DESIGN DATA NOT TO SCALE BEDRO.OMS CONSTRUCTION OF SANITARY DISPOSAL DESIGN FLOW -'�30 GALIDAY C SYSTEM SHALL CONFORM TO MASS . LEACH RATE .,� Z,_.... MIN./INCH e% ENVIRONME -NTAL CODE TITLEM PROPOSE.D LEACH CAPACIT Y : AND THE TOWN OF f. HEALTH REGULATI ONS. �fc�T` :' 4��'/�//rn/ ! `��►!�+ r� f:?f`- �/ 1��rs;/ :; '/" `/` r`'r G A L./D A Y[[ g7- o 7'/<g r 7- . c 1J"7""/0 SITE PLAN SHOWING /.� PROPOSED CONSTRUCTION F • III A J i T " / • /. 1�..I�I LO•CAT1ON � FOR • I;;, , 4s6//440 t. .z APPROVED 19 sCALE. �' ` � '� DATE '' BOARD OF HE ALTH � . R E F E R E N C E / � - . ,%►'EC.1'`.� .�` DATE A G E N T �' ► 47 ram`, ' '� ���` ,. �- -•�v tip. J . M. M O N A H A N, J R . ASS O C I A T E S ,+J •al r!-f -' REGIStEIRED LAND SURVEYORS & ENGINEERS ,,.,,,�•.,,mod, ". < : �:'�/ �,��;�.. , fo51 MAIN STREET DENNISPOR-r, MASS. 02639