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Home My WebLink About4464 FALMOUTH ROAD/RTE 28 - Health 4464 Falmouth Road/Route 28, Cot)'-'it apt ® l �� 0 1jl P 1 I '( x I 1, THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M A� 'L DATA - . ._..:�arw�. -.Yrrr ,Z'y�'3"k<.{— .- :,.�,.4 ..rr;ssvx•'r�'-r*-�.;-.:w-;-.i+rrT'j.I"y-r�'a:-r*f+'.v_� 'xiwa�7`,""e� .rys TOWN OF BARNSTABLE BAR-W 5953 Ordinance or Regulation � l WARNING .NOTICE �/�� j YAI Name of Offender/Manager !'JJpthprT ,., n.r, Address of Offender MV/MB Reg.# Village/State/Zip f,> . . ty-A ON, �� Business Name P 1; ' fir, ani`/pm, on to`fr ?/20Z17 Business Address �:�'xj � �� ,_4<7> I? r St,gnature-of `Enforcing Officer Village/State/Zip r� } Location of Offense Enforcing/,Dept/Division Offense %;..�=•� r�-rr �J� fxrP � Facts ! Q(le r w;'�)5 1' er! „ , 4 ("r f0 Ca le7 This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR-W 953 Ordinance or Regulation WARNING NOTICE d ' 1.2/Vle. jr, I Name of Offender/Manager fs µ i i Address of Offender L (f MV/MB Reg.# Village/State/Zip 5.S _ Business Name- fe" am/pm, on � f20 Business Address ..Signature of Enforcing Officer Village/St ate/Zip Location of Offense Enforcing" Dept/Division Offense Facts This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. - Education efforts and warning notices are attempts to gain voluntary compliance. _Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM_ PART A CERTIFICATION Property Address: 4464 Falmouth Road Cotuit, MA 02635 Owner's Name: Norbert&Mary Crothers S tQ Zb Owner's Address: Date of Inspection: September 16, 2007 Name of Inspector:(Please Print) James M. Ford Company Name:. James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate.and complete as of the time of the inspection. The inspection was 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: f ✓ Passes r r. Con ktionally Passes. - Ne s urther Evaluation by the Local Approving Authority , Val s G Inspector's Signature: Date: September 25. 2007 c�« r The system inspector shall subs a copy of this inspection report to the Approving Authority(Board Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design fl�f ow 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. 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: 4464 Falmouth Road Cotuit, M.4 Owner: Norbert&Mary Cr^others Date of Inspection: September 16. 2007 Inspection Summary: Check A,B,C,D,or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any infonnation 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 detennined(Y,N,ND) in the for the following statements. If"not detennined",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 J Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4464 Falmouth Road Cotuit. MA Owner: Norbert&Mary Crothers Date of Inspection: September 16 2007 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 airunonia 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 f Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4464 Falmouth Road Cotuit MA Owner: _Norbert&Mary Crothers Date of Inspection: September 16 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded'or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6'.'below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds . indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to detennine 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. 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat or answered "yes"in Section D above the large system has 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 lof 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST k, Property Address: 4464 Falmouth Road Cotuit: MA Owner ,, Norbert&Mary Crothers Date o !Inspection: September 16, 2007 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 s 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. ✓ _ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert&Mary Crothers Date of Inspection: September 16, 2007 RESIDENTIALFLOW 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is,laundry on a separate sewage system(yes or no): rda [if yes separate inspection required] Laundry system inspected es or no rY .Y p (Y ).. 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: Currently occupied C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of dc:sign flow(seats/persons/sgft,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: Pumbed in 2005 Was system pumped as part of the inspection.(yes or no): No If yes, volume pumped: _gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF-SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Pri-✓y 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); Approximatc age of all components, date installed(if known)and source of information: Installed on 1217188-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 . t Page 7 of 11 OFFICIAL INSPECTION FORM`-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '. SYSTEM INFORMATION(continued) Property Address: 4464 Fabnouth Road Cotuit, MA Owner Norbert&Mary Crothers Date of1Inspection: September 16 2007 a+ BUILDING SEWER(locate on site plan) Depth be low grade: Material,of construction: _cast iron _40 PVC other(explain): Distance[from private water supply well or suction line_ Cornnen'6 (on condition of joints,venting, evidence of leakage,etc.): { SEPTIC a,rANK: ✓ (locate on site plan) .Depth below grade: . 6" Material of construction: ✓ concrete _metal fiberglass _polyethylene _other�(explain) If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimension's: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thic�'�ness: 1" Distance f om top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions detennined: Measuring stick Coimnentst,(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related too outlet invert,evidence of leakage, etc.): Tees wer•e,`present. The liquid level was even with the outlet invert There did not appear to be any s igns of leakage f GREASE TRAP: None (locate on site plan) Depth beloN grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain):_. p Dimensions: Scum thic0less: Distance from top of scum to top of outlet tee or baffle: Distance fr inn bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(ion pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to+outlet invert,evidence of leakagb,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4464 Falmouth Road _ Cotuit. MA Owner: Norbert&Mary Crothers Date of Inspection: September 16 2007 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) Colruments (note condition of pump chamber, condition of.pumps and appurtenances,etc.): i 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert&Mary Crothers Date of Inspection: September 16 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -4'x 6'(600 3W)w/3'stone-per as built card 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 had Y of liquid on the bottom The scum line was at the same level There did not appear to be any signs of allure. 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): Continents (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 `f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert&Mary Crothers Date of Inspection: September 16 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. l a a 3 a 1t 3a 3 T� Y� 10 ,, •- Page 1 I of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4464 Falmouth Road Cotuit, hL4 Owner: Norbert&Mary Crothers Date of Inspection: September 16, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from-system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_ topographic and water contours naps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+/ to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the septic system, the inspection, this report andlor any components of the septic system which have not been located and inspected. 11 r Town of Barnstable OF tHE Tp� Regulatory Services , STAB Thomas F. Geller, Director 1639. A•�� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 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/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s 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 Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. r , 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERrTIFICATION Property Address: 4464 Falmouth Road Cotuit, MA 02635 t Owner's Name: Norbert Crothers E i - I,�/ --s Owner's Address: S�9 �J ` / Date of Inspection: August 2. 20054' J ` Name of Inspector: (Please Print) James M. Ford ra - , Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 rK 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 Fails Inspector's Signature: % Date: August 13. 2005 . The system inspector shall sub 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 1.0,000 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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION (continued) Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 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 1 4 5 303 or in 3 1 0 CMR 15.30 exist. An failure criteria not evaluated rbelow.y a e mdicated Comments: B. System Conditional) Passes: Y Y 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 1 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: Aujzust 2. 2005 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: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question.in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 t Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after the inspection for maintenance 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 on 1217188-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: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 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: 6" 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 Qal. Sludge depth: 2" 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: How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was pumped after the inspection for maintenance. The tank had roots growing inside. The owner had Ready Rooter remove the roots from the tank on August 9, 2005 (per owner and invoice). GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4464 Falmouth Road Cotuit. MA Owner: Norbert Crothers Date of Inspection: Auzust 2. 2005 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4464 Falmouth Road Cotuit, AM Owner: Norbert Crothers Date of Inspection: August 2, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -4'x 6'(600 gal.)w/3'stone-per as built card 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 had 3'of liquid on the bottom. The scum line was at the same level. There did not appear to be any signs of failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 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. 6 4�a�k 6 rl��• r a o 3 a ! R 30 j y 3 as 3y `f 3 y W 10 � r Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4464 Falmouth Road Cotuit, MA Owner: Norbert Crothers Date of Inspection: August 2, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 25 +/-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 1 _ 7 Commonwealth of Mossochusetts Executive Office of Environmental Affairs a Department of API? o 199Environmentat Protect To Wllllarn F.Weld 130"Mor Trudy Coxe Mgeo Paul Calluccl ��, 'Swum u kloa.n,or0 cc Z i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C PART A �� CERTIFICATION Property Address: 4464 Falmouth Rd`Cotuit MA Address of Owner: same Date of Inspection: 2/11/97 (If different) Name of Inspector: Frederick Kiely ' Company Name, Address and Telephone Number:Environmental Reclamation,Inc. 446 Waquoit Hwy. Waquoit MA 02536 CERTIFICATION STATEMENT (508) 457-5020 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XXXXX Passes _ Conditionally Passes C _ Needs Further Evaluation By the Local Approving Authority _ Fails . Inspector's Signature: Z�W Date: 2/11/97 The System Inspector shall submit a copy of this ins ion report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design Flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: XXX I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septictank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95)' 1 One Wlrtter Street a Boston,Massachusetts 02108 • FAX(617)556.1049 • Telephone(617)292"SSoo w iJ Pnnted on Recycled Paper • l 1 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {R PART A CERTIFICATION (continued) / Property Address: ,• '�� + ` Owner. "' Date of Inspection: B]SYSTEM CONDITIONALLY'PASSES (continued) N/A Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) .SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT- - The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteri a 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. 3) OTHER N/A (revieed.11/03/95) 2 f f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1, PART A CERTIFICATION (continued) Property Address: 4464 Falmouth Rd. Cotuit Owner. Bonnie Campbell Date of Inspection: 2/11/97 D] SYSTEM FAILS:N/A I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ _ Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: N/A The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' / PART B (. CHECKLIST Property Address: 4464 Falmouth Rd. Cotuit Owner. Bonnie Campbell Date of.Inspection: 2/11/97 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. X' None of the system components have been pumped for at least two weeks and the system has been receiving nominal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. IL As built plans have been obtained and examined. Note if they are not available with N/A. _X_The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System, have been located on the site. .2L_The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for`condition of baffles o tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. -3t.-The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C 1 SYSTEM INFORMATION Property Address:4464 Falmouth Dr. Cotuit . Owner: Bonnie Campbell Date of Inspection:2/11/97 FLOW CONDITIONS RESIDENTIAL: Design flow: -Jan gallons Number of bedrooms:•_ Number of current residents:. Garbage grinder(yes or no): N Laundry connected to system (yes or no): Y Seasonal use(yes or no):N ' Water meter readings, if available: .AAA At•tanhmpnt Last date of occupancy: cnirr nt COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: aallons/day 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 OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: see attachment System pumped as part of inspection: (yes or no)_np If yes, volume pumped: gallons Reason for pumping: periodic maintainence TYPE OF SYSTEM .yA 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: compliance issued: 12/07/88 nn f i l p at 1BOH Sewage odors detected when arriving at the site: (yes or no)_Qne �' (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4464 Falmouth Rd. Cotuit Owner: Bonnie Campbell Date of Inspection: 2/11/97 SEPTIC TANK:_ (locate on site Tian) Depth below grade: 2 feet Material of construction: XXconcrete _metal _FRP—other(explain) Dimensions: 11 000 gal Sludge depth: none detected Distance from top of sludge to bottom of outlet tee or baffle:N/A Scum thickness: none detected Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Comments: -' (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid.level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Tha 1-ank and tha T. ara in rzxrP1 1,zni- rnneli t-i nn Tha ac�a1-am has been properly .constrict an main acne GREASE TRAP: .N/A (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART C ` SYSTEM.INFORMATION (continued) Property Address:4464 Falmouth Rd. Cotuit Owner: Bonnie Campbell Date of Inspection: 2/11/97 TIGHT OR HOLDING TANK.- N/A (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons ' Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: XX (locate on site plan) Depth of liquid level above outlet invert: 0.5 inch Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The distribution box is level. There is no evidence of solid carryover-or ea PUMP CHAMBER: N/A (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) r (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4464 Falmouth Rd. Cotuit Owner: Bonnie Campbell Date of Inspection: 2/11/97 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 1 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: . Comments: (note condition of soil, signs of hydraulic failure level of ponding, condition ff egeta'on,etc.) The leaching pit is constructed of precast concrete/ gay There are no signs of ponding or stressed vegi a ion present CESSPOOLS: N/A (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_N/A (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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4464 Falmouth Rd. Cotuit MA Owner: Bonnie Campbell Date of Inapecti0n:2/1l/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' See attachment DEPTH TO GROUNDWATER Depth to groundwater. feet method of determination or approximation: The estimated depth to groundwater is based on the surface water elevation of Lovells pond (21000 feetY and the property elevation t en rom the United States Geological Survey (USGS) 1974 Cotuit Quadrangle i (revived 11/03/99) 9 f `fir C ccl� qZb - 2Z9q TOWN Or. 13ARI4STABu. LOCATION 446!�Falmouth Rd., Santuit _ _ SEWAC,N T 2 VILLAGE S'�i�`. , t ASSESSOR'S MAP & LOT _ INSTALLER'S NAME & PHONE NO._'JY "' Af: I SEPTIC TANK CAPACITY �'.D' LEACHING FACILITY:(tyPe)_____60-Q- (size) NO. OF BEDROOMS ___PRIVATE WELL OR I`UBLIC WATER BUILDER OR OWNER %c DATE PERMIT ISSUED: I " DATE COMPL.IA.NCE ISSUED_ VARIANCE GRANTED: Ycs / / '✓ I 1094 PROMPT HICKEY SEPTIC SERVICE JOB PHONE OAFE OF ORDER PROFESSIONAL SERVICE P.O. BOX 2078 8-2 4-9 6 TEATiCKET, MA 02536 JOB NAME/LOCATION (508) 790.4888 (508) 540.7650 Fax (508) 540.3907 TO Campbell ..............._...........:................... ................................................... ... .. .... . PHONE 4�i64 Falmouth Road 11 .....4.2,8.-.2.2.9.9....... ......... ........... ... .....__....................._.............................................................. ORDER TAKEN BY Cotuit, MA 02635 rEPMS. Payment Due Time of Service DESCRIPTION AMOUNT Ma.i.nte.nan.c.e._.Pum.p.i.n0............_.._-. ........ _.... .... ............................................................. �........... .......... ............ ........................... ................ ......._..... . .._� .. - �..........._...._ .... ..._.......... . . . LABOR I HOURS I. RATE AMOUNT TOTAL MATERIAL TOTALLABOR `.vORK ORDERED BY DATE COMPLETED TOTAL TAX LABOR PAY THIS AMOUNT-► `?"hank`You SIGNATURE(I hereby acknowledge the satisfactory completion of the above described work.) SERVIC K ADDRFS3 1PREV10UyLAN C'E t.. 4484 FALMOUTH ROAD 1612 _ _� uG i PERIOD COVERED CURRENT METER PREVIOUS METER GALLONS - S CURR.ENT PROM TO READING READING CONSUi4IPTLON CHARGES 09/3U/95 10/Ol/96 252000 197000 55000!, r MISC.DESCRIPTION ! MISC.AMOUNT ANNUAL MINIMUM: ! 40 M GALLONS ALLOWED 40000 - 8T 0 i Q5 ! 2 . 45 PER 0 GAL . TOTAL 0* ' MISCELLANEOUS CHARGES BILLS UNPAID 60 DAYS AFTER ISSUE DATE OF ISSUE TOTAL ARE SUBJECT TO 10%LATE PAYMENT CHARGE 1 l� /01/9 6 AMOUNT DUE ~ } }n ! S ESS SM"CE NO_ .: PREVIOUS 4--- 64 FALtiouTH ROAI) 1612 BALANCE 0 CURRENT METER PREVIOUS METER GALLONS CURRENT FR READING READING CONSUMPTION CHARGES ---.-- __CRIPTION _ OU_NT__ ANNUAL MINIMUM: f 40 M GALLONS ALLOWED 7` ' 0 0 � I I I I � I I ! 1 TOTAL 00 ; MISCELLANEOUS CHARGES / I BILLS UNPAID 60 DAYS AFTER ISSUE DATE OF ISSUE l T t 1 TOTAI. ARE SUBJECT TO 10%LATE PAYMENT CHARGE 0 3/01/9 5 AMOUNT DUE SERVICE ADDRESS 5ERVICE No. PREVIOUS 1612 BAI_ANCEi 4-164 FALMOUTH ROAD PERIOD COVERED CURRENT METER' PREVIOUS METER GALLONS CURRENT FROM TO READING READING CONSUMPTION CHARGES 09/30/93 10/01/9 16200 9900 63000 j MISC.DESCRIPTION MISC.AMOUNT ANNUAL MINIMUM: i 40 M GALLONS ALLOWED I � ! 40000 - 80000 1 56 . 35 2 . 45 'PER 1000 GAL . _ 1 ( TOTAL 0,I \4ISCELLA_NEOUS CHARGES A BILLS UNPAID 60 DAYS AFTER ISSUE DATE OF ISSUE TOTAL I 56 . 3 ARE SUBJECT TO 10%LATE PAYMENT CHARGE l 1 1/0 1/9 4 i AMOUN'C DUE ! I f SERVICE ADDRESS SF:RVICRNO. PREVIOUS BALANCE GOV — CURRENT METER PREVIOUS METER GALLONS 1 FROM TO READING READING CONSUbIPTION CURRENT CHARGES 0 700 1 MIS_ S -IPCION C_AA40UNT ANNUAL,MINIMUM: 40 M GALLONS ALLOWED f 40000 - 80000 I7 . 1S ALL OVER 80000 _ 2 . 70 PER 1000 GAL. I 0 . 00 TOTAL mo MISCELLANEOUS CHARGES BILLS UNPAID 60 DAYS AFTER ISSUE I DATE OF ISSUE ARE SUBJECT TO 10%LATE PAYMENT CHARGE } 1 01 9 3 AMOUNT DUE N* 1�. j t� w Ln THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Frederick Kiely Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. December 12 ,1995 Acting Director of the ' ion of Water Pollution Control YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates[cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. rs DATE: Fill in please: APPLICANT'S YOUR NAME/S: 1 A F t !(B,y SIN r YOUR HOME ADDRESS: .� , r $rrraF TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS PE OF BUSINESS �h IS THIS A HOME OCCUPATION? YES NO _ �cmSf�. ADDRESS OF BUSINESS f MAP/PARCEL NUMBER (Ass ing When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual ha e n infor a oft er it�re ents that pertain to this type of business. Authorized Sig ature** MUST,64MPLY WITH ALL Inn COMMENTS: - ;7-A.RBAWS MA-TERIA66 Rr!6W64IeIi'8 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF Bf�RNSTMILE c l.Or°ATION �1 n I• R�• ; SEWAGE # 6�' 710 =PILLAGE C OT�ir' ASSESSO 'S MAP & LOT d�y OT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 LEACHING FACII.ITY: (type) �,� yX�'� (size) NO,OF BEDROOMS 3 BUILDER OR OWNER C rat f PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leachi�-g facility) , J ;~eet a Furnished by �/1 SOc. 1 e•, .3 FD/G 1 a l 30 y 3 as 35� TOWN OF SARI STABLE.47% ' LOCATION_ 446 almouth' Rd., Santuit _ SEWAGE # VILLAGE Sefh4v . ¢ _ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.^'J 4" SEPTIC TANK CAPACITY LEACHING FACILITY:(type) C61)0 (si7.e) ��✓� _ NO. OF BEDROOMS _. PRIVATE WELL OR rUBI.IC WATER S ' BUILDER OR OWNER DATE PERMIT ISSUED: - DATE COMPLIANCE ISSUED: �� -_.?� 5, ld VARIAPdCE GRANTED: -Yes tIo i r �- - .�.. f�_.�.® p hP �. , � ` `` � �� ,�� l j � � � � r / � �'., � � D � �� \ � � �� `�. 9�' �� F�$ �7._.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratiou for Uhipu,i al Works Tonstrurttuaa ramit , Y Application is hereby made for a Permit to Construct ( ) or Repair (V/ an Individual Sewage Disposal System at: Location-Address or Lot No. /1 ,//r1_lr�.... -------------------------------- --- Installer ` Address Type of Building Size Lot............................Sq. foet U Dwelling—No. of Bedrooms........... .......... ________________Expansion Attic ( ) Garbage Grinder/ ) Other—T e of Building ........................... No. of persons____________________________ Showers — Cafeteria Ot�e-r�fixbires--------------------------------------------------•---' W Design Flow...._ ...................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons ., Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date...................................... Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2________________mi tes per inch Depth of Test Pit.................... Depth to ground water........................ x ._..... ----- --. --- OA� Description of Soil--� •••-••.••-•-----•••--•--------------------------------------•----•------•----••---•---•••--•-----•••-------•-•-•-••---•-••--•----•--•----------------------- UW ----•---------------------------------•----•----•-------••-•-'._...._____-••----•--•--------__._....---•^---.._._---.._ _--.................................... --ram Nature of Repairs or Alterations—Answer when applicable.--- --.__ ��'�^_l� � � ��1 � -- ---------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLi4 5 of the State Sanitary e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b i ued by t oa ealth. Signed . .. ............ •--..._....._--- Date Application Approved By•••--•-• "' `t"^- ......... ` --- Date Application Disapproved for the following reasons:....................................................................................-----•--••--------•------ -----------------------------•-----•-•--...----------------..._..---------------•-•--------._..__..---..---•-•-----.•-..--------------------------------------------------------= = Date PermitNo..........D.. .-.._7/- --................. Issued....................................................... Date No.. ...1...L60' FEE/ .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ............................OF.......................................--------------...------------...._................. ApplirFa#ioaa for Disposal Works Toaaotratriioaa Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (k<an Individual Sewage Disposal System at: oca ion.Address or Lot No. ................ � 1 . A... a cQ �.d...._. . ------ / --------------- a 11mP ---- `l "—=e.........-•-•.............................. C- _ l ., ....h? L /�!�i -----r�-_!F--- --•------ ------------------ Installer Address Pq Q Type of Building t� Size Lot-___------•------•--------•-Sq. f t U Dwelling No. of Bedrooms...........d-�....................•........Ex Expansion Attic a g— p ( ) Garbage Grinder p,l Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Oter fixiNres •-•••-•••--•----•------•--••••-•••-••---••-••-•-•-•-•-•-•-••................•---------- ----•-------••-•-............•-•--•......•-••-...........--•• W Design Flow..................................gallons per person per day. Total daily flow..................... WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.........._.........sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ pT4 Test Pit No. 2.......�nntes per inch Depth of Test Pit.................... Depth to ground water......................... O ------ ---------- - ---•-- - -•----------._...--•--•---•........ --•-•-•-•-----.----•---•------•-------.-------------- --Description of Soil..-=--- ---•------....------•-----•-•----•--......----•------•----------------- -----------------------------•._---------•-----------------•----- V -•--•-•-•••---•••••••-••••••••••••••••.....-•--••----•----••-••-•••••-•-•---••••••...•---•---•-•-•-- ' �_ �. --------- ............................. W ...........................•------------------------------------------------.........-•--••-••••••-- ..` r U Nature of Repairs or Alterations—Answer when applicable_-...---_ � "---_.��_. "t"V �,_.ft--------_.,�_f -- .------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n is u bd yytjK5dNded-4iealth. •-•- .... Signed••••• • .. • - Date ApplicationApproved By-•-•-•--•-•-•••-••••-•-•••-•.......•--••--•.............•-•----•----••---•----•-•-•-••......-•--- ........................................ Date Application Disapproved for the following reasons---------------------------------------------------------------•-----------------------------------•-------••-- •-•---•••-••-•--•-•....-•--•-••-•-------•-••-•••----••••-•-•-••--••-•-••---•-•--•----•--•--•-•••---•-•--•................................................................. ............................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of TootpliFattrr T S 'S O TIFY, That the Individual Sewage Disposal ystem constructed ( or Repaired ( ) f. staller at........................ F. :�&_•-----• -----•-- .._... has been installed in accordance with the provisions of T TLr; 5 The State Sanitary Code a. 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 COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J _ OF..............................................._..................................... No..!............. FEE.....................--- �to�oo.�aor� k � rZ ,��r�tr�tton Trott# Permission is reby granted., ..----------'-='n.... to Construct ( Repair Idtv� alFSevcrae D' posal System Street " as shown on the application for Disposal Works Construction Permit No.._ ,; ated..__ ,.:, :.. ................ ]hoard of Health DATE /------- -------- ..... ---------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 1