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Home My WebLink About0181 FOREST HILLS ROAD - Health (2) 293 SanWi - le� to n Road .. i, COtuit 'P A = 026 039 I ' SEWAGE INSPECTIONS "LOCATION �l��i�U/�'d�U DATE VILLAGE %may ASSESSOR'S MAP & LOT -INS ECTOB , SEPTIC TANK CAPACITY f LEACHING FACILITY: (type) � � _ (size) /'�� NO. OF BEDROOMS BUILDER OR OWNER OWNER MAILING ADDRESS 17 Ir ��77 S/r / a:M1 79 1 � I / )> o. � .. Fps........ �-=--•�- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 1 at�Vs�--.-.---_--..---OF..%��ie............................................ Applirattion' for Disposal Works Tontrnrtion ramit Application is hereby made for a Permit to Construct (W-111"Or Repair ( ) an Individual Sewage Disposal System•at: --� -T- ------------------ ------------------------------•--- Location dress or Lot No. -----------------------------•-- •-----....-•------..._._........_.......... ......------.................................. Owner Address �. f4 ........................... .........................__...._.. ••-••-...........- Inst er Address Type of Building size Lot.6_7®�(°__...._...Sq. feet a4 Dwelling—No. of Bedrooms.__.... _.___Expansion Attic (✓) Garbage Grinder (R/G7 p ;Other—Type of Building ____. �:.............. No, of persons............................ Showers ( ) Cafeteria ( ) 04 Othe�.,fixtures ...................................................................................................................................................... W Design Flow_:_ _________________________________gallons per person per day. Total daily flow...........?d__________.._..........__gallons. WSeptic Tank—Liquid capacit/ __gallons - Length_,?.,..`Y__..... Width._9�-A?...... Diameter________________ Depth__`f_°________-__- x Disposal Trench—Now________________ Width.................... Total Length............... Total leaching area...................sq. ft. Seepage Pit No._�>________________ iameter_ .(�___.._____-_ Depth below inlet..,3_:. .....:.. Total leaching area_19'.7......sq. ft. Z Other Distribution box ( +/�D Dosing tank ( ) ~' Percolation Test Results Performed by.... ................................................... Date__.//' ° __________- 4 __14 Test Pit No. 1.�............ per inch Depth of Test Pit_.11 .... Depth to ground water__. S___ .__.___..__._.__. fi Test Pit No. 2............_...minutes per inch Depth of Test Pit.................... Depth to ground water........................ ................------------•------.........:._............---......-••••............_••................................................................... 0 Description of Soil......................................................................................................................................................................... W V -----__----•--•-----•----. -___-•----•-...._.. ............. ------- -....... -------------------------- •---..___-_-_---------_______......--------- •----------- ••---•------•----•--- W UNature of Repairs or Alterations—Answer when applicable. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code hThe�de • e trther agrees not to place the system in operation until a Certificate of Compliance has bee i s by/t Z b f ih alth. Signed.....................�.=_!...................................................... ............................... Date Application Approved B ---------------------------------------- PP PP y---•------•• Date Application Disapproved for the following reasons-----------------------•-------------=-----•---------•---------•--•--•------•-•-•-------------••-•-•-••••-- - -•-••---•-••.....---•••........--•-••--------•-•--------•.....--••--•-••-•---•--••-••--•••---•----•----•-.---------•-------------------------------------------------•---•-----------••--••-•----._....-- Date Permit No.__$•7••=•-.3-7-s�........••---•-•••••-----_. Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR�F ...........................OF./................�.......r .,.... ............................. vrrtifirFatr of Tomplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (—'-or Repaired ( ) by.... ............ ............. -_--• -------••••••-•••-••-••--•-•--•-••••-•--••••-•••••-•••-••-•••••.......••--•••-•••••-••••••....._ st er has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ......1__5_£f_......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................qz:-.............M............................. Inspector...................... s ........................................ THE COMMONWEALTH OF MASSACHUSETTS �..9 BOARD F HEALTH cc�� f1. (......................OF......._......G�!f ...... l.. FEE. ..:.......~ .. Disposal Works TDontration rrmit Permission is eby granted.. — -------------------------•------•------._.........----.....-•----•---...... .. to Constru _o epa>r rya r-I�z wage o System atNo..__..:_._!.. . P -C ..._.....---. - ---------•---••-•--•----._...•-•-••••---•-•----•-••----._._...-••------•-•••...._••-•-- Street - as shown on the application for Disposal Works Construction ermit�No� `✓. to ......--•-••------•---•--•--•-•-•------------------------------------------------------••-•-........._.._ C' Board of Health DATE.----•--•---------....._. .---.....•---•-•-._....G..--•••-•-••••-...•---•-•• FORM 1255 A. M. SULKIN, INC.. BOSTON -------------- . L. � . . . : TOP OF FOUNDATION ° a d"S'xf- CONCRETE COVER CONCRETE COVERS a 4 CAST IRON 12"MAX. SSXO OR SCHEDULE 40 �' P.V.C. PIPE PIPE SCHEDULE 40 PVC (ONLY) I 12�MAX. � PITCH 1/4''PER MIN. I PITCH 1/4"PER.FT LEACH _ PIT PRECAS- o INVERRT /o' /Y' . LEACH IN, •° EL.S6X0. . . � a :.;. SEPTIC TANK INVERT DIET. INVERT p : Q.; PIT OR ,.° INVERT EL�S.XY. . . . . EL�YX� w a" EL.SS.X.�.... �i .. .. .. GAL. INVERT 80tt >_ EQUIV. ELS:3:X.0.. INVERT (� w 3/4"TO 11, ELS3X;0 o WASHED %•Z �a i w. STONE /O DIA.� PROFI LE OF i(/p GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED BY : DATE f'�"*/ . .... TIME. 67/.y. . . Co&llo'/✓ • 'T • • . • ' . BOARD OF HEALTH TEST HOLE I TEST-HOLE 2 T/ac pQ�' �df/� ELEV. . ., ELEV. S7x0 . . . . ENGINEER DESIGN DATA : NUMBER OF BEDROOMS -� TOTAL ESTIMATED FLOW . • GALLONS/DAY he BOTTOM LEACHING AREA �. . SO.FT. /PIT SIDE LEACHING AREA . . . /�f� • SQ.FT./ PIT GARBAGE DISPOSAL X0. .(50% AREA INCREASE) TOTAL LEACHING AREA . . . .l�. .7:' . SQ.FT PERCOLATION RATE . .� ,t.• S��/r� MIN/INCH 'UP. .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .. . . . .. SQ,FT. NUMBER OF LEACHING PITS APPROVED . .. . . . . . . . . . . BOARD OF HEALTH R.Z : •3.!/ �r� 7s DATE. . . . . . . Z. ?�H.: l.dY �s)�•, jog .��,3J. �Z7.,yGP/' AGENT OR INSPECTOR NA L Sq �oT• `�. . �✓Er✓Tow.✓• �'D • • .� ..J 'v I UPPERCAPE ENGINEERING AC z •f��PEsi Os�,cE� �� s P.O. BOX 616 �°• �`� 7� PETITIONER E. SANDWICH, MA 02:,3i NH'EALtN� 362-6281 TOP OF FOUNDATION CONCRETE COVER •- CONCRETE COVERS 0 4"CAST IRONMAX. E/ SSXO 12��MAX. OR SCHEDULE 40 12"MAX. P.V.C. PIPE "S H MIN. 40 PV _' .C.(ONLY) • PITCH 1/4"PER.FT PITCH 1/4"PER,FT LEACH ° INVERRT PIT PRECAS- �o' /y" t J LEACHING ' EL.rOXO.. ... `—INVERT cQa•' SEPTIC TANK DIST. INVERT e . w e:, PIT OR INVERT / EL�S?!yINVERT BOX ELYX.��! �_ EQUIV. a EL.SS.X.�.... �. ., .. .. GAL. INVERT (� ww OS; :i; 3/4"T011/ o,o ELS3XA. U.o WASHED �o/ _� '�. : E STONE ZS W DIA. t °•e'• /O/ DIA.� PROR LE OF _ _ .tt•f-j;! SEWAGE DISPOSAL. SYSTEM ,vaGRourvo WATER TABLE NO SCALE SOIL LOG WITNESSED DV DATE !' ��/`f • .... TIME.�6J/.y. . . oc%lon/ ,7 C BOARD OF HEALTH TEST HOLE I TEST•HOLE 2 T/�co ��, ✓of/�✓- . ENGINEER ELEV, . .,�-�X'D • , , ELEV. S7x0�• • - ----- DESIGN DATA NUMBER OF BEDROOMS . .3. .5 4 TOTAL ESTIMATED FLOW 30 • , , GALLONS/DAY As BOTTOM LEACHING AREA i ��. . . SO.FT. /PIT SIDE LEACHING AREA . . . �'�J� • SQ.FT./ PIT GARBAGE DISPOSAL A40 .(g0% AREA INCREASE) E.0• %3 xo _.._ TOTAL LEACHING AREA . . .1�. �:` • SQ,FT PERCOLATION RATE . .�� .��• S��/rJ MIN/INCH 4vP. .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .. . . .. . SQ,FT. NUMBER OF LEACHING PITS . . . . �!,✓z' 7- / 1 . . . . . . . . . APPROVED . . . . . . . . , . BOARD OF HEALTH �R •3 // <{f✓ " 7!�- DATE . . . . . . . Zh.: C.aY r's��., . !09. ��, 3/. .�. .<Z7•,YGP/� AGENT OR INSPECTOR j aTfl� S'�Z 6P0 • \pNAL i Nk- . UPPERCAPE ENGINEERING N . . . . . P.O. BOX 616 �0. PETITIONER : E. SANDWICH, MA 0263/ ALVA OF�� 362-6281 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH`. ®.G1� ............. OF../&?�Z.i Z............................................ Appliration`filar Disposal Works Tnnstradiun Frrmit Application is hereby made for a Permit to Construct (t4/0.r Repair ( ) an Individual Sewage Disposal System at: ----------------- ------------------------•------- --- ._..................----.,.................. ovation dress or Lot No. ................................. .......................................... ... ....... ........-•-......... .............. Owner Address ---------- ------,A..... --------------------------- ------------------------------------------••----------......------ Insta r Address / o Type of Building 3 ize Lot.4?7�.....(�......•..Sq. feet aDwelling—No. of Bedrooms._....._ s Expansion Attic (✓) Garbage Grinder (Alc0 p, Other—Type of Building ... .............. No. of persons............................ Showers ( ) — Cafeteria ( ) PaOther tures .---•..................................................------------ Design Flow...-.-6. .................................gallons per person-}per day. Total daily flow.......3-:30? ---------............_gallons. Septic Tank—Liquid capacity/ ..gallons Length.Y<.`Y ..... Diameter..........:..... Depth_x---.------- x Disposal Trench—No. .................... Width.................... Total Length................. Total leaching area....................sq. ft. . Seepage Pit No. CAI-'- __ iameter.l.0........... Depth below inlet... :. Total leaching area./.f 7_. q. ft. Z Other Distribution box ( Dosing tank ( ) aPercolation Test Result Performed by.. ................................................... Date Date..../..!� ................. 1 Test Pit No. 1. ....minutes per inch Depth of Test Pit../.lam............ Depth to ground water... ................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P'r •...•-- ..---- ...................................•---•---•-•--•--...-• --- ------------ •-----------...._......--- -------------- 0 Description of Soil.--•---•........................•-•--------•--._....------•--------•-------•--.....-----••-----......---------------....................................._.._.._.....--- V .................•---------------------•-----...---•---•-•------•-----•-•..............••-•••-••--....---•••-•••••-------•--------------------..........-•--------•--•-------•--..................•-----. W VNature of Repairs or Alterations—Answer when applicable.............................................................................................. Agreement: • The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beerL4ssueo by b ealth. Signed..... -- . . -••-........-•-••-•-----•--------•.....-- Date Application Approved By.............a- x ....�. --------------------------- Date Application Disapproved for the following reasons:.............................................................................................................. ......-•••-••.............•-••--.............._.....----•••--••-••._..._....._..•----•......-•--•--••-•_...........--•...........................•••-----------•--......-•----•------•--•-••---..._..... Date Permit No.....9 2..-_3--72....................----_ Issued...................................................... Date DATE: 10/17/02 PROPERTY ADDRESS :1..2K_S_a_at_uit _Newt-own Road f, __Cotuit,Mass *----- - --- - ' 0263b On the above date, I inspected the septic system at the above address. This system consists of the. following: - 1 . 1 -1000 gallon 'septic tank, 2. 1 -Distribution box. 3. 1 -L -600 gallon 1eachi ng Pit � ( 4X1 2 ' ) ` Based on my inspection, I certify the following conditions M' 5. This is a title five septic system. . ( 78 Code) 6,. The septic system is in proper working order at the present time. 7. The leaching pit is presently dry, r 8. The house has been vacant since January ,1.5, 99` 9. Sprinler system accounts for -the. water useage. ' S I /• GNATUR Name : J . P . Macomber Jr . ----------------------- COnlpany : Joseph _P_,_ Macomber & S,o'n, I:nc. 2 Address : Bq: _�r�_------ -22632-00'66 Phone:_ 508-775- 33.38 THIS CERTIFICATION DOES NOT -CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cess pool s-Leachflelds Pumped & installed: Town Sewer Connectlons P.O. Box 6.6 Centerville, MA-02632-0066= 775.3338 775.6412 R , COM>`'fONWE.-LTH OF,IW�SACHUSETTS EXECUTIv—P OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION -TITLE_ 5 OFFICIAL INSPECTION FORA NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL; SYSTEM FORM PART A CERTIFICATION Propert) address: 1293 Santo t ..Newt gwn Road Cotuit,Mass . Owner's Name:CotU t Gol f DeveI ammnt Owner's Address: game Date of Inspection:1 0 1 7 .02 Name of Inspector: (please print). Joseph P. Macomber Jr. Company Name: PJ. P. Macomber & Sons Inc Mailing Address: Box 66 CPntprvillP Ma 2632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected _he se.:age disposal system at this address and that the information reposed below is true. accurate and complete as of the tinnc;or the inspection. The inspection was performed based on my ;ratnoe and experience in the proper n,nction and maintenance or.on site sewage disposal systems. I am a DEP approved system,inspector pursuant to Sectiont1,5.3y0 of Title 5 (3110 CMR 15,000), The system • � 5 a455e5 -. .. Condmonalk Passes :Feeds f ltnher Evaluation by the Local Approving Authority --- rails Inspector's Signature: 7�d`vim The system inspector shall , m.it a copy of this inspection repon to the Approving Authority(Board of Health or DEP)within 30 days of completingt,)is 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 repon to,the appropriate regional office of the DEP. The original should be sent to the system ors-ner and copies sent to the buyer, if applieabie;and the approving authorir). Notes and Comments ••"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/I5/2000 page I Page 2 of 1 1 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address:129-3 Santui.t Newtown Road Cotuit,Mass. Owner: Cotuit Golf Development Date of Inspection: 10 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S st Passes 4)16 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 septic system is in proper working order , . at the present time. B. System Conditionally Passes: 14P 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 leakine and if a Certificate of Compliance indicating that the tank is less than 20 years old is available: ND explain: /V,6 Observation of sewage backup or break out'or high static water level.in.the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution.box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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- obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 293 Santuit Newtown Road Cotuit,Mass . Owner: Cotuit. Golf Development Date of Inspection:1 0/27/02 C. Further Evaluation is Required by the Board of Health: 4b 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 environrnent 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 ,. ?. System will fail unless the Board of Health (and,Public•Water Supplier, if ariy) determines.that the system is functioning in a manner that protects the public health, safety and.envir.onment: 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. �JQ The system has a septic tank and SAS and the SAS is within^a.Zone I 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 taril: and SAS and the SAS is less than 100 feet bu 50 feet or more from a private water supply well*•. Method used to determine distance . —ell "This system passes if the well water analysis, performed ata 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 rriggered. A copy of the analysis must be,attached to this-form. t 3. Other: 3 Paee 4 of I ! OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued.)_ Property Address:1 293 Santuit Newtown Road Cotuit Mass . Owner: Cotuit oit Deveio—p—me-n—t Date of Inspechon:1 0 1 7 02 D. System Failure Criteria applicable to all.systems: You must indicate ''yes" or "no" to each of the following'for all inspections: Yes N( ✓ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharee or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool y l/ Static liquid level in�ntthe distribution box above outlet inven due.to an overloaded or clogged SAS or esspool �9 X l�I` ' �4- n iquid depth in ce�spvt7l is less than 6" below inve or availablevolume ''1A is less than day flow equired pumping more'than 4 times in the last ycar NOT due to clogged or obstructed pipe(s). Number of times pumped 0 . — ny ponion of the SAS, cesspool or privy is below high ground water elevation. .. n) ponion of cesspool or privy is wi-thin 100 feet of a surface.water supply'or tributary to a'surface �water supply. A n nion of a cesspool or privy is within a Zone I of a public well. ponion of a cesspool or privy is within 50 feet of a private water supply well. Anv ponion 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 an (Tbis system passes if the well water analysis, - perlormed 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,aoalysis must be attached to this form.) (Yes'No)The system fails. I hawe 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 now or-10,000^gpd to 15,0001 gPd You must indicate either"yes".or "no" to each of the following: (The following°criteria apply to large s'ysiems in addition 10 the criteria above) des no� I/ the system is within 400 feet of a surface drinking water supply zLh e system is.within 200 feet of a tributary to a surface drinking water supply& !' the system is located ui a ni(Toge.n sensitive area (Interim Wellhead Protection Area - IWPA) or 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 i 5 304 The system owner should contact the appropriate regional of iice'of the Department. 4 Page S of ; I OFFICIAL. INSPECTION FORM - NOT FOR VOLTEM INSPECTION FOMEUNTARY NTS SUBSURFACE SEWAGE DISPOSAL PART B CHECKLIST Property Address: 1 293 Santuit -Newtown Road Cotuit, Mass - Owner:Cotuit Golf Development. Date of lospectioo: 1 fl /1 :7 /n� Check tf the following have bcen done You must indicate 'ycs" or"no" as to each of the following: Yes >\'ol_ Pumptnginformation Was provided by the owner, occupant, or Board of Health were any of the system components pumped out un the previous rwo weeks Has the system receive.d normal flows un the previous two week period '. Have large volumes of water been unc-roduc, d to the system recently or as pan of this inspection ? Were as.built plans of the system obtauned and.examined? (If they were not available note as N/A) Y Was the- facility or dwelling inspected for signs of sewage back up ? was the sue inspccted for signs of break out ✓ _ Were all system components,' ludung the SAS, located on site Wvc the septic tank manholes uncovered. opened, and the interior of the tank inspected for the eondrt;on eft.^.e baffles or jets, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ' Was the factliry owner-(and occupants if different from owner) provided with inforTnaiion on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on Yes n0 _ Existing information.-For examplc,-a plan at.the Board of Health. _ _ Determined in the field (i(any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(3)(b)J S Page 6 of 1 1 - OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM•INFORMATION Property Address: 1 293 Newtown Road Cotuit, Mass : Owner: Cotuit Golf Development Date of Inspection: 10 17 0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,:2 ' Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example:. 1 10 gpd x # of bedrooms):2'JfA"o=Ak'4 0(/W. - Number of current residents: C� Does residence have a garbage grinder (yes or no) Is laundry on a separate sewage system (yes or.no):.C4G' (if yes separate inspection required) Laundry system inspected (yes or no): �`� 4 Seasonal use: (yes or no): i4Wkir Water meter readings, if available (last 2 years usage (gpd)): 2001 —1 68, 000 gallons=460. 28 GPD Sump pump(yes or no): '2002-98, 000 gallons=268. 50 GPD Last date of occupancy: ! t House has been vacant since January 15 , 1999 COMM ERCIAL/WDUSTRIAL �! Water useage is for the sprinkler Type of establishment: 1� system. Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present (yes or no): j Industrial waste holding tan}: present (yes or no):,,,(AI - Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: L�! OTHER(describe): GENERAL INFORMATION Pumping Records Y Source of information:A !& t;4,1 Was system pumped as pan of the inspection(yes or no): L If yes, volume pumped: 0 gallons -- How was quantity pumped determined? iLl/P Reason for pumping: TYPE OF SYSTEM ,!/Septic tank, distribution box, soil absorption system Single cesspool fieOverflow cesspool 4D Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) ` Innovative/Alternative technology.. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank ,j�e Attach a'copv of the DEP aoproval 4)Other(describe): Approximate age of all ponents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no):�>� 6 1. Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)..* Property Address: 1 293 Santuit Newtown 'Road Cotuit,Mass . Owner: Cotui t Gol f Development. Date of Inspection:1 n 1 7/n 2 BUILDING SEWER(locate on site plan) b Depth below grade: 4 3 Materials of construction:,L9cast iron ;l40 PVC VP other(explain): 141# Distance from private water supply well or suction line: 1 0 ' +' Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight .No evidence of leakage.The system is vented through the house vents SEPTIC TANK: ++(locate on site plan) 1 000 gallons Depth below grade: 36" Material of construction XXXconcrete NOmeta1NO fiberglass No - NQother(explain) NA If tank is metal list age: NO Is age confu-med by a Certificate of Compliance (yes or no)IO (attach a copy of certificate) Dimensions: 8 ' 6" long 5 8" high 4 ' 10 wide Sludge depth: Trace Distance from top of sludge to bortom of outlet tee or baffle: .Tract- Scum thickness:Tr a oP Distance from top of scum to top of outlet tee or baffleTr .P Distance from bottom of scum to bottom of outlet tee or baffle: Tea 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.):' Pump the septic tank every 2-3 years . Inlet & -outlet tees are in place ThP tank i sstructurally..:snund and shc)ws; :nn Pyi rlPnn.a of leakage. GREASE TRAP: _(locate on site plan) Depth below grader NA Material of constructionN A concretNA metalNA fiberglassu-8,polyethylenNA other (explain): NA Dimensions: Na Scum thickness:NA Distance from top of scum to top of outlet tee or baffle: NA Distance from bottom of scum to bottom of outlet tee or baffle.:NA ` Date of last pumping: NA 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 is not present . 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address:1 2 9 3 Santuit Newtown Road Cot i , bass . Owner:rot-iii fi C;n1 f Development. Date of Inspection: 1 p/1 7.1 n 2 TIGHT or HOLDING TANK W (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete AM metal dA) fiberglassA/A polyethylene/ZLCother(explain): 21JQ - Dimensions: R?/� Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): ' Alarm level: _ W Alarm in working order (yes or no): /4 Date of last pumping: Comments(condition of alarm and float switches, etc.): Tight or hold ing tanks are not present. DISTRIBUTION BOX: -/f present must be opened)(locate on site plan) 44— Depth of liquid level above outlet inven': _ Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box has one lateral .No evidence of solids carry over. Nr] eviripnrp nf leakage into or out of the box. PUMP CHAMBE (locate on site plan) Pumps in working order(yes or no); y� Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is .not present. 8 Page 9 of 1 1 S OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURYACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM PART C SYSTEM INFORMATION (continued), Property Address:1 2 9 3 Santuit Newtown Road Cotui _1 Mass . Owner: rnt-nit- Golf nPvelopment Date of Inspection: 1 n 1 7 j(1 cate on site plan, excavation'not required) SOIL ABSORPTION SYSTEM (SAS):�Z(lo 1-600 gallon precast leaching pit. ( 6 ' 12 ' )' If SAS not located explain why: Locared: See page 1.0 leaching pits, number: 7 leaching chambers, number: (} leaching galleries, number: <a leaching trenches, number, length: Wn leaching fields, number, dimensions: AZ overflow cesspool, numberD innovative/alternative system Type/name of technology:] , ti✓l✓ �� C.ptG Comments(note condition of soil, siu.ns of hydraulic failure, level of•ponding, damp soil etc.): ', condition of vegetation, Loamy sand to medium fine `sand.No signs of hydraulic - failure or ponding Sci 1 s arr_ cdr Vegetation is normal CESSPOOLS _(cesspool must be pumped,as part of inspect ion)(locate onesite plan) Number and configuration: C� Depth—top of liquid to inlet invert: Depth of solids layer: �)ia ; Depth of scum laver: --- u Dimensions of cesspool: ,/Z Materials of construction: Indication ofgroundwater inflow(des or no); //�T Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are not present. PRI /it (locate on site plan) 'r Materials of construction: s'Jir Dimensions: Depth of solids: Comments(note condition of soil, sans of hydraulic failure, level of ponding, condition of vegetation, etc.): Priuy is nnt- prPsPni 9 Pear 10 0/ 11 OFFICL-,-L I'�F 1HSPec,71C)N_'F0RN _ NOT FORJvOLUNT �. } SUa.St ARY ASSFSSMSTS C� S wnCE DISPOS SYSTEM I.NSPECTIpN FOB PART C, SYSTEIM INPoR AT:IOIq;(ioni'Fnvc,d) 1293 Santuit Newtown Road y Ccu1. a S. �iic 01 Inipici oo'. n - 7 -O2 3 3 S>CSTCH 0 F5 Ye', CI C) 590 YSTCM p(,r X I t ril In<IV+ding IIf)[10 D 0ic 11 Itfl�l (1Y 0 .^. ��+ vti loci ii :: iii n,n i0o'(cci , o<ri wnrrr ,N�i�r l Opi/TTtncn�.r�(tr"cncf I{J� fl➢ Y inleil the Dvil:oinl, . E + Page I 1 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE Sr'WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 2 9 3 Sant_Liit Newtown Road Cotuit,Mass . _ Owner:Cntui ,ol f D vel(:)pment. Date of Inspection: 1 /17 /fi1__.._-_ SITE EXAM d. Slope Surface water Check cellar Shallow wells Estimated depth to ground water t`,�c`-_ fee! Please indicate (check) all methods used to determine the high ground water elevation: , � Obtained from system design plans on record • if checked, date of design p an reviewed: �R )/� bserve site a utttng proper l(,l)Serva(ion hole within 150 feet of SAS)- AtV ecked with ocal Board of H th explain: �, ►-y(}/��7{-Checked with local excavators,. installers- (anach documentation) - - Accessed USGS database-explain _---- You must describe how you establ'rshcd the. high ground water elevation: Used: Gahrety & Miller Model ._Ground water "elevations above sea level. 1 2/lfil 9 4 - --- Used: USGS• nbspr,7ati nn wPl l__ iaa.a._1t111e 1 992 Used: USG un _�2Q11-1 P1 ate 42 January 1 992 Annual ranges • of ground water elevations. } 1 - Leaching r•i Pit t t _ Groundwater:qyreet'$elow Bortor of it Hi h Gr u g o ndwater Adjustment 1.8 ft per Fhmpter Method acre(ore, the vertical separation distance between the botto o the leaching pirand the adjusted g7oundwater table is fe ll i'c'h'tt U`r' Barnstable WARD O,F HEALTH SF.h'/.t, OIShJ`>+1L SYSTF,H INSPECTION FORM - PART D .- CERTIFICATION ..•-•1_r..•...-r.na^-rn.r,r-n•rt:Trir.rr.rr.r ran-,.,-.--. m--::-rm_rr-*R�.-s ns-anrz-c.rm� mmn�+srrerrarv�*�-r+mr.•.:rrr-•r-�. -. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 12�)3 SEintiiit Newtown Road .Cotuit,Mass. ASSESSORS MAP , DLGCr: AND PARCEL # 026-039 OWNER' s NAME Cotuit golf' Development. 1';1 PT D CERTII'ICA7'I0N' I NAME OF INSPECTOR Josep.r P. '.iacomber Jr COMPANY NAME Joseph ?? . : `acoimber &`t6n Inc COMPANY ADDRESS Box 66 'enL'e'ville Mas's 0263.2 Torn or Clty . Stet• 1IP COMPANY TELEPHONC ( 508 ) /75 i ....;38 FAX ( 508 ) 790-1.578 CERTIFICATION STATEMENT I certify that ? F:t pe sonally inspected the sewage disposa`1 system at this address and that t '!c, inlol'mation reported is true , accurate , and omplete as of the time oj� ,'ins>-ection , The inspection was performed and any recommendations regardiiig' :Ipgr,-kcie , maintenance , and repair are consistent with my training and exp F,pnc : in the proper function and maintenance of on- site sewage' disposal syst,_ms', ' Che k one ; System PASSED The inspection i{hi - 11av Pconducted has.. not found any information which indicates th. -!e system fails to adequately protect public healLh or the env ir , + 'r;e ,;, t defined i. n 310 ChR 15 . 303 , ' A•ny failure criteria not evalu�iec a i.s stated in the .FAILURE CRITERIA section of this form , System FAILED* The inspection whic:!� condlicted has --found that the'. system fails to Protect the public 1 '-h and the environment in accordance With Title 5 ,' 3.10- CH 15A03•, c�nd as _,hecificall'y noted on PART 'C -= -FA ILURE CRITERIA of this ns:> cr :iC) forrn , In Signature Date copy of this c t.iIis ion ;,gust be provided to the OWNER, the IIUYER On,e ere applicable and r- '30i�!t') OF II2ALTII • If Che inspection FA1Lc.:` th'e owner oT "Oporat0r ahall upgrade ' the eyetem within one year of the clr. ._• oP � inspection , unless allowed or required otherwise as provided in C ,:: 5 , 30� , partd . doc r T �7�II-1.II—)I 1.l-I,,��,�;,II��,.,I-�;I'-;1�-,).�..4�;l I�..�.�eI..,��*f'�,.l-.N I-�I-`.�:I I,I,!.,-14 I�,�'1"I..�1I.1 i,I-i1.�I t.,,.,- DW bE - :r _ tlj r ;ai - �" fy 1 r ' RDA . ,'B SI" - I. -1 I�I,I'l;,�..��-.I--I;;,I-...I,*�..�.I�".-1 I:.1-I..�1��I,-I�...��'I*I,"I1I-�-,...,,.I.,,....-I-I...�I"'I..01..�1.,LI I.II-':I,..-.I�,�,,I.-.I.-��I.1�.,.,I.1',�,:-I-.,I).I.I.,.�,"-�.,...�,,*-t,1-.�Ik I.I�4,I-I11��1�"II�.L�;,I�1II�.-1,I—.1-..,....I.,.�4 r-..."I I`:-I.1 I.-..-F,,L.--,I..�—f I�--.,m,-�',.,i...':.,..I I I 1.I I.IP�...��I,.,.,-.-I-,.,—,I,�.:,��,.,'I-...�1I..�.-,',.I.I;II—I�,.�.�1,..I I�—.I.I�I��1,.��1fI-,.�.�...-1,�1 I.-I,,-l,-1I..I-,1I��1.7.,.l.-�I t.1-.1.I..j 7.,-...4-..I p-,I�-.-�.,I.-�.*.�*I—.I I..�I.I..I-"I11:'..-�.,-..,.�Q I-,�,.1,.�—�.-.1�"N1—�..�,.1,II�I\_,.-,,,�,..I,-f�-,.��"..II..1�I...�I.I1-I..4�.�,'I-1�..��0 I";�.I'1-I I�..��..�.Ii I I.:-�1.�.1�o-,II..l I,.I.,4 I-x I,,I I'.I.II...�,I-..,.I,,L�,�,.I^,.,�...Ir..,I.I'�,-,��,*�II�I"-'I I.I�-.�.,!�I.I".�..1;-0-l�"II I 1...I—I.',,,.,..1.II,--�?-...I�t.,kI—......,I:- :,I.,,,_"i�-—.,-:�-.�1.I1.I r..,��1I—I...�1I'.-.....,I,...�.f.-..".'-7-�:�'..III-I.,....,�.�-1,1-..1 l�I�-,.-6I/-I l!'�.7,-�-II.��,I.-:-,.-.,,..L--.�.-,,-"p,".:1-lI.,�-,i,,11.-,-:I..,,-!II 1�,.-I...,.,-,.-��.-,-1-,—�-.,.�,�:��1 I..,'I 1..I-.�.�—.1.II..",I.-I*...-�..---�A-I.�I..��I b I:'��;� 1�I"�,�,�1 I,,U 1.1 1I.,1.',.-,�.I�. -I.--,:.I'��1- ,.,."I-..��...*..f.(1. q. 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