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HomeMy WebLinkAbout4782 FALMOUTH ROAD/RTE 28 - Health 4782-Falmouth Rd (Rte 28) Cotuit P A = 009 003 TOWN OF BARNSTABLE (, N LOCATIONS-' 7Bo2u-I�N�w}�/� o SEWAGE # MLAGE Ii ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1L)OV4 � —"S - Cc t.154, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C{--,—kAA (size) /3K 2 '""NO. OF BEDROOMS ,r.,,,p,BUILDER OR OWNER PERMITDATE: il 1140' 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 leaching fa Feet Furnished by tAoF" TOWN OF BARNS ,ABLE LOCATION U. SEWAGE # ULAGE - ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size), r NO. OF BEDROOMS C, WILDER OR OWNER :' PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching.Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .,, �, 0�cK r� �� �y fi4IOWN OF BARNSTABLE LOCATION Y7910 4;0- 27 SEWAGE# VILLAGE .._.3 V/ 7— ASSESSOR'S MAP & LOT �/5jj INSTALLER'S'NAME&PHONE NO. /���Zs C'0422V SEPTIC TANK CAPACITY Ara 42204, LEACHING FACILITY: (type) _//�,G �' (size) x 13A �t Z'� NO.OF BEDROOMS HUI DER OR OWNER Assl PERMPPDATE: COMPLIANCE DATE: Separation Distance Between the: r�6 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili ) Feet Furnished by =8 L3-- �y�8. e No. SJV Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Migpool bp5tem Couttruction 30ermit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. tf"7�Z ��+i0✓ '� �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. / 6�q' S7- Ile K 6- Type of Building: Dwelling No.of Bedrooms Lot Size 2 SD sq.ft. Garbage Grinder(A*) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 73 1 vro© WA-Zees- Description of Soil �` 4 Nature of of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi Bo arLojo.H@a -. Signed=r / .. Date ��13/p_3 Application Approved by • S Date .3 Application Disapproved or the following reasons Permit No. 2��SSt7 Date Issued o3 No. Ito?-'SJO a-,1= "F'• �� 4 r Fee 160— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t PUBLIC HEALTH DIVISION -TOWN OF BARNSTA#BLE., MASSACHUSETT91 Yes 4pplication for 13igpool bpotem Cony tructiott permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) []complete System El Individual Components Location Address or Lot No. _ 7�Z 64%0�,� � O sName,Address Je sTel.No. � 'v T Assessor's Map/Parcel �' _ 7 oy 1 `7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. p,T; 6s7-- eaa,:5 7: U e Ile R Type of Building: Dwelling No.of Bedrooms Lot Size 2 SO sq.ft. Garbage Grinder(N) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �fD gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic,Tank Type of S.A.S. SdD l' Description of Soil ✓l �{ O ST��e--- Nature of Repairs or Alterations(Answer when applicable) �.._ II-..� �[o G-- `'�1.-ice- �rJ c ► L v'1-- r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of'tlie 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 Certifi- cate of Compliance has been issue,d-by-thii B Daard ooffIealtll / Signed ' Date 3 Application Approved by - Date // /Z-/ ,0.3 Application Disapproved for the following reasons Permit No. 2 OC�,- S SLR Date Issued 1/11,1 ,0 3 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 n at 7 9 Z h,©v�� Ot�i has been construct in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 t-C3-5 0_ dated - I►/!�1�03 Installer Designer n The issuance of this permit shall not be construed as a guarantee that the sytem-wfunction as designed. Date 1 h Inspector - No. 27UG i- SSO Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Miqu al *pztem Con5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon System located at J/�,77_ ZE; -®z,, >--4 L1�, and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construc on m st be completed within three years of the date of this permit. Date: 11 I G 3 Approved by 1 � TOWN OF BARNSTABLE I n p LOCATION SEWAGE # 903 5370 VILLAGE �r,��Lc i f ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. CCU SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 3r.;'x /3-A'Z ` NO. OF BEDROOMS l BUILDER OR OWNER PERMIT'DATE: i II 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 leaching fa ' ' Feet Furnished by 0 tA� C- D Z 0 -5;C;) ' L �� E 22� �•�p t Z Z � O P &3a 'Ile 6 ��' t r 4 w ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS x. DEPARTMENT OF ENVIRONMENTAL PROTECTION A A d } F A yr RtS TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner's Name: HERB JONSON C/O JACK CONWAY r~�y Owner's Address: 38 RT. 134 SUITE 1 S.DENNIS MA.02660 Date of Inspection: 12/1/00 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O."BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813iFAX 508-564-7270 CERTIFICATION STATEMENT ,� 4 I certify that I have personally inspected the sewage disposal system at this address and that the informal n ep d below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes N _ Conditionally Passes _ Needs Fu er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 12/1/00 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 'ry, 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,thex inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments c THE SYSTEM PASSES TITLE.V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO t PROLONG THE SYSTEM'S USEFULL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 In-mPrtinn Fnrm 6/1'NO0 0 i' Page 2;of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4782 FALMOUTH`RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. System Passes: t X 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: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. n/a 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 tail:failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved boy the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed w. pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is'iemoved _ distribution box is leveled or replaced ND explain: n/a r n/a 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 t _obstruction is removed ' ND explain: n/a ' Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 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. C' 1. System will pass unless Boa4of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ., $ ;: 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the " system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. t _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ,f. _ 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'd`etermine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to"this form. 3. Other: b: n/a t f "fv • E; Z Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM z, PART A CERTIFICATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool x X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow X Required pumping mor'.e than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool orprivy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool pq;privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or`privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool o'r privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality_analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided'tt at no other failure criteria are triggered.A copy of the analysis must be attached to this form.] t F " (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 fi"7 VS 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. s 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. iy You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no °.; X the system is within 400 feet of a surface drinking water supply ' _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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 systemhas 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. i . d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 Check if the following have been'done.You must indicate"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 Were any of the system components pumped out in the previous two weeks? _ X Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or.as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs cf break out? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ 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: Sj`•r Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] •s �, + i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203!(for example: 110 gpd x#of bedrooms):220 Number of current residents: 0 Does residence have a garbage grinder(yes or,no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a '�'1. Design flow(based on 310 CMR 1'5,.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO-,, Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings, if available: n/a .t Last date of occupancy/use: n/a OTHER(describe): n/a ` . t GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection,(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a F TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy x- _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.;Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ` _Tight tank Attach a copy of the DEP approval Other(describe): n/a ,F Approximate age of all components,date installed(if known)and source of information: 1950 Were sewage odors detected when arriving at the site(yes or no): NO t• a Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 BUILDING SEWER(locate on site plan) Depth below grade:48" Materials of construction:_cast iron =40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:36" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions:6'X 6' BLOCK CESSPOOL" t' Sludge depth: n/a Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a ' How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,'structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE TO TWO YEARS DEPENDING ON USE TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site°plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc")t,} n/a y4 .a pit • ,it Page 8 of 1 I = tx' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 > ' TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons 4 Design Flow: n/a gallons/day Alarm present(yes or no): N/A ,,0 Alarm level:N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:n/a 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.): n/a JIs PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NOF'• Alarms in working order(yes or no):NO. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a s . 4 731C t ie L • R F.. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a , Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a �> n/a, leaching galleries, number: n/a 1 leaching trenches, number, length: 14 n/a leaching fields, number: n/a n/a ; overflow cesspool, number: n/a n/a l' innovative/alternative system. Type/name of technology: w n/a _t Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH TRENCH APPEARS TO'BE,FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY IN LEACH AREA. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a i Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a a Materials of construction: n/a Indication of groundwater inflow(yes or no):=NO Comments(note condition of soil,signs of hydraulic failure,`level of ponding,condition of vegetation,etc.): , n/a PRIVY: (locate on site plan) ; Materials of construction: n/a t •°:' Dimensions: n/a fir. Depth of solids: n/a F Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation;etc.): n/a q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY 4 Date of Inspection: 12/1/00 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. •l LA b&IL M f � �f 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM]INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4782 FALMOUTH RD.RT 29 COTUIT,MA 02635 Owner: HERB JONSON C/O JACK CONWAY Date of Inspection: 12/1/00 SITE EXAM r„ _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a 'S You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS-12+FEET Q+ 4 V�: . .......:.,. r µ .. 1N_C...6YM�t'.CS- i. r—�C,; �.-.r cc• 4 ; Y I _ 77 z . 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AP � G AGITY: T � IDEWALL: -, pOT70M:--/3 ,r 33,� X o,)s� = ..�Z2. 3 �. GENERAL NOTES .,� �� rorAL: CONTRACTOR TO l3E RE5PONSI�PLE FOR THE LOGATONOF ALL UTLTES A15OVE AND 1"EROROUND,PROR TO ANY LX6AVfi»TUN OR C,0N6 FfKLGT'VN. iI _ _.. ,.. ew U C L � � i i I AN F ,SOT r0!�5E U6E'?f=OR P,� L Ives G"_T LI• M l IAT r'N h. ALL DSTUR[�ED AREAS TO bC LOAMED,INL��CEDLD old, � \ -�, 5. CONTRACTOR TO PROVDE 24 MOUR NOTGE f-OR ANY RLQL)RLD NSFEGToNS vR - xis���� ,t� �-G• y ,s �G WELD✓ �76,n oz �cs -�,�'i' �% OF 1� ^TEVE W. M o U p�- ' 35 N A L i MCP SIT SEWAGE FLAN LOCATION: y a z �� PREPARED FOR: /9�--7 7' ' J SCALE: DRAWN 13Y: c� 2� Y JO1f5 NLWER: DATE:��7" 24 0vo3 e4l=--r: ((45 FALMOUrM RP N SUITE qG OENTERVILLE, MA OUn TEL.: (5O8) 775--0735 FAX: (508) 775-0754 PROFESSIONAL ENGINEERS & LAND SURVEYORS