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HomeMy WebLinkAbout0076 FOX DEN BLUFF ROAD - Health 76 Fox .Den Bluff Road i Cotuit. P A 041 034 - - --- — - _---- -- I f . Doc= 1P081sb48 01-25=2008 1 :43 BARNSTABLE LAND COURT REGISTRY I DEED-RESTRICTION WHE S, , of owners n e ,., 7 MA is.the owner of 70 /? /V located /'1' (address) at L�P9'/ p, MA(hereinafter referred to as Lam` / 'la 'Nw" arid being n on a plan entitled "Subdivision of and in MA, Property of l rlN 0 a / -�' , et al, -- - duly recorded in Barnstable County Registry of Deeds in Plan Book Page ; Or on Land Court Plan Number f WHEREAS,. as tha owner of said lot has (owners name) agreed with the Town of Bamstab a Board of.Health to a restriction as to the number,of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal Works.construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of.a building permit for the construction of asingle family home on this property,. is requiring that the agreement for the,restriction on ttie WWbgr bedrooms in an house constructed on the lot be "��" th Y put on repord w�fa p _. Y Barnstable CountyRegistry of Deeds b recording tl�is document, 9� trY Y g , .,; . . YGGW NOW, THEREFORE, (ovmdoes hereby place the Osn e) following restriction on his above-referenced land in accordance with his agMeMant.witlLthe Town wl-i+ehf" trshalt run with the land and be binding upon all•successors in title: 1. may have constructed . (address upon the lot a house containing no more than bedrooms. agrees that this shbll be. . . permanent deed (owner's na 'e) restriction affecting- located on MA, and being shown on the plan reco ded in Pla Book , Paged Or on Land Court Plan For title of see the following deed: Book . , Page . Or Land Court Certificate of Title Number Executed as a seale ristrum. ent 25 day. of January 2008 Owner's signs ure Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS Barnstable . ss January 25 20 08 Then personally appeared the above-named Norman Knight known to me to.be the person who executed the foregoing instrument and acknowledged BARNSTABLE COUNTY the same to be h's � free act and deed, before a •REGISTRY OF DEEDS Evidence of Identity roved y Massac setts Driver's Licen e A TRUE COPY,Ar rEST 00 Notary P b !D • a f NM ¢; 16. My commission expires: n (date) deedr " "'"` BARNSTABLE REGISTRY OF DEEDS f v COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION s 0W TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 76 Fox Den Bluff Road Cotuit MA 02635 Owner's Name: Patricia McDermott Owner's Address: Same Date of Inspection: June 7,2007 Job#07-114F Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD _ MARSTONS MILLS MA 02648 r: Telephone Number: 508-428-1779 C�e1 frt"t -,-CERTIFICATION STATEMENT co I certify that I have personally inspected the sewage disposal system at this address and that the informati n reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local A roving Authority Fa U Inspector's Signature., 2- Date: 6/7/07 The system ins ector shall submit a co of this inspection report to the Approving Authority Board of Health or Y p PY P p pP g ry( DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Tank is not in need of pumping at this time, both leaching pits have one foot of effective leaching. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: I ' Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 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(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. 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 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 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: ' Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed 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 forma _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 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 of 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: 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)] i f Page 6 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x#of bedrooms): 440 Number of current residents: 2 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): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years total including irrigation: 412,000 gal. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/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): Approximate age of all components,date installed(if known)and source of information: Compliance date: 12/10/93 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5'long x 5.8' wide—1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles are intact and clear, liquid level is at bottom of outlet invert.Tank does not require pumping at this time. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or high stains present. PUMP CHAMBER: No (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.): Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Two 4x6 pits. leaching chambers, number: _leaching galleries, number: _leaching trenches,number, length: _leaching fields,number,dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Liquid level is one foot below inlets in both pits. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): r . Page 10,of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO SAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 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. 34 2 19 47 18 . 33 Water Service Fox Den Bluff Road Page 11 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Fox Den Bluff Road,Cotuit Owner: Patricia McDermott Date of Inspection: June 7,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water : More than 10 feet 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 plan reviewed: _X_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) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.40 and topo map shows property at or above el.50.Cranberry bog on opposite side of road is lower than bottom of SAS. i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIONlop tj r- D nn l r;IAR 03 2005 I v�/ L O rc�'h JFBARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 7/b / CERTIFICATION Property Address: FO LI) / I Owner's Name: n �✓ a . _or A Owner's Address: G o 6 ?j Date of Inspection: 10 Name of Inspector: lease print) Company Name: &iV✓1 0 — EC Mailing Address: Pa Telephone Number.-( CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below and compkse as of the�e-of the ce The� Perfonew based��en my training and experience in the proper function and maintenan was approved system inspector pu=ant to Section 13-W-of f Title 5{31-0,CMR 15r000 sposal ems'I am a DEP ). TI3e system, Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: r L.- Date: The system inspector shall DEP)within 30 days of com eting this inspection n stem is a shared system or has a design flow of gpd or greater,the inspector and the system=w".rball � AoA ' zCP0ztDEP. The original should be sent to the system owner and copies sent to the buyer,if he authority. applicable,and the approving Notes and Comments ****Thus report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does noaddrem conditions of use. -m erdifierent f Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DiSPOSAi.-Sy-STEM SPECT �� PART A n/ CERTIFICATION(condoned) Property Address. /(J Po x Oe in Ql k,ce Owner. k Date of Ins pec *on: ox- 3- o Inspection Summary: Check A4%--CB-or g/ALWAYS"mMLe-ag efl ties a A. Sy asses: I have not found any information which indicates that 15.303 or in 310 CMR 15.304 exist s «teda�at u anyzeds ure described in 310 CUR �belQu+. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional repaired The �4 Pass"section need to be replaced or system,upon o0 �� APPM'edby 1heBeard efli aith,will pass. Answer yes,no or not determined(y,1J,ND)in the e for the follawmg statements.If"not determined"please The septic tank is metal and over 20 years old*or the unsound,exhrbits subsMot al MAh ahon�4xii1tration or septic tank(whether metal not)is structurally tank ihilur+e i$' pass inspection if the existing tank is replaced with a complying septic tank as a S A metalnspection approved by the Board of Health. �11 indicating that the tank less than 20 sold is� d'not leaking and if a Certificate of Compliance ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or aobstructed ofBoard of Health):pipe(s)or due to fin,filed or uneven distribution box System will pass�n if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system( Vprova1 Of the Board of g more than�a year due to broken or obstructed pipe(s).The system will .Pass inspection if with Healthy broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE RjSpOSAL&YAM jNSpEC�'�O)1i PART A fORM CERTIFICATION(continue Property Address: ok / o Owner. Date of Inspection: C• Fu r 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 rs failing to protect public he#,- mAt-env� 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/k mmnerwhich — Cesspool or privy is within 50 feet of a surface water . — Cesspool or privy is within SO-feet of a%rdeftvegetated 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 healtb,safely and environment: has a septic tank and soil absorption system(SAS)and the SAS is surface water supply or tributary to a surface water supply within 100 feet of a, — 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 onk 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 bacteria and volatile organic laboratory,for coliform cwmpoun ds indicates that the well is-frce 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: Page 4 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TS PART A CERTIFICATION(cogtinued) Property Address: 9/ FOx 0?h /��1r Owner. tee I� l� �, �, Od�G3 Date of inspecti D. System Failure Cdted#aPPHeable to all systems: You must indicate`fives"or"ao"to each of the following for an insp o ; Yes No/ — of sews into sewage facility or system m co — =� Discharge or ponding of��to the component due to overloaded or clogged SAS or /clogged SAS or cesspool Mace of the ground or surface waters due to an cesspool — v Static liquid level in the box above outlet 0�10�or cesspool distribution invert due to an overloaded or cloggedSAS d depth or — — rgtn m cesspool is less than 6"below inverReTured t or Pimping more than 4 times in the last avazlable volume is less than%day flow /of times pump y NOT due to clogged or obstructed Number — vAny portion of the S Any portion of �'cesspool or privy is below high ground water elevation water supply, cesspool or privy is within 100 feet of a surface water`� supply or to �a — portion of awithin ��3' surface —fir/ Portion of a cesspool or p v�y is within SOZone 1 of a public well. eet of a private portion of a cesspool or pry is less than 100 feet but water 'well. supply well with no acceptable water greater than 50 feet from a private water performed at a DEP certified laboratory' ems. m a feria Peres if the well water analysis, indicates that the well is free from���for conform bacteria and volatile organic compounds nihtigen and nitrate nitrogen�equal! uflOII from that facility and the presence of ammonia are�l��.A copy of the anal 9�1 to or less than 5 PPak Provided that no other failure criteria ,/�� ysh must be attached to this form.] �v v (Yes/No)The system fad„I have determined that o ne or more of the above failure exist as described in 310 CAM 15.303 Health to determine whatb therefore the system fails.TIM system should contact the Board of will be necessary to correct the failure o E. Large Systems: ` To be considered a large system the system must serve a facility with a Yougpd design flow of 10,000 You must indicate either � � gpd t01S,000 (The folio 'yes or 'no to each of the following: aPAIY to large systems in addition to the criteria above) Yes e system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surfaceaa�yuPply system is located in a nitrogen sensitive area ne R of a public water supply well Wellhead 1ection Area-IWpA)or a mapped If you have answered"yes"to any Question in Section E the system is considered a sggnrficant threat,or answered "Yes"in Section D above the large system has failed significant threat under Section E or failed under The owner or Operator of any large system considered a 15.304. The system owner should contact the al Section D shall upgrade the system in accordance opt regional office of the Departmemt, with 310 CUR ! Page 5 of 11 OFFICIAL INSPECTION FORM._ SUB NOT FOR VOL SURFA IINTARY A CE S SS SWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �peltyAddreag: /�//� Fo,� ��, Owner. fr, Vj Date of Inspectfon; Check if the f011Owine have been Flo,,,ypn mnet indi �e es"or"no"as to each of the followin yo 9 information was Providedby the owner,o or Board of Health — Were any the n compote lamed out in the previous two weeks — 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 . � W and inspection r Were as built plans of the�m obtained examined?(If they were not available note as N/A) • Was the facility or dwelling inspected for signs of sewage backup _ Was the site inspected for signs of break out Were all system componeuts,awjuding the SAS lo cated on site . the septic tank of the wtm%mftrW manholes uncovereck open, d the interior of he of coon,dnnensiam depth of liquick�h of tank d for the condition Was the o ludge a�depth of scum maintenance of��disposal( systems a nt from owner)provided with information on the lxoper The size and location of the SOB Absorption System(SAS)related on the site has Yes no been determined based on. Existing mfrnaiation.For example,a plan at the Board of Health Determined in the field(if any of the failure criteria re is unaccePt")13 10 CM15.302(3)(b)j Part C is at issue approximation of distance .J Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTAR ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOMENTS PART C RM SYSTEM INFORMATION A'operby Addr, s : % Oe, O 14 i Owner. /� , G 3 Date of Inspo - n:_ 9-0 i RESIDENTIA Flow CONDITIONS ` Number of bedroom DESIGN flow (��) Number of bedrooms c based on 310 CMR 15.203 for (��)' Number of current residents: D ( example: 110 gpd x of bedrooms): Does residence have a �f a ` Is es residence en a age Winder(yes or no): *,o Laundry system e sewage system for no): °a [ifYes sepazate inspection r%A i Water :(yes or no):� Sump pump(yes or no Table(last 2 years usage(gp�); :. a� r YPC of establishment.•COMAIERCLALINDU$ Design flow(based on 310 CM-R 15.203): Basis of designflow( Grease nap present(yes or ft,etc.): }. odustrial waste holding tank pint(yam or no):_ Water �Wharged to 5 system(yes or no):_ Last date of occuparxy/use: OTHER(describe) e E Pumping Records GENERAL INFORMATION Source of information: Was system pumped as Part of the i If yes,volute pumped; m sipecti °r no); � R Reason for pub was quantity pmnped determhwd? T����SYSTEM —Single distribution box,soil absoitimz system —Overflow cesspool _Privy — Shared ve tec nolog attach inspection records,if previous obtained�y3,�owner) �OIO�' Attach a Dopy of the current operation and fiance confim(to be —Attach a copy of the DEp approval a _Other(describe): i Approximate age of all cozuponen�date / �if�kno"�) �of information: Were sewage odors detected when g Wivin at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimned) Property Addresst o�C e� Owner. Date of�spection: - 'I- o j BUILDING SEWER(locate on site Plan) Depth below grade: o240 Materials of construction _ C Distance from private water supply well or suction line:other(explain): Comments(an condition of joints,venting evidence of leakage,etc-): SEPTIC TANH; " _(locate on site plan) Depth below grade: Material of construction: —other(explain) concrete fiberglass_polyethylene If tank is metal list age:— Is age confirmed by a�fi� certificate) of Co cafe) mpliance(yes or no):_(attach a copy of Dimensions: X /o Sludge depth, dL Distance from top of sludge to bottom outlet tee or baffle: Of o2 9 `� Scum thickness. �� Distance from top of scum to top of outlet tee or baffle:­2-�' Distance from bottom of scum to bottom of outlet tee or baffle: 7 How were dimensions determined; v e R �c ( ga Comments on punVing neoommendaii�mlet and et we or baffle co asy l+elated to outlet invert, dew of l �� edition, iMgdt,,limed levels ge a GREASE TRAPaZogte on site plan) Depth below grade: Material of construction:—ce (explain): metal— —pobethylene._other . Dimensions: Scum thickncss:_ Distance from top of scam to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baff1�—' Date of last pumping C° (°II PwnPng recommendations,inlet and outlet tee or baffle condition,structural Integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: IL SYSTEM 6 Owner.- Date of"Ispewon• TIGHT or HOLDING TANK: must be Pumped at timeof. wspection)Qocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass—_PolYcklene other(explain): Dimensions: QaLons Design Flow: ttr�y Alarm present(yes or no): Alarm level:Date of last pumping Alarm in working order(yes or no); II Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be ocate on site plan) Depth of liquid level above outlet invert [/Jol,-j-) / Comments(note if box is level and distribution to outlets leakage' or out of bog,etc.); mil►�3'evidence of solids carryover,any evidence of p live /119 �o%c r o �ewl�s, PUMP CHAMBER:Ay (locate on site Plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Cow (note condition of Pump chamber,condition of PCPs and aPpartenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o O C eh Q�y 1"•o 0 Owner. / Date of 'on: _ or SOIL ABSORPTION SYSTEM(SAS): (locate on site 1 P an,excavation not required) If SAS not located explain why: Type leaching pits,number. leaching chambers,number: leaching galleries,number. /J -5 leaching trenches, ,length: !� leaching fields,mumber,dimensions: S f o a overflow cesspool,number:imiovativelaltemative system Ty name of technolov:Comments(note condition of soik eta):/) signs hydraulic failure,level of ponding,damp soil,condition of vegetation, L,4e— CESSPOOLS: spow must be pumped as part of mspectr• on)0ocate 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 l;mwxwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation,etc.): PRIVY:///(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition ot'soil,signs of hydraulic failure,level of pending,condition of vegetation,etc.): Pap 10 of 11 OFFICIAL INS PECTION ON FORM_ NOT FO R SUBSURFACES VOLUNTARY ASSESSM ENTS FORM GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cow Property Address: / OwnerO Date of SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal benchmaft.Locate ate all wells within 100 f�Locate includingties to c least two perana��emce or R'��Pp13'enters the building,X Pro ty - 3- Po +0 I page 11 Of 11 i OFFICIASUBSUL INSPECTIO FORM NOT FOR VOLUNTARY ASSESSMENTS RFA N RM_CE SEWAGE DISPOSA L SYSTEM INSPECTION FORM � PART C nn SYSTEM INFORMATION(contimmm PrWrtyAddresa: /b Pow �h o Owner. h'' 1 L4 Date of Inapcction: -0� r SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to gr ound water at 4,12-C Please' 7cate(check)all methods used to determine the high ground water elevation; Obtained from system design plans on record-If !0 p "merved�local �> Y/observation hole��of SAS) dedga Imo°reviewed: �l c of Haft-eglain; Checked with local ucavators,installers-(attach Accessed USGS ��) n. You must be how you established the high 217nd w/ater elevatiioon: n •S � g O�G S� wc;�-S3 zoo — - / y ' - ✓�►1 �� 00000r, i O p o ; d a 0 u . , f 9�� CAPE COD PLANNING AND ECONOMIC DEVELOPMENT COMMISSION 1ST DISTRICT COURT HOUSE. DARNSTAGLE. MASSACIiUSL'll:: U.-G.10 TCLcr►+oNE: G17-3G2-2511 USGS OBSERVATION WELL DATA* July 1987 *To be used in conjunction with the USGS procedure for estimating high groundwater levels on Cape Cod, Massachusetts . The following water level measurements are taken monthly and will be available the last week of each month. Water Level Below Well Land Surface Datum Barnstable 230 22.7 Barnstable 247 21.8 Bourne 198 31.9 Brewster 21 8.4 Chatham 138 22.5 Sandwich 252 46.5 Sandwich 253 47.2 Truro 89 10.6 Wellfleet 17 8.6 NIA ''o L'C 1A1�U✓EL '. - rDQ Z. ,rr PMT.l id( 2'IAyG¢or -y.'IT A41e0C s/1'-1I Y��1.11R 4'01A.sal 0-p,a ��-,� � 14' \Xi.2s //�•'", x'�s 5G.So 40 '%L.oO fkYTTe.(eK&-52.-e kAIS--AU-tr. F—HAu44j. e-ve-a!: a tJ11FHJ IZ"o Fl.�ls� gl�aoe. LoT Ila 1 s( _-W-L ... SSly 1,1.107 p-4'S�JI A//�� QAQFa "�`(6 :LI,o WaLLJ4 Ij :tee 1 97 5 j q¢A✓t . 46.2 i� � '� NE MAxI.?:J•-I 4Ro.w4k�a Ws Fatpara� xtD 1 ^21:n I FI=opeassvl:te,d o.J011.�4 1 .op'F Smnl —' I ol•4 '.J r4 _Y — I - '1311J �ovlCgotas Ea)1(4)pvwm.l%c' A9K4�� 1� 5 AI uTyr'to.� d.> � i 1 �e.l t�f.:1 I 1 i - �1•DI I I ' - l �1'.r of..oJu:f1L AealaO /.Fox Dom) B111 i<:: No. 1 58 ' - supIts ,n,� r o 1.1„L °sue u w.u.uc a IiQ 51tP`"���a• 1J:°� 18 ocG�.1 aVa,Co'rO. T.HASl, 9 F+ 3 Gl60 -�)nAtt PReY'w'cv'� 7-`7-93 'F.0 O x 11-1 YAO.400 Z mar,NA f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 W J d ly , Y v�. In JS TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 LA Owner's Name: ANN COURVILLE Owner's Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Date of Inspection: 6/4/01 jDEPT. �.P--vName of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 JUN 1 Telephone Number: 508-564-6813 FAX 508-564-7270 TD HEALTH CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditional lyh6ses _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: Date: 6/4/01 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec on. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO 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. Titlp C Form 01C0000 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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: SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY 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 tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 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: n/a 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 _obstruction is removed ND explain: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 FOX DEN BLUFF.ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 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 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 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: n/a �4 f, Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 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 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 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed 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.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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—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 M should contact the appropriate regional office of the Department. n Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 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 of 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: 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)] �r S Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 FOX DEN BLUFF ROAD COTUIT, MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 5 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 Design flow(based on 310 CMR 15Q03): n/agpd Basis of design flow(seats/persons/sgft,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 Last date of occupancy/use: n/a OTHER(describe): n/a 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 TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/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 Approximate age of all components,date installed(if known)and source of information: 7 YEARS Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 BUILDING SEWER(locate on site plan) Depth below grade: 180" Materials of construction:_cast iron X40 PVC_other(explain): n/a 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: 120" 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: 150OG L 10' 6" H 5' 6" W 5' 8"" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM 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.): n/a I aZ 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: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/0I ` 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 Design Flow: n/a gallons/day Alarm present(yes or no): N/A 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: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 1S STRUCTURALLY SOUND,SYSTEM APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a I q Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS ARE STRUCTURALLY SOUND AND APPEAR TO BE FUNCTIONING PROPERLY.THE PITS SHOW NO SIGNS OF HYDRAULIC FAILURE. 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 Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/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 Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "SYSTEM INFORMATION(continued) Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN COURVILLE Date of Inspection: 6/4/01 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. �p SAC t' � C AA 18i At AC 33 AD L � 3a 33t I .s in Page I 1 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 FOX DEN BLUFF ROAD COTUIT,MA 02635 Owner: ANN.COURVILLE Date of Inspection: 6/4/01 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 10+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 You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS-10+FEET tl 11 TOWN OF BARNSTABLE LOCATION�� T'O� �$ �U SEWAGE#-17✓nSr VILLAGE OqU i`— ASSESSOR'S MAP&PARCEL NAME&PHONE NO. Tf «<®,G(b y\h SEPTIC TANK CAPACITY ,S60 Cf-J LEACHING FACILITY.(type) C9 q ITS (size) 660 NO.OF BEDROOMS OWNER �,, c0C-1y Me_LD-,(1(v\0ft PERMIT DATE: C004ftfA44eE DATE: *3/O- 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 r _ 34 2 1 33 Water Service r Fox Den Bluff Road 03 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH G� TOWN OF BARNSTABLE A liration for Di�� ooul 3�i urko Toastrurtion rr�� � � mtt AppIicati t�s�hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disp a System at _X ff d. Location-Address ex � 1 et/E of ---------- --- - •••••--•••-••-••••-•-• JJ W Owner t Address Installer Address UType of Building /� Size Lot............................Sq. feet ., Dwelling— No. of Bedrooms.......4.............._-----------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( 3) — Cafeteria ( ) Otherfixtures•.._ .. ___ __________________________.________.______-..-.__.-_....__--.__...__..__._.....__.._.____A __ ___ W Design Flow...........................�__.�I __ gallons per person per day. Total daily flow_.______._______._.___.. .____gallons. WSeptic Tank—Liquid capacity_ gallons Length---------------- Width................ Diameter---............. Depth.............. x Disposal Trench-- N . .................... W• th__ _-._.-_-___._.. Total Length.................... Total leaching area....................sq. ft. 3 Seepage u _--_ Depth below inlet____________________ Total leaching area..................sq. ft. See a e Pit No._______ , _.. Diamete . /'' Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by....... .................................................................. Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •...•••••-••-•--------------••••-•--•--•--•••-...•••-•-•••---••••••--•-••---••--••------•--•-...._...._......---•---•-..._.._--•-•-•••-...._...----•--__---•- ODescription of Soil.................................................................................................................................................... ................... W •••••••---•----------------••......._.._._.._...-••---•-•-----•----•---------•-•----•••-••••---•.. --•--- •-• •••-•••.................. U Nature of Repairs or Alterations—Answer when applicable---------------------------- __________ _ _ _ __ _ __ ___________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environm ntal Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenTssue -by--the board of health. Signed . ...... ...............: . ...................................... �- to Application Approved By ... . . ........... ...... ... ...... -O. .... to Application Disapproved for the following reaso ............... ............................ ............................. .... .................................................. -........ ... �-•{ .............. 3 Permit No. .... ........... .... .................... Issued ...... ..--. .... — /Date...... ���� — ——————————— �'^.^"'w^r`i�r.l'�v-..-?:.--/ti--r'�1..'�.'v'+J"• '--�..✓-:i-o--lip•.-'--r'+ir`tiy/-r'� - V �--w4i'.._.. _ �...ra._ No...... ....._....... FEB...AV THE COMMONWEALTH OF`MASSACHUSETTS I BOARD OF HEALTH I TOWN OF BARNSTABLE a\X Appliration for Di►ipwial Works Towitrnr#iun Frrm' d Application is!!--hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �'W Location- \ddress J /1 � _.ps/�,ot --- 6x De Owner /JO 1 �/�/� ..Address � �._..--•--.._.../jam.`... •----------------•--._...-•-•--------•-------------•--•------ -•S/.-----❖r-•-u�-------f••---v.r--=-l-�--(--:.....----•-••-----•----•--..........---•--......_.. � lustaller Address Type of Building / L Size Lot............................Sq. feet Dwelling— No, of Bedrooms.--_-.- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ---------------------------- No. of persons---------------------------- Showers (3) — Cafeteria ( ) d Other fixtures .-. . W Design Flow../......................�..��._....gallons per person per day. Total daily flow....................__. .._,. .....gallons. WSeptic Tank—Liquid capacity_�.r,�._galIons Length---------------- Width---------------- Diameter_- ............ Depth................ x Disposal Trench—N ...... W• th..J............... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No------- ._.. Diamete ._ . ! ___... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by Date....-.,.................................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w .....................................-.............................................. ....--••-•............................................................. ODescription of Soil...................................................................................................................... ----- ............. ---------- --------- ----------------- ----------------------------------------- ----------------- '- �� x '--....---•-----------------•-------•---••••-----•••--.....---•---•----------......-•••••------------------. l-..... �l_.)(%/ •--....... /--- l._....-----....--- U Nature of Repairs or Alterations—Answer when applicable...........V.............c / ._.__.._.- V/f. ............................. Agreement: ( / The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian e-has beewissued-by the board of health. Signed . Application Approved By ..Lv.. ....:.7� ,<------ -- ----- .-............ ...,te Date Application Disapproved for the following reaso ............................... ...................... ....................... ............ .........:.. .. --------------- --------------- ................................................ ..... Permit No. .... . ................ Issued .. ate...... .... '------` Date......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifirate of Tomplianre THIS FS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) y -... --------------------------------------b at ........... .... ..... 0 ...0 V------/�.�1 -1 r ��J........ - ,-J ...1./ !-.-f---------------- ---------- has been installed in accordance with the provisions of TI fI, o he St tv ronmental Code as described in the application for Disposal Works Construction Permit No. ...... .. dated .f...................._ _................. THE ISSUANCE OF THIS CERTIFICATE SHALL.NOT E CONSTRUED AS A GUARANTEE THAT THE C SYSTEM WILL FUNCTION SATISFACTORY. ARia- .................... DATE.......__........ .........�.......... alt .. .... Inspector .. . ..:16 - ".: ... ----................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q"_�)� K TOWN OF BARNSTABLE ��� No. _...... FEE...................•--• # Bispoiial L' rr//nr dun r r#i�n rrnti� Permission is hereby granted......... �! ............................................................... --..------------------------......._....... to Construct ( or . epair ) an k divi�'ual Sewage Disposal^Sys em/� T- I I at No.-----•-••-- -----------�- ..... �v17-'-----��/�- l - ..... I - • Street as shown on the application for Disposal Works Construction e mr it No.- --��-Y - ted_-e...................&.4.......... ....... .ten .: _ _.. / n/, Boar of ealth « DATE - // ; �..............•. 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I �90 �A=04'1' 03-�TVC'�x 0* 01se 134 ZA LO NO. : ADDRESS:_ejrul7"' r OWNERS NAME: /�r/ SEIJAgE P IjMIT 0. : ,�.- £W / REPAIR: . DATE ISSUED: -3 DATE .INSTALLED:.f� �© � NSTALLERS NAME: INSTALLATION OF:/5-04;> WATER TABLE:' FINAL INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE : NIS �� Fox . stvrF TOWN OF BARNSTABLE LOCATION j.f l SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER 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 c t�l� JE L mm ,ob / i4 1 SaTj o,t a 5-. S-l_,. Flo isbA. �� •�E'� ��-(��. L2 nil��J 60 28 58 5�,2 tom" sum"' s• � i Leo �51 , - �w .1e MIr "-i ��RoJ�-1�1+1d. Q rzisF�. 17!00 EjC �sla•�Ara '!,5g Z. J-�oP 'P �`'"n I i i mot•4' p-v V1il. FLZ�iA CilD t .,EQ) 4'qO(+�O �� 1 ✓' AIL 'fi�Y 44o ctpt�x Iso/ = 6 c►o G�D — -�, coo i I" OF 4lj X. SC 5'f `j -� ----- --'- ----5$l Goy -- --;x -------- 69 •5-- -- ogo STEVENW4�G� l RUM e NO 1rP Sg � Of `p p F�•kNIEL E. �'yG CDy CIVIL U I:;i.32686C y - r,„'4At. r t ,LPy 1 A {, ! S(dd - o `Dec k 3 � 00 A P'�- o vc-r -�q req 9-c- ------------.. ........ .I . 13 v e- � � v - c, qve. � . �, � y