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Home My WebLink About4810 FALMOUTH ROAD/RTE 28 - Health 4810 FALMOUTH RD, COTUIT A= Uv 9 t 1, i I d 1 � i f bo q ow ---01 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . ....... 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is COTUIT V MA 02635 02/25/2021 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5( 5a(P�-- on the computer, JR use only the tab OHN P GRACI S key to move your Name of Inspector cursor-do not GRACI SEPTIC INSPECTIONS LLC use the return Company Name key. PO BOX 2119 Q Company Address TEATICKET MA 02536 City/Town State Zip Code 508-548-7500 S1468 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Eval iation.by the Local Approving Authority 4. ❑ Fails 02/25/2021 Inspector's Signature Date The system inspector all submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)withi 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, t e inspector and the system owner shall submit the report to the appropriate regional office of the DE . The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: AT TIME OF INSPECTION THE SEPTIC SYSTEM PASSES TITLE 5 2) 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): NA t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is COTUIT MA 02635 02/25/2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): NA ❑ 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): NA 3) 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. a. 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: t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '' 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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: NA 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. c. Other: NA 4) 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 t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4810 FALMOUTH ROAD W6 Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/2 day flow 0 ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doe•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 -commonwealth of Massachusetts Title 5 Official Inspection Form '; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No T ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: INFORMATION TAKEN FROM INSTALL CARD DATED 11/22/96 Number of current residents: VACANT— Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gP ))� Detail: 2019-46000 2020-21000 Sump pump? ❑ Yes ® No Last date of occupancy: APRIL 2020 Date t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: NA Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NA / Last date of occupancy/use: NADate Other(describe below): NA 3. Pumping Records: Source of information: WINDRIVER 2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: MAINTENANCE t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form yt Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code 'Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source ofiinformation: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3'6"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s dy 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NAyears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 1500 GALLON SEPTIC TANK Sludge depth: 41- Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness ZERO Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AT TIME OF INSPECTION. RECOMMEND PUMPING EVERY 2-3 YEARS DEPENDING ON USAGE. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tea., 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert BOTTOM OF PIPES 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.): DISTRIBUTION BOX APPEARS TO BE FUNCTIONING PROPERLY AT TIME OF INSPECTION. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form .�I� Subsurface Sewage Disposal System Form-Not for Voluntary g p y Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NA Type: ❑ leaching pits number: NA ® leaching chambers number: 2-500 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500 GALLON LEACH CHAMBERS WERE EMPTY AT TIME OF INSPECTION. STAIN LINE INDICATES NEVER MORE THAN 8". 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Yla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s �s. y 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' 11 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code Date of Inspection Do System Information (cont.) 14. 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 2.27' 2- ZO A u M TANK. ® 2- & �J LE c t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells .Estimated depth to high ground water: 12+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4810 FALMOUTH ROAD Property Address ROGER WITHERS Owner Owner's Name information is required for every COTUIT MA 02635 02/25/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included II f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Naffib information is q' � fD�required for /� �� `7 every page. Cityl I own State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. ✓?/p�� Important: - When filling out A. General Information forms on the . computer,use 1. Inspector: only the tab key to move your cursor-do not Name of lnsp or A,,�,` / /✓ use the return key. Compan Name Company Addr,ss City�/T�orw�n{Q Z State Zip Code u50 � J 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 p ormed based on my training and experience in the proper function and maintenance of on site 4x Er,sewagi disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: M Id asses El conditionally Passes ❑ Fails - c'n ❑ eeds Further Evaluation by the Local Approving Authority In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 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. , ****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. f5insp.doc•08/06 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y~ Property Address `\7 OSgsa-? Owner Owners Name information is required for o every 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: f I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND).in the ❑for the following statements. If"not determined,"please explain. < ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is aVailable. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):- broken pipe(s) are replaced El obstruction is removed tNnsp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts/ , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 6)V11, Property Address Owner owner's Na information is �� required for -b every page. CitylTown State Zip Code Date of Inspection B..Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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: 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: f ❑ Cesspool or privy is within 50 feet of a surface water r ❑ 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: J ❑ 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 t5insp.doc-08/06 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 3'of 15 I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for V luntary Assessments f Property Address Owner Owner's Na information is O� required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): - ❑ 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 col iform " bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.'A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes .No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ �. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 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: ❑ [A Any portion of the"SAS, cesspool or privy is below high ground water elevation. ❑ [j - Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. l5insp.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts. . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Prope Owner Owner sham information is ,� 0 required for every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No - ❑ 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. ❑ X1 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ [ ,the system is within 400 feet of a surface drinking water supply ❑ K 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 youy 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. l5inso.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Volunta Assessments _ Property Agee •_ • Owner Owners N information is required for every 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 ❑ Ptimping.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 El 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? o ,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. ❑ F 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)] t5insp.doc•08/06 Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Page 6 of 15 d" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Volunt ry Assessments b2lX/d IoO Property Address Owner Owners Nam `�/ �� ®� information is � required for every page. City/Town State Zip Code . Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: Does residence have a garbage grinder? ❑ Yes [ . No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes NJ No Laundry system inspected? ❑ Yes W No Seasonaluse? ❑ Yes RT No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes g No , �Zq , O� Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons p r 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: Last date of occupancy/use: Date ' Other(describe): t5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposalstem Form- Not for Volu ry Assessmen 4YI 0 Property`Address �}- _ Owner Owner's Narr information is required for V every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: yti/o% Source of information: � Was system pumped as part of the inspection? ❑ Yes No If,yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) J ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Volu ry Assessments ol Propert�� Owner Owner's Name information is i1 o6 required for t every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron d4o PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 36 u feet Material of construction: Xconcrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes ❑ No Dimensions: '1 Q-� Sludge depth: 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 21I Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? AMi y��' 15insp.doc•08/06 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Volunta ssessments Prop e Ad�� Owner Owners Na information is required for - every page. Cityffown 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 itivert, evidenc of leakage, etc.): E / Grease Trap(locate on site plan): Depth below grade: feet " Material of construction: concrete ❑ metal 'El 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 Comments'(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding.Tank(tank must be pumped at time of inspection)(locate on site plan): • 4 .. - Depth below grade: %� Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp.doc•08106 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15, `Y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -_11VX0 Property Address Owner Owner's Name information is /Z ��7 O� required for !v J! every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ► Tight or Holding.Tank(cont.) 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 ff'No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 6000 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑. Yes ❑ No ` I5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 15 ' Commonwealth of Massachusetts Tithe 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assess nts Property Address _ Owner Owner's Name,"' t �J� information is required for , every page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: 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.): 662:2 � ► t��1/. t5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 12 of 15 Commonwealth of Massachusetts IFS Title 5 Official Inspection Form Subsurface Sewaa)ge Disposal System Form -Not for Voluntary Assee ments Prope essC / Owner Owner's Narrye) information is required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) V 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 e Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑r Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,.'condition of vegetation, r etc.): Privy(locate on site plan): "y" Materials of construction: Dimensions Depth of solids Comments (note condition of soil;•signs of hydraulic failure;level of ponding,,condition of vegetation, etc.): t5inso.doc•G8106, Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 15 _. Commonwealth of Massachusetts NMI . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Volunta sessments Property Addre Owner Owner's Na e information is required for City/Town every page. State Zip Code Date of Inspection D. System Information cont. Y (cont.) 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. e-Ayt- '3 Z 3o�z 4- 6® oa S� 'S .� t5inso.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pane 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Propeity Address �� Owner Owner's Name ., 0� information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: [n'Check Slope Surface water [5/Ch ck cellar Shallow wells 3 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high and water.elevation: ah t5ins9 dnn•n8w Title 5 Official Ingnegtinn Fnan'Suhsurface.Sewage niSpnsal Sv tem-Pkap 15 of 15 No. THE COMMONWEALTH OF MAS TS BOARD OF HEA T �A` , VVfiration for 43hivooa1 A.:ystrm Tonstrnrtion prrmit Application is h reby made fora Per it > nstal ( °� or Repair/Replace ( ) an Individual Sewa e Disposal System at: N - 1 PeE QOC H � 4_,Va(.1, Local -Ad rss No. Q( ` FYI k n(��Sl V1 t Address Designer or Inslaller Address Type of Building _ I Size Lot Sq.feet Dwelling—No.of Bedrooms Expansion Attic ( ) Garbage rinder ( ) Other—Type of Building No.of persons (111 Showers ( )—Cafeteria ( ) Other fixtures Design Flow _� gallons per person per day.Calculated dais flow ,_:�;`=-C) gallons. Septic Tank—Liquid capacity. gallons Length �,'V Width F_I V Diameter Depth r ' 41 Disposal Trench—No. Width 3"Z`P Total Length SI l Total leaching area sq.ft. Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft. Other Distribution box Dosing tank ( ) Percolation Test Results Performed by ',PX 4 klt4j, � .G Date to—' Test Pit No. 1 minutes per inch 'Depth of Test Pit Depth to ground water Test Pit No.2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil 2 4 ; ,�i tSL 11 Nature of Repairs or Alterations—Answer when applicable Date Last Inspected Agreement:—The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code.The undersigned further a ees not to place the system in operation until a Certificate of Compliance has been issued by the Bo rd of Health. Signed f Dat Application Approved - ' Date Application Disapproved for the following reasons: Permit No. °' Issued Date Date ,•'4N 1. Y+b .V ^ • • . , ~ ~ Ro"An^ / . .i - No Z 47 THE COMMONWEALTH OF MASSACHUSETTS. s]- FEE _ 'm3 BOARD OF HEALTHW,jQ ��JJ of : t L t ApVtiratinn for B ilip' n sal ItIystrm Tonstrnrtiun Vrrmit '- Application is hereby made for a Per it t'o install ( �or Repair/Replace ( ) an Individual Sewage Disposal System at: Lorily -Add s. or t Nu. A.. <)wnrr 7 Address aJS rvli nnGL..• , 1 Designer or lnslaller Address Type of Building Size Lot 4W. q.feet Dwelling—No.of Bedrooms Expansion Attic ( ) "iGarbage GVrinder ( ) Other—Type of Building S No.of persons Showers ( )'—Cafeteria ( ) Other fixtures Design Flow 5 gallons per person per day.Calculated daily flow �F gallons. C'V� t „ —� Septic Tank—Liquid capacity-' gallons Length�.�Width" � _Diameter -,,,Depth f5 Disposal ��-�— Trench—No. Width t " Total Length 'o15'I Total leaching area _sq.ft. Seepage Pit No. Diameter Depth below inlet Total leac�ing.area sq.ft. r• Other Distribution box ( Dosing tank ( ) _ � Percolation Test Results Performed by Wail l Date l r 13— �n Test Pit No. 1 �i minutes per inch Depth of Test Pit �tom" Depth to ground water Test Pit No.2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil 24t_I� I��aArL '! Nature of Repairs or Alterations—Answer when applicable F Date Last Inspected Agreement:—The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the A provisions of TITLE 5 of the State Environmental Code.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date v} Application Approved ",� 4 "�. Date AW t Application Disapproved for the following reasons: Permit No. 946 ✓ Issued � e Date Date THE COMMONWEALTH OF MASSACHUSETTS 1Qi1/�i7tkl�il BOARD OF HEALTH Cnrrtifirtttr of(�nmpli�nrr � THIS IS TO CERTIFY, That the On-Site Sewage Disposal System installed ( 1/ ) or Repaired/Replaced (` ) on by Z 2::C,_b ' for at 265e,93 has been constructed in accordance with the provisions of TI E 5 of.Thhee State Environmental Code as described in the �i^application for Disposal System Construction Permit No. . � Z�2 dated '7 J,J6 Use of this system is conditioned on compliance with the provisions set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on ((t � Date DATE Inspector '�1 No.c !,3 THE COMMONWEALTH OF MASSACHUSETTS�' FEErI� ———— BOARD OF "HEALTH x ispnsal 1�3,ystrnt Tomstxnr#inn Prrmit Permission is hereby granted to to Construct ( or Repair/Replaces( ) an On-Site Sewage Disposal stemlocated at f I Street as described on the application for Disposal System Construction Permit.The Applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. I All construction must be completed within three years of the date below. ;Boardldf Health DATE FORM 1255 (REV.4/95) H&W HOBBS'B WARRENrM PUBLISHERS - BOSTON _ THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION I I I T i-- --I -I--i I -�---i--I�-•-;--�-!- _� L-j-I I- I I ! � I i ! i ?- I�� ''>-T ' - - - _ T I I 17 i 1 I T-T I I I , T 7- i I i ----- -�1 I � I, i �Iti f•} , I - — I I tst r — AIA IAH I I _ i I i i T, '-I- L T: I I I ! r i I I I L S YS TEM PROFIL NOT TO SCALE TOP FNDN. FINISH GRADE OVER FINISH GRADE EL . c FINISH GRADE se, ° _ d 2, a FINISH GRADE OVER DIST. BOX - ' OVER TRENCHES SEPTIC TANK h! c, / 'a.PIP 0o ip•.. „ rrlA :o'or4a 12 MAX. 4 M Cor C •'� p, .•• •p.a .A,�y q::Q,o fY '0•,0•v•O.b'"4p'+.3• L.tj ''° __ _ ...._._. _ p TOTAL LENGTH OF TRENCH o a'.PA z OUTLET PIPE LEVEL a 3„ FOR 2 FT. MIN. it I vQ •D c m •... °^° a •o ',9d• ,�a' ,6=• no 0 CA P END f . P C. I. OR PVC TEES '�, ;,� $c'r,.� w� +� r' �� :' t� 7 ® ® ® p EL •,.o o b o �� A: b,a,•d D p� -�' F—y� el ;op:oa. �• �� ® 1500 GALL ON aa. X .0• BSMT FL . PO EL . —4-1, -,;0 : p a.°o a �°� INSTALL ON LEVEL BASE tJ 5a0 GALLON DRYWELL SJJ Z ®°�A' PRE CA S T CONCRETE da iia°b�:o o p 70 a..a ®b —1 /O REINFORCED : •d:a:c,:o.®,:,, •.ap.'d•.b•'d::G,;:�;.; x �;�':4b� o' �':�`'•f°;a ° "•°4 7 `: a.O. P•sY P .0"0 TRENCH SECTION SEPTIC TANK . '�° INSTALL ON LEVEL BASE �,��. •� � %� r/ �: � ��.:� _ NO TE.• EXCA VA TE TO EL EV V. OR 2 L OWER TO REMO VE AL L IMPERVIOUS MA TERIAL BENEA TH THE LEACHING AREA 12" MIN. 4" tIIAM REPLACE EXCA VA TED MA TERIAL WI TH 4� 3 OF 1/8"-1/2„ Q• og '4;d to :AaQ, b'6;a,':o;A �r :' WASHED PEASTONE � CLEAN, CLAY FREE SAND � �„. ''�'. �.•n•' q •Q y _ 4` / 8 3/4" 1-1/2" OVA SHED CRUSHED STONE ,. f r /, oaf-9 N TRENCH WID TH 1. E fv°S SHOWN ARE BA ON ASSUMED NUMBER OF TRENCHES ? �+°Savinelle ( ALL EL VA TIO / — 0 o d � � •� 2. ALL PIPES IN THE SYSTEM MUST BE OAST IRON NUMBER OF DAYy✓EL L S 2 ---gymm ,�y A� G�qF'°bi('�0 y� OR SCHEDULE i! Pis. - 029SER VA TION Pr T p Pond / �p S 'O P—.J'6V t °° 3. THE BOARD OF HEAL TH MUST BE NOTIFIED B i�"HEN . 'e"3N5TRU�° °IiN IS COMPLETE PRIOR ,. TO BA CKFIL L ING PERCOL A TION RATE.' 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <2 MIN./IN. \ sQ a WITNESSED 8 Y.• 8Y THE BOARD OF HEAL TH AND CAPE C ISLAND S SURVEYING CO.. rAlC. TOM MCKEAN 5 MA TERIALS AND.: INSTALLA TION SHALL BE IN ` \o C®MPL IANCE KITH THE STA TE sANI TARY BARNS BRO. OF HEALTH DESIGN�(y� �� T� �Fin'neo 5� 'a Rd Q o CODE — TITLE V AND LOCAL APPLICABLE DA TE:• ✓UNE�13J_ 9888 ' RULES AND REGULATIONS /U 2 6. NORTH ARROW IS FROM RECORD PLANS AND 0 NUMBER OF BEDROOMS -� IS NOT TO BE USED FOR SOLAR PURPOSES GARBAGE DISPOSAL NO TOPSOIL G GAL . N d 7. FLOOD HAZARD ZONE C (NON--HA2AAD> __ SUBSOIL DAILY FL Oi►l � GA L . 1 8. WA TER SUPPLY. �—a„" , ,�, ,,� �. SEPTIC TANK' REG 'D. 1500 01 LoT 26 SEPTIC TANS' PROVIDED 1500 GAL . 4 �'- L EA CHING REGUIRED 930 GPO. MEDIUM 4.4 SAND SIDERALL AREA = 152 S.F. 152 S.F.X 0. 74 G/S.F. 112 GPD. BOTTOM AREA = 329 S.F. LEGEND 329 S.F.X 0. 74 G/S.F. = 243 GPD LEACHING PROVIDED 355 GPD NO GAOUNONA TER -- PROPOSED EL EVA TION 156 •s- � ;, zo.� _?>� /".r . EA _ 2a/ - " ' --- EXISTING CONTOUR SINGLE FA MIL Y RESIDENCE 6 OB SERVA TION PIT DISTRIBUTION BOX PROPOSEDE DISPOSAL SYSTEM 1 . , _N T PREPARED FOR SEPTIC TANK � JA SON ROSSI ✓fir. .. LOT 2 (HOUSE 4810) ROUTE 28 RE ERVE AREA -- �T UI T — MA SS. �— DA RNS TA BL E CG PIE INVERT ELEVATIONC DA Tom• i-/�f �� ,f��'� CAPE G ISLANDS ENGINEERING PLOT PLAN �� zrts SCALE AS NOTED 133 FALMOUTH ROAD - SUITE RE—, SCALE: 1 N N ` % `lam MASHPEE MASS. nnpp,,tt L\1 � • S YS TEM PROFILE NOT TO SCALE TOP FNDN. ` FINISH GRADE EL . <s"9, o se, o - �s- ca FINISH GRADE OVER FlNrSH GRADE OVER FINISH GRADE DIST. BOX - � , OVER TRENCHES SEPTIC TANK_: y Q � 12"' MAX. Q OUTLET PIPE LEVEL TOTAL LENGTH OF TRENCH =� ' o.o.o•. .o•.•o'Pu a 3'„ c"ON FOR 2 FT. MIN. _ ti :p V :Q. :b. a ;�. ,w}. a o• p'� �qq .D.o°gp. 440 �.. 6" o p: -. '4 O �� a • Ooot�fa01 0 � a :b•::*. c° :• 9r CA END dt — • C. I. OR PVC TEES v G ,'._.C•-`" " Q .. �'9 5 0di ® ® o LP P• % ° ° 1500 GALL ON DISTRIBUTrON BOX BSMT FL EL . . "" o 9 T'NSTALL ON LEVEL BASE „500 GALLON DR YWEL L.S " PRECAST CONCRETE ; H /0 REINFORCED ° Q• r b� , �.__�_..- � �•eL^a•o..�r:,,Q•.�d-4••b ';d::v:b.:�•A';o';'�'w^p D`Q:p ,�y •••o;Q'ryq°� TENCH SECTION SEP TIC TA IVEC' INSTALL ON LEVEL BASE Allel NOTE:' EXCA VA TE TO ELEV. OR LOWER TO REMOVE ALL rMPERVIUS \G� 12�' MA TERrAL BENEA TH . THE LEACHING AREA 4" or,�,y. REPLACE EXCAVATED MATERIAL WITH 4. �,,b• •a.,�• ,d �6�p, Re;a:o,+ ,��wti 3" OF 1/9"-1/2" iiz7 p CLEAN, CLA Y FREE SAND qo °'� o o.'.;p' � .Q WASHED PEA STONE S 3/4" - 1-112„ WASHED ,0"p A a • �"• �° b CRUSHED S TONE _ _N'' �✓P�nJe� poi ,E �� /3roM 3?SArwNc / GENERAL TRENCH WIDTH NOTES 1. ALL ELEVA TI.ONS SHOWN ARE BASED ON ASSUMED r o / N.IMBER OF TRENCHES 1 - V„ o Savinelle � 2. ALL PIPES IN THE S YSTEM MUST BE CAST IRON NUMBER OF DRYWEL L S 2 .,r.. r,rri rr. �, 4 �r,�V , OR SCHEDULE 40 PVC. - i Oil (� .� p� G� �«' .nay:. �� 3. THE BOARD OF H 'AL TH MUS'T BE NOTIO=IE A ° p. d -,�SSD WHEN CONSTRUCTION IS COMPLETE PRIOR PERCOLATION RA T TO BACKFIL L ING E.' n �span 1te1d t, ! 4. ANY CHANGES, IN THIS PLAN MUST BE APPROVED <2 MIN./IN. BY THE BOAR, OF HEALTH AND CAPE 4° ISLANDS WITNESSED BY: SURVEYING CO.. INC. TOM MCKEAN 5. MATERIALS AND rNS TALLA TION SHALL BE IN . , �ve� BARNS BRO. OF HEALTH Ginn eo x oa COMPLIANCE WITH THE STATE TE SANITARY DESIGN DA TA 4 z o DA TE.' ✓UINf�3 1946 A _� � CODE - TITLE V -- AND LOCAL APPL rCA�3L E -� — — RUL ES AND REGULA TIONS 6. NORTH ARROW IS FROM RECORD PLANS AND p NUMBER OF BEDROOMS -� T TO BE USED FOR SOLAR PURPOSES GA RBA GE DISPOSAL NO • IS NO TOPSOIL 6 N 7. FL 000 HAZARD ZONE C (NON-HAZARD) -_ SUE3SDIL DA IL Y FL ON 330 GAL . 8. WATER SUPPLY' T"cy a1..•r GAL . . /.�I..p -,ww ,. SEPTIC TANK REGJ D. SEPTIC TANK PROVIDED L o,- 26 1 GAL . /o y 3 L EA CHING REOUIRED 330 GPD. MEDIUM SAND SrDEWALL AREA _ 152 S.F. ,- 112 152 S.F.X 0. 74 G/S.F. GPD. BO T TOM AREA - 329 S.F. .. �" L E EN 329 S.F.X O. 74 G S.F. = 243 GPD LEACHING PROVIDED 355 GPD -� PROPOSED EL EVA TION 156" NO GROUNDWA TER h �r y-e way ,5";q s z d .._-N ._.._. EXI STING 'CONTOUR SINGLE FAMILY RESIDENCE C OSSERVA TION Pr 7" •, r. G ® DISTRIBUTION sox Kr , PROPOSED SEWAGE DISPOSAL SYSTEM 1 .-- PREPARED FOR F0 a SEPTIC TANK LJA SON ROSSI L O T 26 (HOUSE 48.E 0) ROU TE 28 RESERVE AREA a BAIP°NS TABL E -- CO TUI T MASS. o 7 C_ .' PIPE INVERT EL EVA TION SANiCKI N I DA TE.* ��Q, _ �> ,� CAPE & ISLANDS ENGINEERING PLOT PLAN ` SCALE.• 1 "_ h/o ' �_„ � ,�, � , , �"��- u,% SCALE AS NOTED � 1,�3 FALMOUTH ROAD — SUITE 2E 2�-, •3� �`` PLAN NO.-`- �1- r?,, � MA SHPL E, MASS. MA P SEC PCL L 0 T HS'E