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HomeMy WebLinkAbout4748 FALMOUTH ROAD/RTE 28 - Health 4748 Falmouth Road/R2f)ute 28, Cotuii I� 31 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the I computer, r,use 1. Inspector: {{{ 111 only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 U.34"f. Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes El R C ❑ Needs Further Evaluation by the Local Approving Authority -ta -M 2/21/13 Inspe is 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. ***"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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM s 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: S.A.S WAS INSTALLED A LITTLE LESS THAN 3 YRS AGO 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 gnu►=' Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): ' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -g p y Not for Voluntary Assessments 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page.. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): r _ C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in.a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Cityrrown 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 hpatt# , safety and environment: ❑ The system has aseptic 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 El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high-ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of,;a,surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design:flow of 2000gpd- 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•11/10 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 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is MA 2/21/13 required for COTUIT _ every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following:, Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes,of water been introduced,to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® _ ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health: ❑ ® Determined in the field (if any of the failure criteria.related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 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 , 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 5 ROWS OF 5 ARC 36HC CHAMBERS OLD S.A.S WAS ALSO LEFT IN PLACE Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑' Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d WELL 9 ( Y 9 (gP ))� Detail: WELL Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on-310 CMR 15203): Gallons per day(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): _ Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM . 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 3/2010 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-11110 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 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NEW S.A.S INSTALLED IN MARCH OF 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron' ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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: 1500 Sludge depth: LIGHT t5ins•11/10 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 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. CityrFown 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 Scum thickness TRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE 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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owners Name information is required for COTUIT MA 2/21/13 every page. Citylfown 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•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owners Name information is required for COTUIT MA 2/21/13 every 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 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or`out of box, etc.): BOX LEVEL NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 25 ARC 36HC ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields _ number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp,soil, condition of vegetation, etc.): _ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is COTUIT MA 2/21/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of:vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I I t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA' 2/21/13 every page. Cityrrown 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: GREATER THAN 5 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: 2/2013Date ❑ 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: , Before filing this.lnspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts W v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4748 FALMOUTH RD RT 28 Property Address PINEO Owner Owner's Name information is required for COTUIT MA 2/21/13 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i TOWN OF BARNSTABLE LOCATION �� 11:�1` . SEWAGE# �C/�IL ©� VILLAGE� ASSESSORfR'S MAP&PARCEL f1N) 9 'D3 INSTALLER'S NAME&PHONE NO.. orks A � �C SEPTIC TANK CAPACITY isco a go 1FX 15 11�J C t LEACHING FACILITY: (type) A f C w R (size) NO.OF BEDROOMS OWNER �. PERMIT DATE: �_� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility - Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac • .1. ) Feet FURNISHED BY i , x ;n .9 to 1 en rZ 0 , a. ✓� v TOWN OF BARNSTABLE , w LOCATION q 7q I C,6 SEWAGE# 2010—®7:3 VILLAGE COtm't ASSESSOR'S MAP&PARCEL A?lV 9"M) INSTALLER'S NAME&PHONE NO. x � A Broot,�INC. SEPTIC TANK CAPACITY ISM N�X® JFX/57-14 C . LEACHING FACILITY.(type) A=C 3G FFf (size) NO.OF BEDROOMS OWNER N is PERMIT DATE: -2-2-11 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leach' 'lity) /i� Feet FURNISHED BY l4�cwlk iv 43 Tw� IQ ©r� s oOPB 00-b#A S-q9 o0 s.q•s 1-ell,4 1 ioG 3-iI'siS, DWA 96.7 T i I � � � No. DO/V Fee THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippficatiou for Mispo Y *pstrm Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L/7 JI- 8 1';1m19v1X I? ,6 f Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4 N -p . cot ZOb Rweo Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1 slams T pc so$`I00-11 �N i�r>or;N G�a��S S -/r Type of Building: Dwelling No.of Bedrooms Lot Size i,LIE)R"es sq.ft. Garbage Grinder( ) Other Type of Building �,� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) iq Wito gpd Design flow provided i/b/ gpd Plan Date 11.' 1. ®c1 Number of sheets 3 Revision Date Title Size of Septic Tank I,= t{ 20 EX fS}nK Type of S.A.S. Q iC. ?a(, o L )d=Qo Description of Soil SN r' p Wl Nature of Repairs or Alterations(Answer when applicable) lA�S 1 C��� ��.W S J , ca 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 yt�Boardalt . D ate 1 7- �D Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. d I0 —� Fee " THE;,lOMMONWEALTH OF MASSACHUSETTS Entered in computer: Y: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yeses r� }„ 2pplication for -isposal �pstm (Construction VPrmit I �b ;' Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components iA Location Address or Lot No. L�7 d��' �y� ��J ' 2� Owner's Name,Address,and Tel.No. Y Assessor's Map/Parcel 4` A) —0 Ot i} KJ ?1 N r o Inst_aller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �, A 13(o.v e,) I tic Sob t,00.7l S� Type of Building: Dwelling No.of Bedrooms W Lot Size 1,LlA a S sq.ft. Garbage Grinder( ) Other Type of Building �r) �c�p No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) W f-10 gpd Design flow provided gpd Plan Date 1 1 - �, - 0 r1 Number of sheets 3 Revision Date Title Size of Septic Tank I` cr) � 2 Type of S.A.S. k C N c_ w -;?o Description of Soil P •� U.J i Nature of Repairs or Alterations(Answer when applicable) ti)S G. I�P W S • A Date last inspected: Agreement: - -4 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.. r igned >� Date - Z Z o Application Approved by Date 0 Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(//� Upgraded( ) Abandoned(( )by ,&-s A i)(©w(o PC at 1-11 `('b fc, �moJk`n �C) Z F�((9f,)i 1- has been constructed in accordance with the provisions of Title j5 and the for Disposal System Construction Permit No.�)0/0 3dated Installer 0t7 J CA C,S A \7(Oyjeo Designer���"�p f t Q� W od��g #bedrooms LA Approved design flow; Ll Ll Ll�gpd The issuance of this permit shall not be construed as a guarantee that the system will fiin)ction as designed. _ Date ho Inspector ------------------------------ ------- -------------------------------=----------- --------------------------------------------------- No. C,— 0 / Fee 0 �" �y /dn / �s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal �&pstpm Construction Permit Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( ) System located at L)77 tl3Fc.1,neoi- Cz.c7�2SC_D+ o 1 1�.c7�2SC.D+ o t 1' 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. Provided:Construction. u f be comp eted within three years of the date of this p Date�� Approved b�y� TRANS .NO.: CITY/TOWN. C>�3 APPLICANT: ADDRESS: DESIGN FLOW.: . �� :gPd' REVIEWED BY: DATE: N/A OK NO . Legal boundaries denoted 310 CMR 15.220(4)(a)] ✓ Street, Lot, tax parcel number and lot number noted on plan [310`u CMR 15.220 4 1 Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40'for plot plans, 1"= 20' or fewer for V/ components) 310 CMR 15.220 4 Easements shown 1310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for V upgrades]-if not, a variance is re ired 310 CMR 15.412 4 Location of impervious surfaces (driveways, parking areas etc.) 310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR ✓, 15.220(4)(c)] Location and dimensions of system components and reserve areas. ✓, 310 CMR 15.220(4)(e)] System Calculations 310 CMR 15.220 4 ✓ daily flow ✓ septic tank capacity(required andprovided) soil absorption system(required andprovided) whether system designed for garbage grinder North arrow 310 CMR 15.220(4)(g)] Existing and ro osed contours 310 CMR 15.220 4 Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220 4 h and i Location and dale of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? 310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220 4 ' ] Observed and Adjusted groundwater (method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR L 15.220(4)(n)] Address I She J.of 9 , N/A OK , NO Location of every water supply, public and private, [310 CMR' 15.220 4 k within 400 feet of the proposed system-location in-the case' of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of privaf6 water s6ppig wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in,310 CMR 15.211 and any catch basins , located within 50 ft 31.0 CMR 15.220(4)(1)], Waterlines and other subsurface utilities located [310 CMR ✓' 15.220 4 rr E E-line cross see 3 10,CMR 15.211 OA 1 Profile-of,systerri showing invert elevations of all system . com onerits asid the hottom of the SAS. 31.4:CMR1;5 22, .4 0; Stam 'er of deli 310 CMR 15.220 i and 310'CNM 15.220 2 Stamp of Registered Land Surveyor(required if construction activities wi'.hin-5 ft. of lot line),: 310:CMR 15.220 3 Test Holes adequate(two in each of the primary and reserve unless-trenches as permitted in;310 CMR 1-5.102(2):or as approved for an u ade under LUA at 3l0 CMR15.405 '1 k Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.1 3:4 Test Holes adequate to confirm adequate groundwater separation? 3-10 CMR 15.103(3)1 ' Benchmark-within 5045' of system 31.0 CMR.15.220 4 Materials specifications noted?.[various sections of 310 CMR 15:000]....:., SystemP comp "on nts not>_36 deep unless Local U� p ( Upgrade Approval. or�LUA re uested 310 CMR 15.405 1 Address Sheet 2 of 9 I N/A OK NO Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15,214, 310 CMR 15.215 and 310 CMR 15.210 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? 310 CMR 15:214 2 Are the nitrogen loads proposed in compliance? [310 CMR 15.2.16(l)]. ` Pumping to septic tank ? 310 CMR 15.229 Shared System 5 W CMR 15.290 E. Address Sheet 9 of 9 � p3, Pressure Dosed System ? Provided pump and piping calculations as required 310 CMR 15.220(4)(r)] Pressure dosing Tequired on all systems>2400gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A s Remedial Use ovals] -� If used in gravellpss system-make sure jet is directed as not to scour soil interface Guidance Document Inspections once per year(systems<2000 gpd)or quarterly >2000 dgood to note on plan 310 CMR 15.254(2)(d)] Construction in JW -Did the plan specify that the fill shall meet z/ the s ecification;of 310'CMR 15.255 3 ? Im ervious barrier and/or retaining wall ? Guidance Document Impervious burier instaliation must be supervised by designer 310CMR15.2552 b Retaining.wall must be designed by Registered Professional Engineer 310 CIVIR 15.255(2)(a)] Side slope not exceed 3:1 ? 310 CMR 15.25 5 2 Breakout re4uirements met? [310 CMR 15.252(2)and L/ Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 f1. / recommended 10 CMR 15.255 2 e - Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a q}ote on the plan regarding the requirement for perpetual maintenanceagreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has li:2 t submitted a c2a of a maintenance!Bement?. Naomi i Are the variances listed on the plan ? [310 CMR 15.220 4 V RLS Stamp;-necessary on plan if a component is within five feet of property One 310 CMR 15.412 4 Address S4eet;7 of9 x New construiction or increased flow proposed - [Refer to 310 r _ C1V15.414 . A� NSA �Qol Li S W .r a , Address Sheet,849r ' "Ar N/A OK NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240 1 Required separation to oundwater? 310 CMR 15.212 Aggregate specified as double washed 310 CMR 15.247(2)] System Venting required/provided?-(system under driveway or >36 d 310 CMR 15.241 Inspection ports.specified and within 3"final grade? [310 CMR 15.240 13 Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document Chambers and Gal. in trench configuration supplied with inlet _ every 20 ft. 310 CMR 15.253 6 Each structure Y�ith one inspection manhole(if>2000 gpd,must be tograde) 310 CMR 15.253 2 Aggregate 1'minimum-4' maximum: 310 CMR 15.253 l 2' sidewall credit maximum 310 CMR 15.253 1 a In bed configuration, inlet ev=40 ft. 310 CMR 15.253 6 Width 2'minimum 3' maximum 310 CMR 15.251 1 100 feet-maximum length 310 CMR 15.251 1 a Minimum separation 2x effective depth or width whichever greater 3x if reserve between trenches 310 CMR 251 1 d �v Situated alonE cpntours 310 CMR 15.251 2 Breakout OK? 10 CMR 15.211 1 41 and Guidance Document minimum 2 distribution lines 310 CMR 15.252(2)(a)] ,f Maximum separation between lines 6' .310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 / CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum,1 12" maximum. 310 CMR 15.252 2 Separation-betwe�n beds 10' n�itnum. 310 CMR 15.252 2 Bdft 61ml area use4 in calculations.only 310 CMR 15.252(2)(i)] Address. Sheet of 9 Buo aric calculations needed?Provided? 310 C-MR 15.221(8)] x .x f Address Sheet 5:0f 9 N/A OK NO Located at least ten feet from any water line? [310 CMR 15.222 2 Disposal piping 4:t least 18" below water line(when water and sewer cross see 310 CMR 15.211 1 .l . Cleanouts-r "uired/ rovided ? 310 CMR 15.222 8 Thrust blocks s ' ed.in-force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable 310 CMR 15.2 . .6 Proper pitch'on'all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251 9 and 310 CMR 15.252(2)(c)] Siphonproblem/ eachfield below pump chamber. R Endca s or vent'manifoldspecified? Size and orientation of discharge.holes specified?.(not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252 2 Materials specified (310 CMR 15.251(5) specifies various pipe types'Allowdd) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if dee er than 9" 310 CMR 15.232( Inside minimum;dimension 12" 3.10 CMR 15.232 2 b Minimum s 310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd 310 CMR 15.232 3 d Capacity(emergency storage above working`=design flow)? [310 CMR 21l(2- Proper setbacks 310 CUR 15.211 same as septic tanks Watertight.20-in minium access nwihole at least 20" MUST BE TO GRADE 310 CMR 15.231 5 Service components accessible(not too deep with piping, Alf Ftr disconnects accessible Alarm floats - alarm on circuit separate from pumpsspecified? Exceeds two unites must have two pumps operating in lead-lag mode. 310 CMR 15.231 6 and 8 Stable Compacted Base 310 CMR.15.221 2 Address Sheet 4 of 9 N/A OK NO Size OK? 310 CMR 15.223 1 Inlet tee located ten inches below flow line 310 CMR 15.227 6 Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227 6 Outlet tee with gas baffle or approved filter 310 CMR 15.227 4 Note regarding ipstallation on stable compacted base [310 CMR , 15.228(l)] Separation between inlet and outlet tees(no less than liquid depth) VX 310 CMR 15.227 2 Inlet/Outlet elevations at least 12" above high groundwater (except as descri* 310 CMR 15.227(5)) or permitted for upgrades under LUA 310 CMR 15.405 1 k Muumum cover Tanks.buried more.than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(l) and 310 CMR 15.232 3 Three access coyers (inlet and outlet must be 20" or greater) - middle access at least 8" 7/07 310 CMR 15.228(2)] Access to within 6 " of grade -one port for systems<I 000gpd, two for.s sterns>1000 d 310 CMR 15.228(2)] All at-grade covers Isecured to unauthorized access? '[310-CMR 15.228(2)] > 10 ft from boil foundation 310 CMR, 15.211 1 Buoyancy calculation Required/Done 310 CMR 15,221(8)] c/ H-20 Where appropriate? 310 CMR 15.226 3 Setbacks from resources 310 CNIR 15.211 Required when gther than single-family dwelling or flow>1000 d 310 CMR 15.223 1 b First compartment 200% daily flow; Second compartment 100% daily flow 310 CMR 1.5..224 2 .and .3 . "U"pipe through or over baffle, outlet of each compartment with as baffle or approved filter 310 CMR 15.224 4 Address Sheet 3.of 9 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: 508-79076304 Installer.&Desianer Certifcation.Form Date: 1 Sewage Permit# Assessor's MaplParcel Designer: � titi Installer: T A- s � Address: ` Address: ti c c�-e4� -2r`Ju 11x � On /'� ��`tl �� c`�L' was issued a permit to install a (date) c.� +,� (innstaller) QIA ��/ septic system at 1.7 q ` �fll -`'� " based on a design drawn by (address) dated (designer) I certify that the septic system referenced above was installed substantally;according. o the design, which may include minor approved changes such as lateral;relocation of;the distribution box and/or septic tank. I certify Ghat the.septic system referenced above was installed with major.changes (i.e. greater.than 10'lateral relocation of the SAS or any vertical relocation of any component of.the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. \A OF 4946,d�e PETER T. G;T, WENTEE (Ins ier's Signature) CIVIL No.35109 Q Xc NAI--'a (Designer's Signature) (Affix Designers Stamp Here) PLEASE RETURN TO BARNSTABLE .PUBLIC .HEALTH DIVISION. . CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD .ARE RECEI'VED:BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:HWth/Scoc/Designer Certification Form 3-26-04.doc Town of:Barnstable r# Department of Regulatory Services s ,.� Public Health Division Hate 4 s NAM 200 Main Street,Hyannis MA 02601 1 ._ i - x Date Scheduled 0 o Time .�0�-1�, Fee Pd. (GC).C�C� of Suitability Assessment for Sewage zsposal Performed By: Pam ' f"tE'C.n�--a� Witnessed By: �v ViJ• S, LOCATION:& GENERAL INFORMATION Location Address Owner's Name ea 4746 PZ) Cr,_ 1. a Address A74R '1-aA.�.wV .,ZcA Assessor's Map/Parcel: a(3q aQ S ) Engineer's NameC NEW CONSTRUCTION REPAIR Telephone# 567—7-37—4"7 G 6 Land Use (7`�V��. 99 ✓� S� � Slopes(g'o) I '- Z� .surface Stones Distances from: Open Water Body�Z� ft Possible Wet Area -"`�2 ft Drinking Water Well ft: Drainage Way 7 'rz-) ft Property Line ft .Other y ft SKETCH:(street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fti proximityto holes) ZC' ' • Parent material(geologic) lS `L� ` (f �� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: /j j Weeping from Pit Face. Estimated-Seasonal High Groundwater 7 1"L= DETERMINATION FOR:SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well#_ Reading.Date: Index Well level �„ Adj,factor �. Ad{.droutldwaterLevel,,,� J PERCOLATION TEST Diste , Thne Observation Hole# I - Time at 9" Depth of Perc 2 010"'4,me at 6". Start Pre-soak Time @ V% lime(91'•6") � End Pre-soak Rate Min./Inch. �2 Site Suitability Assessment: Site Passed Y Site Failed: Additional Testing Needed(Y/N) Original:-Public Health Division Observation Hole Data To Be Completed on Back----------- i ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole Depth from Soil Horizon q Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling '(Structure,Stones,Boulders. itGravel)10 0� �J LS G M—c _ 1k,14 5y11 ( asp DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface.Ou.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.; . Consistency. i 2v M-C 5a►c/ 4 U es 17 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consistency, Flood Insurance Rate Mao: Above:500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material four feet of naturally occurring pervlo s material exist in all areas observed throughout,the Does at lea st Y absorption system ? �I osed for the soil absorp . area prop - If not,what is the depth of naturally occurring per ious material? Certification nviro I certify that on 4 (date)I have passed the soil evaluator examination approved by the Department of E mental Protection and that the above analysis was performed by me consistent with the required train pertise and experience described in 31U C1vIR 15,017:, Date Signature l G Q:\SEFnCVERCPORM.DOC '• p Imo, I� .0 o OFFICIAL Ln Postage $ C� MA p ru Certified Fee Postmar O Return Receipt Fee 1e O (Endorsement Required) {�1`2 p��'EEE���" E3 Restricted Delivery Fee JU M (Endorsement Required) m c� cO Total Postage&Fees Is USp Sent To Street,Apt.No.; or PO Box No. 9 -1 I!,�/t/)!I D ... City,State,ZIP+4 „L 1 f I O Certified Mail Provides: o A mailing receipt { to A unique identifier for your mailpiece e A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a 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 USPSe 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. PS Form 3600,August 2006(Reverse)PSN 7530-02-000-9047 oF�►,t r� - Town .of Barnstable Barnstable ""` aicaMy Regulatory Services--Dep artment '$ ,� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205008796 7/28/09 Robert E. Pineo 4748 Falmouth Road Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 4748 Falmouth Road, Cotuit MA was last inspected on April 27, 2009 by Frank Nunes III, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. TH BOARD OF-HEALTH s cKean, R.S., CHOW. Agent of the Board oHealth Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 4748 Falmouth Rd .Property Address Pineo i ILi{'x r f Owner's Name - . 1 A�U j MA 02635 4/27/09 f -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. A. General Information 1. Inspector: 5 ` 0 Frank Nunes ill 's Name of Inspector saa - Company Name , ;g ' 25 Deer Ride Rd ? '- Company Address Mashpee MA 02649 Cityrrown State Zip Code 508.272.6433 Telephone 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. 1 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 4/27/09 Inspector's ature 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4/27/09 Cityrrown 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: System Fails due to hydraulic loading at the leaching chambers B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not. determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. NO Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced b tr i nis removed r v El , ostruction s uct o e T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4/27/09 CitylTown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 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. t 1 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4127/09 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4/27/09 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,-occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ' ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue w approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•�y< 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA - 02635 4/27/09 City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): - unk DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ®. No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: r 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: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentslug , 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4/27/09 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: pumped last summer per owner 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1989 per as built ` Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4748 Falmouth Rd Property Address Pineo Owners Name Barnstable MA 02635 4/27/09 Cityrrown State Zip Code ' Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1'6" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: undetermined feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Tank is of H-10 construction and is in the driveway If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Sludge depth: 311 Distance from top of sludge to bottom of outlet tee or baffle '12' Scum thickness . - >219 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >21, How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form ., Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4748 Falmouth Rd Property Address Y Pineo Owner's Name Barnstable MA 02635 4/27/09 Cityrrown State Zip Code Date of inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: . - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order Yes El No Date of last pumping: pate Comments(condition of alarm and float switches, etc.):' "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or,out of box,etc.): D-Box is under paved driveway and was not inspected n Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4/27/09 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number,.length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers are 3'below grade and the liquid in the chamber has surpassed the effective leaching capacity and has risen into the riser y APR.22.2009 8:11AN BARNSTABLE BOARD OF HEALTH N0.529 P.1/1 i TOWN OF BARNS'TAB1L8 LOCATION .A - sEwc�Gs M~ .- t vii.LAGB `fal d33a83ot'S MAP At LAP INSTALLER'S NAME fa PHONE NO._� I SEPTIC TANK CdPACt°,i"T L"CMNO FACILI'FI'A Ape) No.OF BEDROOMS pmvATS WELL OR PUBLIC WATER BUILDER OR O ti�'NBR _- i OATB PBRICT iSOULT2 `" $ J)AT8 CO7. PLIANCS ISSUED; vdItI1NCB GRANTF3 : ye2 i 44 �3. j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4748 Falmouth Rd Property Address Pineo Owner's Name Barnstable MA 02635 4/27/09 Cityrrown 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' 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: Visual of nearby pond Town of Barnstable Public Health Division nAn"srAni.e. 200 Main Street Y .MASS. 63 q. 00 Hyannis,MA 02601 Bob Pineo PO Box 2941 Hyannis, MA 02601 TOWN OF BARNSTABLE LOCATION CZi�e„off$ SEWAGE # VILLAGE 61,4 ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. &,Q !ate . c3 -7'7S"-Ile� G3i SEPTIC TANK CAPACITY 1000 6* - LEACHING FACILITY:(tVpe) dal/zy (size) Z+ NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT.ISSUED: 7 DATE: COLIPLIANCE ISSUED- VARIANCE RANTED: Yes No ( / . � y�y� � �3. ' yy ��� ro �" o 0 } No.--- ...�. Fss.... lam........... THE COMMONWEALTH OF MASSACHUSETTS " BOAR® OF HEAI,--H �✓ .............OF.....Ii�?�✓l;s.cl ApplirFation for UhipasFal Marks Tomitrurtion Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...... ................ ! ' Location-Add �s or Lot :�o. .. _i .i�.r�?. ----•------------------ -----•••--•---------.......--•--------•--- ...................................................... ,Q Owner Address a •----------------------!1= •- ............................. ................................•. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___..._.............. .__..Expansion Attic ( ) Garbage Grinder ( ) ��tdlY_�............. No. of persons..... Showers — Cafeteria Other—Type of Building _ p ( ) ( ) Q' Other fixtures -----------------------------•-- - w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................. ` P4 •-••-•••-•-----------------•---••-----------•••--•-•---•-•-•••......------••••-••---•....--•-.........--•----•-----••-----•---•-•--....._..------------------ 0 Description of Soil........................................................................................................................................................................ x w V Nature of Repairs or Alterations—Answer when applicable_-__:____�__,Y'"""_ ...__... -- -----------------------------------••--•---••------•--------------------------------....---••-•---------------------------------------------------------------------------------------..........---•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T': ., p S of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has b n ' s ed b e bo of health. Signed..... .......................... Date Application Approved BY `��-t~-'} . � ---------------------------------- ............. "--- ------- Date Application Disapproved for the following reasons:.......................•---••-------•--•---------------•---•---------------------------•--.........•--•--...•... ---------------------•------------------------------------------------------- ----------------------------------------------------- Q_ qq Date PermitNo......&[-•="•--•�-�-�-----•---------------- Issued-----•-•---------------------------•------------------- D t2t Fps.... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---------...0F..... i�y.n S►�?h- - -------------------------------------------- Applirtttiun for Diupuual Workii Tunitrurtiun Ilrranit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: X_ ....1. r!--. ......._o.�!C . ��s . -------- ---•---------•--•-•------------ Location-Add ess or Lot No. Owner •Address W Installer Address UType of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms......._-______________------------------- Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building �_r a�t J_____________ No. of persons___.�_________-_.________ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------•---------•----------•--••---•--•••-----•.....•-•••-•-••--•-• ••-•-••-•--••---•-----•••-•--•---•-- <11 W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ..a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Li, Test Pit No. 2................minutes per inch Depth of Test Pit__-____-____________ Depth to ground water_-._--________________- a ••----•••-----•-------------------••----...--•--•-••---•••-••-•-----••••--••-•-•----•--•••-•-_--••--......................................................... ODescription of Soil....................................................................................................------------------------------=----------------------••----•--•••- W ------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------•-----------•-••--•---•-- V Nature of Repairs or Alterations—Answer when applicable___--__-_,��y___ ____.._ .-------------------------_------- _____. -•- •••----••------------•-----•-----••.............•--•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of SIT p 5 of the State Sanitary Code— The undersi ned furti er agrees not to place the system in operation until a Certificate of Compliance has b .n • s ed b e bo of health. ....._._...�......................... ------------•••-- Signed Date Application Approved By.......______ _._� __ Date Application Disapproved for the following reasons------------------•--------------•-------------------------•---•-------------•--•--------- ........_...._ ---•--•--••.................................•---...••--•-•-•-----••-•-...-•----•---.........----•--...._--•----•---•------••---------••••-••--•••-------------•-------•--••••---•--•---•--•-••--------- GG Date Permit No.....Sa�_ — x__ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r .. . . OF........... -�i ............................................ GG ......... (Irrtif irate of TuntpliFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal-System constructed O or Repaired ( ) by----------------------------------------------------------------------------------- :" - er-•...............................................................}_..........._..--------____ Install ----------------- y has been installed in accordance with the provisions of T I i IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- _________ dated-_............ ................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS.,A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... .�. ......1<_ ................ Inspector............... A ...................................................... 4. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T- ! sGr..- j..........oF.. :aCr' ii�A_ ... x .......... No.---+r•-•-••-------•-� FEE....Z ...... Disposal Workii Tunutrudiun amit Permissionis hereby granted.............................................................................................................................................. to Construct ------- or Repair ( ) an Individual Sewage Disposal System �/ atNo lf.'-.,,_'' l t�G� - �7 .................................................. street as shown on the application for Disposal Works Construction Permit No._'S%_2j__ Dated.......................................... C� t� Board of Health DATE......................................._ U FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M AI �--I C(�� C DATA I� Department of Environmental Management/Division of Water Resources I ntmm�mmnnmmnnmrmmmmm�nmtmmfi, :. • 4t WATER WELL COMPLETION REPORT I . WELL(�L CATION r ►ATORIES Address r '`�e city) ylti•k rMc­ nab 3 5/ (508) 888-6460, Town G.S.Quadrangle Map Grid Location Owner f + A r' Address ot1 SC' Ne rnC 4748 Rte 28 COtuit WELL USE CONSOLIDATED WELL Domestic Public ❑ Industrial ❑ Type of Water-bearing Rock E: 1�27�89 TIME: 11 :45 AM - Other Water-bearing Zones /ED: 1/27/89 SAMPLE ID: 198 �� r 1) From To 50 f t Method Drilled 2) From To Date Drilled �--- 31 From To 4) From To CASING „ Depth to Bedrock Length. 1' Diameter )mmended limit Result I Type t ( L"S iic UNCONSOLIDATED WELL y 0 — i STATIC WATER LEVEL Water-bearing Materials 0 r Feet below land surface Sand: fine�rrtedium coarse❑ 6.0-8.5 Gravel: fine❑ medium❑ coarse❑ 5.34 Date measured Screen: i 500 GRAVEL PACK WELL Slot# /-)-length from to_ 275 Yes ❑ No R Split Screen (or 2nd screen) 20.0 WATER QUj CITY TESTS MADE Slot# length from to _ 34.0 Chemical rU�/ Biological ❑ Depth To Bedrock 10.0 4.68 _ PUMP TEST j� Drawdown feet after pumping days 7 hours at �y GPM. 0.3 y 09 I pp feet after hours. How measured G J. V Recovery 0.05 _ LOG of FOR ATIONS COMMENTS: (On well or water) Materials From To 0 500 _ I ( I/1 e Aed f U� 250 =' r DRILLER �1 , � FirmQ r\Qn ullQ " ��r r�q o Address U• v Onj 20.0. 1 4110 — City 200 Registration No._�/ - j 250 Turbidity NTU 5.0 - Color APC units 15.0 Background bacteria 1 z I = COMMENT: _= Sodium level is not a health hazard. Low pH indicates corrosive characteristic of water. BE YES NO WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS (ESTED. _ xnx ❑ . � ---------- DATE i �11Eil1ll!l1Ull!l1111!!!!lli iii111UtililiUillllluiililliilili11U1111i191ii11111111144111illUlli llLilillltlllil11U1!!1llitliililaalillilllllillilllillill1111lllilliil!!Ulllilil lllillUlllllitilli111UUliUUiUltltillillllll�� 1 iit??1t??i???tt??i':1?1??1???ti?i1t??tiiilt??t?^it?Tii[!!11'1iji?I'itt!ITiT}?1?1ti11t'liTliii!J(?ilT':[T:T^?iS.... ..... fiJJrJ?JJrJJJJJrtrtlT?t}!?????ii???1T1?i?1l1JTi11Ii1!TiilHiit?i1T(1t1(iT'11?t111111tTiii??Ff!i(TinT(1':J?i(1j!I?�� _.. . t....................... ENVIROTECH LABORATORIES _ } 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 i -= I CLIENT: Robert & Patty Cabral LOCATION: 4748 Rte 28 ADDRESS: c/o Meehan Well Cotuit COLLECTED BY: Meehan SAMPLE DATE: 1/27/89 TiME: 11:45 AM _ DATE RECEIVED: 1/27/89 SAMPLE iD: 8 z 50 f t _ JOB a: New WP11 WELL DEPTH: =x RESULTS OF ANALYSIS: w' Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 = pH pH units 6.0-8.5 5.34 Conductance umhos/cm 500 275 = i = Sodium mg/L 20.0 - 34.0 Nitrate-N mg/L 10.0 4.68 - Iron mg/L 0.3 .09 Manganese mg/L 0.05 =y Hardness mg/L as CaCO 3 500 _ E: Sulfate mg/L 250 = Potassium mg/L 20.0 Alkalinity mg/L 200 I Chloride mg/L 250 Turbidity NTU 5.0 Color APC units 15.0 e== Background bacteria COMMENT: Sodium level is not a health hazard. Low pH indicates corrossive i characteristic of water. i _ YES No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS STED. xnx O DATE I r+ � -� COMMONWEALTH OF MASSACHUSETTS y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA 4 _I 1� .) DEPARTMENT OF ENVIRONMENTAL PRO ION ONE WINTER STREET. BOSTON. NIA 02108 61 7-?9?-5 p " y SEP .Sp WILLIAM F.WELD rOKWNpfB 199r TRLD.y COXE Governor H4tthf pSrAB(f f�' ecretan 350 MAIN STREET r /ems ARGEO PAUL CELLUCCI & WEST YARMOUTH, MA 8 D�Vai) '.STRUHS Lt.Governor 508-775-2800 ommissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ( PROPERTY ADDRESS: 4748 Falmouth RoacllCotuit ADDRESS OF OWNER: DATE OF INSPECTION: September 5, 1997 f Bob Cabral NAME OF INSPECTOR: Jeffrey D. Cannon I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street, West Yarmouth, MA 02673 TELEPHONE NUMBER: (508)775-2800 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: M^ 0 AkjjjUN DATE: September 21 1997 The system Inspector shall submit a copy of this inspecto okto the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A 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 b the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Page 1 of 10 (revised 04/25/97) DEP on the World Wide Web:http:/Aw Av.magnet.state.ma.un/d K SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 4748 Falmouth Road, Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4748 Falmouth Road,Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 D]SYSTEM FAILS: You must indicate either"Yes" or"No"as to each of the following: N/A I have determined that the system violates one or more of the following failure criteria as defined,in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than'/Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a.cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic. compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 406 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. . (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4748 Falmouth Road, Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health. X None of the system components have been pumped for at least two weeks and the system has not been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information. Ex. Plan at B.O.H. X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)(15.302(3)(b)] (revised 04/25/97) Page 4 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4748 Falmouth Road, Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g,p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 3 Garbage grinder(yes or no): NO Laundry connected to system es or no): YES Seasonal use(yes or no) NO Water meter readings, if available(last two(2)year usage(gpd): N/A Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: Type of establishment: ' Design flow: gallons/day 9 9 Y Grease trap present: (yes or no): Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) NO If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 1989 PERMIT#89-123 Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4748 Falmouth Road,Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting, evidence of leakage, etc.) SEPTIC TANK:X (Locate on site plan) Depth below grade: 10" Material of construction X concrete _ metal _ Fiberglass Polyethylene _ other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined AS-BUILT&TAPE MEASURE Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) TANK IS AT WORKING LEVEL, OUTLET BAFFLE,TANK&COVERS 10" BELOW GRADE. GREASE TRAP: N/A (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4748 Falmouth Road,Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to, or at time, of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene other(explain) Dimensions: Capacity: Design flow: gallons/day Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc,) BOX IS 16" X 16",2' BELOW GRADE, BOX IS LEVEL WITH NO LEAKAGE, ONE LINE IN,ONE LINE OUT. PUMP CHAMBER: N/A (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.) (revised 04/25/97) Page 7 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4748 Falmouth Road, Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, if possible; excavation not.required, but may be approximated by non-intrusive methods). If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: 4 leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number, alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) GALLEYS T BELOW GRADE, COVER 6" BELOW GRADE, 16"WATER IN GALLEY'S CESSPOOLS: N/A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil, signs of hydraulic failure, , level of ponding, condition of vegetation, etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4748 Falmouth Road, Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100(locate where public water supply comes into house) L,)e-�� x o iv! i (revised 04/25/97) Page 9 of 10 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4748 Falmouth Road, Cotuit Owner: Cabral, Bob Date of Inspection: September 5, 1997 Depth to groundwater feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained fro Design Plans on record X Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) HIGH LOT TEST HOLE LOG ON ENGINEERED PLAN, NO WATER 1 (revised 04/25/97) Page 10 of 10