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HomeMy WebLinkAbout4363 FALMOUTH ROAD/RTE 28 - Health 4363 Falrnoutf � 28 Cotuit F 024 065 --- - - - --- - --- - -- Commonwealth of Massachusetts Title 5 Official Insp edbon Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Falmouth Road: . ...... Property Address Heather Miller Owner.. Owner's Name Cit /Town State :Zip Code Date of information.is.. required for every Cotuit MA 02635.. . 3/13/15 page. �y :. p 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 A. General Information filling out forms .on the computer, use only the tab 1. Inspector. : 'key:to move your cursor-do not use the return Matthew F'. Gilfoy key. Name of Inspector Excavation Com Company.Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 . City/Town . . . State Zip Code (508)477-0653 S113640::...::. Telephone Number. is License Number B. Certification 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:. R. Passes ® Conditionally Passes D. Fails Needs:Further Evaluation by the Local Approving Authority 0 3/13/15 Inspector's Sig ture.: Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of:Health or.DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of.10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate re ional office of the DEP:The original should be sent to the system owner _ ... P9 _ 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: --- -- 1 _.. � m t5ins�3%13 Title 5 Officiajinspection i surface Sewage Disposal System•Pa_ge 1 of 17" Commonwealth of Massachusetts Title 5 :0fficia1 Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t` .. 4363 Falmouth Road :. Property Address Heather Miller Owner..:: Owner's Name information is required for every Cotuit.. MA 02635. ::. 3/13/.15 page. Citylrown State Zip Code Date of Inspection . B. Certification (cont.) Inspection Summary: Check A B,C,D.or E/always complete all of Section D A) System Passes: have not found any information which indicates.that any of the failure criteria described in 310 CMR 15.3.03 or in 310 CMR 15.304 exist.:Any failure criteria not evaluated are indicated below.:.. .. Comments: B) .System Conditionally.Passes: One or more system components as described.in:the "Conditional Pass section.need to be replaced or repaired. The system, upon:completion of the replacement or repair,:as approved by the Board of Health, will:pass. Check the box for,"yes", "no".or"not determined" (Y, N, ND)for the following statements. If'.'not determined," lease ex lam P P :The septic tank is metal and over:20 years.bld* 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. 0..Y N ND (Explain below): ::.. w. t5ins•3/13 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 .. .Commonwealth.of Massachusetts Title 5 0 icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t Falmouth Road:':.. Property Address . . .. . Heather Miller Owner. Owner's Name information.is required for every Cotuit MA 02635:: 3/13/15 page. Cityrrown State :Zip Code Date of Inspection p. B. Certification (Pont.) ❑ Pump Chamber pumps/alarms not operational. System will pass:with Board of Health:approval if pumps/alarms;are repaired. ) :System Conditionally Passes;(cont.):B _ . 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)` Distribution box is in poor condition and must be replaced q. w. El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval:of the Board of Health): _. ❑ broken pipe(s)are replaced ❑.Y:: ❑ N ❑ ND (Explain.below): .... ❑ obstruction is removed ❑ Y ❑:;N ❑ ND (Explain:below)::, C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment.:: 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a'manner which will protect public health,; safety and the environment: Cesspool or privy is within 50 feet of a surface water, ❑ .cesspool or privy is.within 50.feet of a bordering vegetated wetland or a salt marsh.:: _ . t5ins-3%13 Title 5 Official Inspection Form:subsurface Sewage Disposal Syslem•Page 3 of 17, Commonwealth of Massachusetts Title 5 icial inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4363 Falmouth Road:;.. Property Address q. Heather Miller :.:.: Owner: : Owner's Name information is:. required for every Cotuit: MA 02635 3/13/15 page. City/Town State :Zip Code Date of Inspection R Certification (cont.) 2.. System will fail unless the:Board of;Health (and;Public Water Supplier, if any) determines that the system is ,functioning:in a manner that protects the public health, safety and,environment: Fj The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feefof a surface water supply or tributary to a urface 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.se tic tank and SAS,and the SAS.is within p 50 feet of a private water supply well. ❑ The system has a septic tank and.SAS and:the SAS is,less than 1:00 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 DER certified laboratory, for.fecal coliform bacteria indicates:absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form.:: . 3: Other: s. 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 ❑ . . z Static liquid:level in:the distribution box above outlet invert due to an overloaded or clogged SAS or:cesspool ... .. ... ❑ ® Liquid depth,in cesspool is less,than 6" below invert or.available..volume is less than day flow l5ins 3%13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth.of Massachusetts Title 5 Official Inspection Foein Subsurface Sewage,Disposal System Form Not for Voluntary Assessments 4363 Falmouth Road::.. Property Address Heather Miller :. Owner:.::. Owner's Name information is required for every Cotuit -MA 02635: : . 3/13/15 page. Citylrown State :Zip Code Date of Inspection B. Certification (Pont.) Yes . No . Required pumping more than 4 times.in the last year NOT due to clogged or obstructed.pipe(s). Number of times pumped: _. . _. ❑ . Z Any portion:of the SAS, cesspool or privy.is below:high groundwater elevation. ElAny portion:of cesspool or privy is within 100 feet of a surface water supply or tributaryto a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. q. ❑ ® 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 servin a facilit :with a design flow of 2000 d 10,000 pd: . The system fails.f 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 design flow:of 10,000gpd to 15:,000 gpd.:.; For large systems, you must indicate.either"yes'.' or"no"to each of.the following, in addition to the questions in Section D. Yes. . No. . . ❑ ❑ :the system is within 400 feet of a surface drinking water supply the s stem is within 200 feet of.a tributary to a surface drinking water supply ❑ ❑ Y Y . g . pp Y : 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 15.304.7he system owner should contact the appropriate regional office of the Department. _.. t5ins•.3%]3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 commonwealth of Massachusetts- Title 5 Official Inspection orm Subsurface Sewage Disposal System Form =Not for Voluntary Assessments .�' 4363 Falmouth Road: ., Property Address Heather Miller : :. Owner :: Owner's Name .. information is required for every Cotult:.. MA 02635 : .. 3/13/15 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 ; . . 0: 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? ... El ® .: Have large volumes of water been introduced to the system:recently.or as part.of this inspection? ETWere 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? I ❑ Was the:site inspected for signs of break outs Z ❑ Were all system components, excluding the.SAS, located on site? Z ❑ 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? w. 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 Z .. .:: approzirriation of distance is,unacceptable) [310 CMR 15.302(5)] D: System Information .Residential Flow Conditions: Number-of bedrooms (design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms); 330 t5ins�3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4363 Falmouth Road .. .. . Property Address Heather Miller :. Owner:.: Owner's Name information is . required for every Cotuit:. MA 02635:: 3/13/.15 page. I. Cltylrown I I. State I :Zip Code Date of Inspection D. System .Information Description: . .. Number of current residents: 0 .. Does residence have a garbage grinder? ❑ Yes ® No .. .. .. .. . . Is:laundry on a separate sewage.system? (.Include Jaundry system inspection information in this report.) ❑ Yes ® No Laundry system.inspected?.. ®. Yes El No Seasonal use. ❑ Yes ® No : Water meter readings, if available (last 2.years usage,(gpd)): Detail: 2014 = 284 gpd 2013 = 1249 gpd Sump pump? es o :.. E. Y N Last date of occupancy Octo ber 2014 p : Y'. Date Commercial/Industrial Flow Conditions: Type of.Establishment: 9 310 CMR '15.203);Desi n low(basedon Gallons per day(gpd) Basis of design flow.(seats/persons/sq.ft;, etc.): _. Grease trap present? ❑ Yes ❑ No .. Industrial waste holding tank:present? :' ❑ Yes ❑ No Non-sanitary waste discharged to the Title'5 system? ❑ Yes .❑ No s. Water meter:readings, if available: t5ins'.3m{ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 .. .. Commonwealth.of Massachusetts Title 5. Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments .�' 4363 Falmouth Road:: . Property Address Heather Miller .: Owner Owner's Name information is Cotuit MA 02635.': 3/13/15 required for every page. City/Town State :Zip Code Date of Inspection D. System Information (Cont.) Last date of occupancy/user Date . .. . Other(describe below): p. General Information Pumping Records: Source of information: Was system pumped as part:of the inspection? ❑ Yes ® No If yes, volume pumped: gallons::.. How was quantity pumped determined? Reason for pumping: Type of System:::: ® Septic:tank, distribution box,soil absorption system ❑ Single cesspool i ::.. 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 D.EP approval. El Other(describe): t5ins•3%i 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 q. .. Commonwealth of Massachusetts Tit e 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t .,� 4363 Falmouth Road:.. Property Address Heather Miller Owner:.: Owner's Name information.is.. required for every Cotuit - MA 02635 : 3/13/15 page. Cityrrown State :Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage,odors detected when arriving at the site? ❑ :Yes ® No q. Building Sewer(locate on site plan): 4' II Depth below grade; feet I 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.): At time of inspection building sewer appeared to be in good working order. No sign of leakage. Septic Tank(locate on site plan): 3' Depth below grader::.: feet Material of construction: ® concrete ED.netal El 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 1000 gal. Dimensions: Sludge depth: t5ins 3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4363 Falmouth Road:.. .: . Property Address Heather Miller Owner.. Owner's Name information.is.. required for every Cotuit - MA 02635:: :.. 3/13/15 page. City/Town State :Zip Code Date of Inspection D. System.Information (cont.) .. _ .. Septic Tank(cont.) Distance from:top of sludge to bottom of outlet tee or baffle 281 ... 6 Scum thickness 5„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Howwere dimensions determined? measured .:.: _. Comments (on pumping recommendations,:inlet and outlet tee or baffle condition, structural integrity, ., liquid levels as relatedto outlet.invert, evidence of leakage, etc.): At time of inspection septic tankappeare.d#o be in working order: Tees present no'sigh of back-up. Liquiojpvel equal;With outlet invert. .;: q. s. j. p. Grease Trap..(locate;on,site plan):. .p. Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass El polyethylene other.(explain): .. Dimensions: .. .. ..... Scum thickness Distance from top,of scum to top of outlet tee or baffle i Distance from; bottom of scum to bottom of outlet tee or baffle . w. Date of last um in P P 9 .. Date 5 0 on F ace t5ins�3%13 Title Official Inspecti orm:Subsurf Sewage Disposal System-Page 10 of 17 Commonwealth:of Massachusetts- Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4363 Falmouth Road Property Address Heather Miller Owner:. .. Owner's Name information is required for every Cotuif _MA .02635 3/13/15 page. Cityrrown State Zip Code Date of Inspection D. System Information:(pont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert,:evidence of leakage;:etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade:: Material of construction: . ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: p. y' gallons Design Flow: gallons per day ..Alarm present: Yes No:: ::. Alarm level: Alarm in working order; El Yes ❑ No Date of last pumping: .: Date,..,.. Comments (condition of alarm and float.switches. etc.): .. .. Attach copy of current pumping contract(�equired): Is copy attached? El Yes ❑ No ... t5ins�3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 97, I Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4363 Falmouth Road . Property Address Heather Miller Owner.. Owner's Name information is required for every Cotuit - -MA 02635.;: 3/13/15 page. Cityrrown State : Zip Code.: Date of Inspection D..System lnformation:(pont.) - .. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0:.:. . . Comments (note if box:is level and distribution to outlets equal, any evidence of solids carryover,'any evidence of leakage into or out of box, etc.):: At time of inspection d-.box is deteriorated and showing heavy signs of carryover. Must be replaced Pump Chamber(locate on site plan): Pumps in working order []::Yes No Alarms:in working order: ❑ Yes: ❑ No* Comments(note condition of pump.chamber,.condition of pumps and appurtenances, etc.):: If pumps or alarms are not in working order, system is a conditional pass. . Soil Absorption System (SAS) (locate on site plan, excavation hot required): If SAS not located; explain why: p. p. t5ins 3%13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth.of Massachusetts Title 5 icra nspection orm Subsurface Sewage Disposal System Form =Not for Voluntary Assessments .�' 4363 Falmouth Road:: Property Address Heather Miller :.: Owner.. Owner's Name information is required for every Cotult MA 02635 :: 3/13/.15 _. page. City/Town State :Zip Code Date of Inspection D.-System Information:(eont.) Type; q. ❑: leaching pits:: number ...: ..... . (3) 3050's . leaching chambers: number: - ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: overflow cesspool number: . ❑ innovative/a.l.terna*bve system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of :vegetations etc.): At time of inspection leaching was dry and appears to;be in working order:;: Cesspools (cesspool must:be pumped as art: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;. ElYes ❑ No t5ins.3%13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�° 4363 Falmouth Road:: Property Address Heather Miller Owner:.: Owner's Name information is required for every Cotuit MA 02635 3/13/15 page. City/Town State Zip Code : : Date of Inspection _. D. System Information (eont.) Comments (note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation; etc.): .: Privy(locate on site plan).: : . Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure; level of:ponding, condition of vegetation;' etc.): p. t5ins'-3%13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 63 Falmouth Road:_ Property Address ..Heather Miller Owner Owner's Name information.is required forevery Cotuit MA 02635 . 3713/15 page. City/Town State . .. Zip Code Date of Inspection D. System Information (Copt.) Sketch Of Sewage;Disposal System-:Provide ai 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 EJ drawing attached separately. V ALL 0 03 y D X: 3�- ayl a I obse.v a�i o,� Vol t5ins•3%13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 . . • Commonwealth;of Massachusetts ' Title 5 OfficiaHnspe0tio n- Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments .�' 4363 Falmouth Road : Property Address Heather Miller Owner. : Owner's Name information is required for every Cotuit MA 02635 : 3/13/15 page. CltylTown State Zip Code Date of Inspection D. System Information (Pont.) Site Exam: p. ® Check Slope Surface:water Check cellar _. ® Shallow wells:.: nogw@ Estimated depth to high groundwater: 120" .. . 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: 10/6/06 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of.Health -explain: p. ❑ Checked with local excavators, installers-(attach documentation) Accessed U.SGS database -explain: You must describe how you.established the high ground:water elevation: Plan on:file Before filing:this Inspection:,R,eport, please see Report Completeness Checklist on next page. t5ins'-3?O Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 11 - Commonwealth of Massachusetts W Title 5 :Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4363 Falmouth Road Property Address Heather Miller Owner. Owner's Name information is required for every Cotuit - MA 02635 3/13/15 page. City(rown State Zip Code Date of Inspection E. Report:Completeness Checklist - ® Inspection Summary: A,:B, C, D,.or E checked p. ® Inspection Summary p (System.Failure Criteria Applicable to All Systems)completed System Information- Estimated depth.to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•-Page 17 of 17. TOWN OF BARNSST�ABLE -LOCATION Ile-1 SEWAGE #.,7-069 -- uSA VILLAGE T ASSESSOR'S MAP & LOT QDL INSTALLER'S NAME&PHONE N0.-01e—+ G ws>4a ct'®& > >L i 3 d3 SEPTIC TANK CAPACITY € LEACHING FACILITY:_(type) 3 NO.OF BEDROOMS BUILDER OR OWNER 2-0 6-9 2 7-0 439 2/I aS d PERMITDATE: 10�a0% el COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by BC C4 G� ' PO o zls , 5- oi Cb3C4�Vp�k�r ..r.. .. - .. r �,__-.y .err-�•'-•.-�,:!'"-._ ""'_. . ..:Y.-. .�+ J.-- - i. - _ _ t /g) No. Ck)o(0 41 5-a-- t Fee V THE COMMONWEALTH OF MASSACHUSET4 Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[pplication for Mi5po5AY 1p5tem Con5trurtion Permit Application for a Permit to Construct( ) Repair�rade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. / /� P Owner's Name,Address,and Tel.No. �`363rn/ p�,- � rD7'U �I ecdeotro. i3 2.�oso Assessor's Map/Parcel O a Y o eor-s— $,*✓+ Installer's Name,Address,and Tel. o. r Designer's Name,Address and Tel No. , �dLC -/ �D 5 J 05P/L 2 •v Y" C Y s"�Zr 7 r.3 G 7 NSF 3 C o�s 5'6 6 a 5 a 2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow(min.required) <�5 gpd Design flow provided 3 —3 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b this B9_QJ of Heal igne jC Date Application Approved.b Date Application Disapproved by; Date_-_ for the following reasons Permit No.p��� s Date Issued a� .. .. - ..,r. .,..�� ... _ � .�. ..ti«.;w�'.-.`..r -� s ..end•-....:. <. - .._. _ _ No. // ' t0 J ^9` 4 , Fee�U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETT'ZIS Yes pplication for Th5pont *V.tem Con5truction Permit Application for a Permit to Construct O Repair(grade O Abandon O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. ,{ r � � � TU / !2nl�2ro �3s►itQG►sr.� Assessor's Map/Parcel p ,Z e�/ p r S•� —'"' Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. ff OTC Al (p v 5 / ���'JL i2 t 4" Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 c� gpd Design flow provided 3 3 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil .7 Nature.of Repairs or Alterations(Answer when applicable) r Date last inspected: Agreement: a The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of - Compliance has been issued b thiUBoaof iS gned' Date Application Approved by L. Date c� Application Disapproved by: Date for the following reasons r Permit No.c-,-�004P 5 a— Date Issued Q aU 0 —_—.---------------------------- ——— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (/r Upgraded ( ) Abandoned( )by _4 at �3 6 .3 //51��a T G/� has been constructed in accordance with the provisions of itle 5 and the for Disposal System Construction Permit No. C ✓p� dated Installer Designer #bedrooms Approved design flow - gpd The issuance of this permit shall not be construed as a guarantee that the system will function desigNed. Date lQ/' �'1� Inspector ^� � � No. � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS I� 1=i!5po$at *p!5tem (Conotruction Permit Permission is hereby granted to Construct (�) Repair Upgrade (� /� Abandon ( ) System located at � 6 _J /`/9�/ a!/T t `_jL /7,9a2G' a S C and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction ust be ompleted within three years of the dat L f this petxmit. Date �� ao�L� Approved by Town Of Barnstable o�1�1E T. Regulatory Services t Thomas F.Geiler,Director + BARNS�ABEE. s DfAS$.. A Public Health Division Thomas McKean,Director 200 fain.Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer: _ f Installer: '4�-G1-1 ,cis r Address: �� rJ Grz Address: 136 1c S l On was issued a permit to install a (dat (installer) septic system at �� �nffi OV7-H P.2. CoTOi based on a design drawn by / " L (address)v . l dated (designer) certify that the septic system referenced above was installed substanti ally.according to the design, which may include minor approved.-changes such as lateral relocation of the- distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greaten than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State"&Local Re. . ns. Plan revisi or certified as-built by desi o ow. SIN OF AM4 .o ARR N o � U U, (Installer's Sign re) ' No. 1140 Sq"N/TARN' ]V G QDLesigneer�s Signature)gn } (Affix Designer's Stamp Here) PLEASE RETURN TO BARNST LE PUBLIC HEALTH DIVISION. CERTIFICATE` OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- . BUILT I;A RD ARE RECEIVED BY THE BAxtNSTABLE PUBLIC HEALTH DIVISIM THANK YOU. Q:Health/Septic/Designer Certification Form i t f Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every Cotuit Ma. 02635 04/15/2014 , 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 A. General Information filling out forms _ on the computer, use only the tab 1. Inspector: t�J key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address roan Mashpee Ma. 02649 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 14 Inspector's Signat Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins 3113 Title 5 Official Inspection Form:S u ce Sewage DispoZVem'.Pale 1 of 17 _ f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every Cotuit Ma. 02635 04/15/2014 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every Cotuit Ma. 02635 04/15/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N` ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every Cotuit Ma. 02635 04/15/2014 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ . ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 . Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 plus Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2013 456,000 gallons used 2012 342,000 gallons used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 IL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4363 Falmouth Road Route 28. Property Address „ Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): z General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w ' 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Leaching installed in 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 42" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 3611 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard 1000 Gallon Septic Tank Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every Cotuit Ma. 02635 04/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 39" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? field instruments Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass' ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts w - Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:' Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4363 Falmouth,Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every Cotuit Ma. 02635 04/15/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): _ Depth of liquid level above outlet invert 01. 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.): Pump Chamber(locate on site plan): Pumps in working order: _ ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why:, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of V I f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: one apx 11 x 33 ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I_ r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •.�' 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. ' 02635 04/15/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site plan). ( p ) Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 ' 04/15/2014 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r 4 Assessing As-Built Cards Page 1 of 1 TOWN/OF BARNSTTABLE LOCATION 411a tit�n ou r� /24 A4/ SEWAGE#ILL — V Sy VILLAGE Ca?V T ASSESSOR'S MAP&LOT OG 5 i .INSTALLER'S NAME&PHONE NO.AAA#6,..1T 4' •S'og .>11,1 ?e z SEPTIC TANK CAPACITY x•ir / ado LEACHING FACII.PI'Y:(type)3 3vrb f►im,_, acC9iu /.2x X� NO.OF BEDROOMS BUILDER OR OWNERQ' PERMITDATE COMPLIANCE DATE: / Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by gc /= lq � LYJ o f L3Oz 13 0 abs pav�►t, NOr % ScA�e �pfi� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4363 Falmouth Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is Cotuit Ma. 02635 04/15/2014 required for every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus 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: I auguared a hole to 12 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 17 f . . Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3r G .y M a 4363 Falmo uth h t Road Route 28 Property Address Deutsche National Bank Owner Owner's Name information is required for every COtUIt Ma. 02635 04/15/2014 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 n Town of Barnstable Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 29, 2006 Roberto Barroso 4363 Falmouth Road Cotuit,MA. 02635 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.000 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REOUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE The property owned by you located at 4363 Falmouth Road, Cotuit was visited by Donald Desmarais RS, Health Inspector on June 28, 2006 in response to a complaint of overcrowding. The inspector was told that the house had Four bedrooms . The following is a violation of the State Environmental Code: 2� 32-5: Maximum allowable wastewater discharge: A. Within zones of contribution to existing and proposed public supply wells,the maximum allowable wastewater discharge from new individual on-site sewage disposal systems shall not exceed 330 gallons per acre per day. On September 23, 1987 Septic permit 1987-636 was issued for 3 bedrooms. You may have no more than three bedrooms total at said location. It was also discovered that you have a Failed Title 5 inspection dated 9/23/2004. You are directed to repair your septic system no later than September 23, 2006. You are also ordered to correct the violation by eliminating the extra bedroom so that a total of three bedrooms are present at said location. This must be completed within thirty(30) days from receipt of this letter. The Town of Barnstable Health Department has a policy to eliminate the privacy of being considered a bedroom by installing a minimum five (5) foot cased opening with no doors, and no beds or people sleeping are allowed in the room. You are required to obtain a building permit to accommodate this order. Please call Health Inspector Donald Desmarais, RS to schedule an inspection of the property when the extra bedroom has been eliminated at(508) 862-4740. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. QA0rder letters\Sewage violations\33 Emily Way.doc i Non-compliance will result in a fine of$100.00 per violation. Each days failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Dale Saad,PhD Acting Director of Public Health Town of Barnstable Cc: Building Dept. j Q:\order letters\Sewage violations\33 Emily Way.doc j . . I Town of Barnstable P# °f Department of Regulatory Services Public Health Division Date 200,Main Street,Hyannis MA 02601. ; Date Scheduled , ' ' ''rime — Fee Pd. r • i `oil a5uitability Assessor ent for,Sewage-D* al Performed By Witnessed By_ i_ LOCATION& GENERI',L INFORMATION Location Address . �-3(� l_t�0 U 1 Q Owner's Name �} .QS® pp C0`V TT Co TViT• WO/ Address 43&3 f.�j Assessor's Map/Paicel: ®pt I® i!�� 'get I• Engineer's Nam a 2q Z.�i NEW CONSTRU 170N REPAIR I Telephone# So% 36 2 l Land Use `•�`��l lr�tJ"�1 . Slopes(96) ' ` O Surface Stones - d0 ( 7 2�ft Drinking Water Well 2 Z oft Distances from: Open Water Body, S ft Possible Wee Area g i drainage Way a ft:,'Property Line fl .Other ft SKETCH:($fleet name,dimensiods'of lot,exact locations of tesrholes&perc tests,locate wetlands in,proxiinity to holes) u1 i W I Parent material(geologic) f U j Depth to Bedrock ' Depth to GroundwaWr. Standing Water in Hole N i Weeping from Pit Race Estimated Seasonal high Groundwater rlbq D*TERmnv TION FOR SEASONAL HIC14 WATCH TALE Method Used. ! i In. f In. Depth t0 splltnottles Depth 00perved standing;in obs.mule. fr. + (n, ©raundwnter Ad)ustment Depth toiweeping from side of obs.hole: Adj,faotor-,. , Adj,drpundwater UV01. Index Weil# . Reading Date Index Well levt'1 PERCOLATION.TEST ` . Dtp Y 'Plme•_.e...�. Observation / Tim c at9'^ Ltj4L AA -�- -- Hole# 6 j Time at 6". • Depth of Pere ' . 36 j Time(9"-6') Start Pre-soak Time.Ca) Lit - End Pre-soak !'y Irate MmAnch ! Site Failed: Additional Testing Needed(YIN) — Site Suitability Asse�smenC�Site Passed . Original:.Public HoIth Division h Observation Hole Diata To Be Completed on Back-- ***If percolalipn test is to be conducted within 100' of wetland,,you must first notify the Barnstable C4#Servation Division at least one(1)wedk plrioir to beginning- . , DEEP OBSERVATION HOLE:LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munseil) Mottling (Structure;.Stones,Boulders. onsis enC , %Gravel 414 (o �I L4" 16yeS �aSSwP a/ P 2`r— 126`! G �nc — 0 �I-T Z.Dose- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in:) (USDA) (Munseil) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) D q � t! t 22 x w S r \ >LJ DEEP`OBSERVATION HOLE-LOG, Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulders. n isle c %Gravel) •i , 1 I I I DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulders. nit Flood Insurance Rate Man: Above 500 year flood bv.:Pdary No Yes Within 500 year boundary No LX Yes Within 10.0 year flood boundary No - Yes 1 . . Death of Naturafiv�Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? ti-`• 4 If not,what is the depth of naturally occurring pe ious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of iron ental Protection and that the above analysis was performed by me consistent with the required raini g xpertise and experience described in 310 CMR 15.017. Signature Date d d D Q:\SEPTICIPERCFORM.DOC M p . rl M �. • 0 fl 1� Im Iru -OFFICIAL USE- "n Postage $ 1-3 q- e)"� 026 III M Certified Fee 4 . 416 j•.r,��✓' �� .4 ORetum Receipt Fee > Postmark g% 1 O (Endorsement Required) y !:, �1 ' Restricted Delivery Fee rl (Endorsement Required) u'l Total Postage&Fees $ o UcJQS p Sent To ,��p� lti Sheet,Apt.No.; �a or PO Box No. 43- 6 3 Yv � Certified Mail Provides:a A mailing receipt (esiea �++ sal aooaeunr ooeeozisd o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. n For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. SENDER: COMPLETE THIS SECTION COM' PLFTE THiS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A gnature item 4 if Restricted Delivery is desired. ❑Agent X ■ Print your name and address on the reverse ❑Addressee so that can return the card to you. � eived by(P n d Name) C. Dat of D livery ■ Attach this card to the back of the mailpiece, ��'-D or on the front if space permits. D. Is delivery address different from item 17 0 Y§ 1. Article Addressed to: If YES,enter delivery address below: ❑ No 4-50 3. Service Type ` �rr}6 3}� OkCertified Mail ❑Express Mail ❑Registered AReturn Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ! iiii;;7004 2510 0002 6231 0313 J(rransfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 1 02 5 85-02-M-1540 , UNITED STATECMM SMWE IMA— �'..5-I: as P e" eai .. ia%<N Sender: Please pri your name, address,and ZIP+4 in this box_• p lic Health DivisioA T wn of Bamstable 17 20, Vlain St -L. I pihnis,Massachusetts 02601 .a -j �. 24W3 FAILED INSPECTION • ECOJECH ,v�AP PARCEL - r � I Environmental q www.eco-tech.us LOT THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION " Property Address: 4363 Falmouth Road Cotuit Owner's Name: Roberto Barroso Owner's Address: 4363 Falmouth Road 1 Cotuit,MA 02635 0 , Date of Inspection: September 23, 2004 =z h C.'IF Name of Inspector: (Please Print) David D. Coughanowr,R.S. of " meµ^ i,r7 Company Name: Eco-Tech Environmental p Mailing Address: 43 Triangle Circle - Sandwich,MA 02563 4' rn Telephone Number: (508) 364-0894 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 X Fails ' Inspector'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 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 Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23, 2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: No I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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,or 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 breakout or high static water level 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 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 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 ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23,2004 C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety and 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 by 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 l 3) OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTII'ICATION(continued) Property Address: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23, 2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes" or"no" to each of the following for all inspections: Yes I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by 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) Yes (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 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 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 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23,2004 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? f'I Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeluding the SAS. located on site? Y _ Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y Existing information. For example,Plan at the Board of Health. Y _ 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: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept. Number of current residents 5 Does the residence have a garbage grinder(yes or no): no. Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings, if available(last two year's usage(gpd): 552 gpd Sump Pump(yes or no): no . Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd 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: System not pl nped in recent past(Owner) 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: X 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/Alternate 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: Age: 15 years. System is assumed to have been installed at time of dwelling's construction in 1989. 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: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23, 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 36 in Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments (on condition of joints,venting, evidence of leakage, etc.) Sewer appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK: Yes (locate on site plan) Depth below grade: 24 inches Material of construction: X concrete_metal_fiberglass polyethylene other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000gallon) Sludge depth: N.D. Distance from top of sludge to bottom of outlet tee or baffle: N.D. Scum thickness: 10 in Distance from top of scum to top of outlet tee or baffle: N.D Distance from bottom of scum to bottom of outlet tee or baffle: N.D. How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Inlet end of tank was uncovered and evidence of system failure was observed. Septic tank should be pumped dry at the time of system repair,and the interior of the tank should be examined for structural integrity. A schedule 40 PVC tee with a gas baffle should be installed. 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: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23,2004 TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain) Dimensions: Capacity: gallons. Design flow: _gallons/day Alarm present(yes or no)-.— Alarm level: _ Alarm in working order(yes or no):_ pumping:Date of last Comments:(condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yes (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: N.D. Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.) D-box was not evaluated as conclusive evidence of system failure was observed at leach pit. A new distribution box should be installed at time of system's repair. 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: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23, 2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located, explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries, number _leaching trenches, number,length _leaching fields,number,dimensions _overflow cesspool, number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) Leach pit was uncovered and effluent was observed welling up into hole before cover was removed. CESSPOOLS: none (cesspool must be pumped at time 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: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100'(Locate where public water supply enters the building) LEA LOCATIONS � S A B 1 24 It 24 It 2 52 f t 37 It Z❑ D-BOX 3 61 Ft 44 It SEPTIC TANK o A g EXISTING DWELLING # 4363 FALMOUTH ROAD NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4363 Falmouth Road Cotuit Owner: Roberto Barroso Date of Inspection: September 23, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 40+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators, installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Barnstable GIS department records indicate that property is over 40 feet above groundwater table. 11 No. � Fee lJ� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4phratloii for MispoBAY *pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System [44vdividual Components Location Address or Lot No. Y,9G'7 /mow �cO Owner's ni�ame,Address,and Tel.No. es �!s lt-.e Assessor's Map/Parcel op`l ^C,[s S Installer's Name,Address�and Tel,No. Designer's Name,Address,and Tel.No. ✓tee. 6r,�n��joo�/ �9s'f�uctfe�� OdG?c �r�iri y.yc•,��ar�� 3 /l/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) X�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig ed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ®, rj '� t¢. Date Issued 3 7 J� No. d`�'I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplicatlon for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(ty"Upgrade( ) Abandon( ) ❑Complete System [].I•rrdividual Components Location Address or Lot No. jz3� %s��, � Owner's Name,Address,and Tel.No. r` .i 1' I e t--,`sF� Assessor's Map/Parcel f ; Oo'Z — 0:.1,S Installer's Name,Address and Tel.No.' Designer's Name,Address,and Tel.No. s 3 �/ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) 1" Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil F Nature of Repa rs or Alterations(Answer when applicable)�.o�� /4 �, r�� X �,o Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 'r�i Application Approved by Date Application Disapproved by Date for the following reasons Permit No. D 5 —� w Date Issued 3 ' A THE COMMONWEALTH OF MASSACHUSETTS ✓✓''�r�� BARNSTABLE,MASSACHUSETTS 0 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(e-15 Upgraded( ) Abandoned( )by %L�/r����a,l„d� �,.�J�,g c,•.�`r-r' at e./ /-c 4 4,;e• has been constructed in accordance l with the provisions of Title 5 and the for Disposal System Construction Permit No -G� dated 3 Installer , eo Designer #bedrooms Approved desi n flow / d d t✓ The issuance of this permit al of be o s ued as a guarantee that the system wi cti ,g de igned. Date Inspector 0 --------------------------------------------------------------------------------------------------------------------------------------- No. �;)G 1 —G 60 t Fee O C5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair(v) Upgrade( ) Abandon( ) System located at [,/ 3G /,..,m��e� yes/ /'f�,<L,f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. �by Provided:Construction must a compl ted within three years of the date of this mit. Date 7/� J Approved I OWN O B RN TABLE I., iCATION& ( SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Soo, z&"/ SEPTIC TANK CAPACITY 0 0 U 5 i LEACHING FACILITY:(type)!jj� (size) ®�U ENO. OF BEDROOMS _PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER �0 �3.c. U 'V -23 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: _— VARIANCE GRANTED: Yes No �/ __ r �. No......�'?.. � THE COMMONWEALTH OF MASSACHUSETTS /� BOAR® OF HEALTH rO 4`,94-6- Appliration for Bigpaa al Work.6 Tom3 rurtiuu Frrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal -System at Location-Add,,. c � - •TRA LTL_0•1).... .0---- �_...:rt .,%� t 7 -------•----------------------- Owner Address �f �--------------- ------------- �-.. ' - . ...... ................................ ` Installer Address Type of Building Size Lot..1_5_". ------ feet �-, Dwelling—No. of Bedrooms........3--_--•_-•.-----__.___•-_--_•---Expansion Attic ( ) Garbage Grinder ( ) a Other—Type Pk ype of Building ����l�G No. of persons.___._.-_�3............... Showers ( ) — Cafeteria ( ) Other fixtures - f----------------•- W g . ________________gallons per person pert/day. Total lyoflow._.____ ._ ga�lons0/ Design Flow WSeptic Tank—Liquid capacity./.gallons Length... Width. 1@----- Diameter................ De th.._ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area______________-----sq. ft. Seepage Pit No........./--________ Diameter...........6...... Depth below inlet........ ........ Total leaching area.... t_y0.7_sq. ft. Z Other Distribution box (¢-) Dosing tank0-4 ( ) a Percolation Test Results Performed by........ �_.�jQ,2.F, _._.._�_ f2_ j �/. Date.._ f1/✓ .. _-"_.�l Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..,_{ �� 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate --_.-� --_ _._ a' --------- - - -------------••----------- ....---•--• ... ---- -•-------------------•-•-----------------------------•--•-------------•-•-- O Description of Soil...................A .45 0.l__•1_4.1.....--4.4.a 43------------•--------•--......-----•-•---------------•--------------------.------ x V -------------------------•--•----------------------••----------•---•••-----------••------------•-----•--•--•-----------------•-••-------•-•-----•---•-----••........................................... x --•----------------------------------------------------•-------------•-•------..........----•-•-----------•-------------------------•------•-------..................................................... V Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. --------------------------------••-•---------------------•---------------------•------......._-----•----••-----•----------------------••----------------------------------------------•-------------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I;E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of hea Cons rl Application Approved By................. ............................. ._,.__..... a ------------ ------- .............. Date Application Disapproved for the following reasons----------------•--------------•---•------•--••--------••-----•-------------------------------•---•-----•••------ --......----•---•-•--------------------•-------••-•----•-----••---•-------------•-----••-------•-------•------•--•-----------••-•---------••-------••---••--•--•--------•------------------•----...----- Date PermitNo......................................................... Issued--..----. ---------------- Date A No.... FEE....... ..... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rC)- LA/' .......... ....................... Appliration for Bispviial Workii Tomitrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ..TA14---el)......C.0..ru L7................ -------7........................................... Location-Address or Lot No. .................... ... T. C.Q...L.()­1y-.f­T..R.14..4�:Tt..A....C n----- ..........7 .... ..... - Owner Address ..S................ ........... .f........—Z 1?.f..A. nl�r ................................. Installer Address Type of Building Size LotIS'&.0.0-------Sq. feet U Dwelling—No. of Bedrooms.......3---------------------------------Expansion Attic Garbage Grinder Other—Type of Buildin g Q allo. of persons........b................ Showers Cafeteria Other fixtures ........................................................................................ ......... :(I I Design Flow................ .................gallons per person per,,day. Total &ily flow.._... .............................pallon4./ W Septic Tank—Liquid capacity/A60--gallons Length../ Width ...... Diameter________________ Depth.6------ Disposal Trench—NTo--------------­---- Width_..._............... Total Length..._........._...... Total leaching area--------------------sq. f t. Seepage Pit No--------I----------- Diameter.........6....... Depth below inlet............... Total leaching area..4-.0!7---sq. ft. Z Other Distribution box (4—) Dosing tank aPercolation Test Results' Performed by-------/V-0 xXi AH...... j KM,$.,k./.. Date..TL�1.4( Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....j---------- V b V I 44 Test Pit No. 2................minutes per inch Depth of Test Pit...............__... Depth to ground water.................. 04 ............................................................................................................................................................. 0 Description of Soil----------------- ........................................... ...................................... U .................................................................................................................................................................................;...................... ---------------------------------------------------------------------------------------------.................................................................................................. U Nature of Repairs or Alterations—Answer when applicable................................................................ ............................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'IE 4 of the State Sanitary Code—The undersigned further agrees not to place the system in t L-- t operation until a Certificate of Compliance has been issued by the boar of liea 21h, S-4gned­/­�L,e,��j..... -4.. . . . .... ............................... Da' ApplicationApproved By--------------- ... .................................. ...... ....................... ------ ... .... ............... Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo..................................... ............. Issued....... . ................-------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ........OF..... 6.7....................... (9rdifirate of TI-Intlititturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by--------------------------- 4..P.E.A..O........7,Z-12'6:0.Z/.14 ..L I .............................................................................................. lnstaller at........4.0..T.....!7...... ........R­Q--------- .................................................................. has been instailed in accordance with the'provisionsof T."-L 11 5,of The State Sanitary Code as desphqd in the I W application for Disposal orks C .onstruction Permit No.� t.......(....`.�s .... ...... ......... dated-...-__,.V- ------­-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. . . ........................................................ DATE.................. .... . .=­?'d.......................... Inspector....------. VZ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF.... ....................... xoSl................. FEE........................ Rapofial Work.5 0511ustrwtion 'phrutit Permission is hereby granted_.._.._17ACV...... I .......4 ...................................... to Construct or Repair an Individual Sewage Disposal System all No.......J­ T.......�.7.. ... eet as shown on the application for Disposal Works Construction Permi --No� t Dated..... ............ ............... Board of -------------------------------------------- IDA IINF-------­----- 7 .. ............. J-- ---------.......................................... FORM 4„255 HOBBS & WARREN, INC., PUBLISHERS s { �.�L� �..1 USG � 5 C�cT�...��--1 �.►.1+,rr. ---..�r• -..;�. - --•- V tTG w A+t. -L L-t j E5 p, t►J t J r off' Ate PiPE.�S zQ ,c��.�� I" T'NlF_ �y'�T�►��1 St�A.�.L cm " l � / I 1 ___—.__. __�____ - � cAs-t�` t i�.�•J � �-+'Et�v,...� �4c� P v° c j 0 0 �J�l 45 ALL EP k ra,� S c>>sTV-\150Ttx>� fix., Ago L.., - t�.E�c�a;►��, �rr� SN A.L_�._ $� ��5.u5►c�...,+�ra �.. 10 00 c � (� �l.J 'LJ ' -�•�IE t u.iJ�c�-r E�-E�/A-r t o a S :7 rr i�A�N t,� P rtS 1�. ' 1 r ' �---.-► z` } �v of I a o �k LA- \Aj rt't-+ a. S Ar..f ; - nT fo 1 ,r(�'�t �TA�E �r K)- W—r `� 00 0 '4�✓ tV � t'n � � � � PL_�T l O�! 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". «a,. �1 c>� �►►'T ins 1 rCST t-icaL.W r ►► , .Jew �'> t 3+ i: nossS� �.. 12�.l tL 1T MA455. -- v,� "O.t t t7 t.,Er .t-+►,•tC-, C_ A t-F- A� t.-IC c`1�O to -t S C FA(_..t�tCD G3—t I-�� '� ��TE ���.} �r.J C s4� -'� ram' 2d �2�aT Po wto Orz vuc �!�/YTC7/ ! .:'Y/�-G�� _" V' ��( 4./Z �Q' �.-• 1- '� 3 1i�:. /�`_ �`�r '� �/ `�"�3alrr F �r��..1c+�1 ��-«i�'��:��, ^r.� {�. t t � 3c31 _...-.. .. �!` / >�CD3a't�� i ' )•.� ; alit ... v r 7cn,,Z 427 T✓Z? c,'� ,� ,� , ,' 2�7 Co UL.L-q po t KID f U- `,' P ASSESSORS MAP :O2,q TEST HOLE LOGS NOTES: PARCEL : C' ) I i 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH FLOOD- ZONE : )��'V"y �� ? SO 1 L EVALUATOR : ��'L( �' �7' �'' p-#F �� " � THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF � BOARD OF HEALTH REGULATIONS. WITNESS : �4. � �MPrr � SPNNj 0 ' Ff .E} REFERENCE : �(r IL� �� � � DATE : = ` TOO(- 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLAT ION RATE : G llcr S AND SEPTIC COMPONENTS PRIOR TO �.� SEWER INVERT L'T-P,s INSTALLATION. ,pC I �7grL�n1 a r TH- I �L ; � „ TH-2 �-� O 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION �7r l I �'(tr'"Z>>' f'(-b ( i � j�j C7���� v! 1 � t����t(1.(;�7 1< L- �� ��11 O ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE �l loy�`r/, DETERMINATION. 06. 7 4) ALL PIPING TO BE 4" SCHEDULE 40 1/8 "/ FOOT. (UNLESS (9�l @ S ' SPECIFIED OTHERWISE) 1 �..,•..C I Y� .5�f� BUY w LOCAT ION MAP(0-T .`� J t 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. to 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) 17 t- - cc)fj i s C MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON 150.00 F{ --- 2 A BASE OF 6"OF CRUSHED STONE. _ _ . / N -- --- �lr> N °� 1 Tf.k f'1 ( F) v In j r V J 1�D -NG'U�h� f' I/1! "12; b1ftl�l.� wb '► I.S6 of SEP7 I C SYSTEM DES I GN Ln �.) �lra �i �L�,,lw� , wll�j J�bt-T_ or-, egW, L.erc-tJjo FLOW ESTIMATE 10. �8 1-)`K 12 Ft FLOW I" (D I O I I ®� .I "Q I BEDROOMS AT I U GAL/DAY/BEDROOM - �'C)GAL/DAY 2. rai�-S N YS LwiNT TU r ' .v kip � Q Xls�tlp�T- 01SEPTIC TANKfi-( g T E ?) `?2UGAL/DAY x 2 DAYS - &&UGAL (yODI — Z o o I ' rj USE VO GALLON SEPT I C TANK J..S I fJ ' r ��A c t vv� � o� C��//,;,I ll�l�-Cn I 7 f<7 3 e P TT O ++ - I SOIL Al SORPTION I ON SYSTEM E U I z w U I �� I Z �m __ /V/ .s w —1 Z)&IF_,_ I�Q 00 �� —�, — �nJ S 1 ?c_:y z z / I - DJm I I ;31 DE AREA: 2�i}2 -r( 12-10z� `� ^ k U , /1 d mW I N / BOTTOM AREA: Z5 X K 6, 7Ll - 2Zq, 76 G P D r e EIS TING I SEPTIC. SYSTEM SECTION IEL L—ING- I N FNDN - y TOP OF �o.vu;5 � n. I -� -" �� �,r E,P�1 � � 9 "ti'� 4 1450 Fof t w/,,, ' 3 A�MAC' &4 4 ��/Sk�✓a II Gas 13a &6•17 �. 25 D-BOX (p$ GAL I �� I W i SEPTIC TANK62,67 I � w � l n I- � D13 .3 l vv �, o I L Zs x 2 !6 17 S I < � I I I y �o��� SITE AND SEWAGE PLAN I , 2 d g�A ,,,�a S bt I � 3y I ot .i LOCATION : H --- OF v � �� � _ w 3/ r, ' 1�2 r, Co Tv 150.00 Ft ` PREPARED FOR : MEYER �, ,, „ DDv io(e No. 1'140 4� � ��' i (�i/Ltl hoc �. 0 � DARKEN M. MEYER, SCALE : W EDGE OF PAVEMENT NITAR�P R R.S. 1� P.O. BOX 981 DATE : ❑ JMOUTHRDA � EAST SANDWICH MA 02537 T DATE HEAL : H AGENT Ph: 508 362-2922 Z