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HomeMy WebLinkAbout0068 GROVE STREET - Health L68 GROVE ST. (COTUI7) f i ,1 ' \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Grove Street Cotuit Owner's Name: Karen Daley Owner's Address: 52 Copperwood Drive StQughton, MA Date of Inspection: "/ "G Name of Inspector:(please print) Wi 1 1 jam E_ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailin Address: P O Box 1089 -T, _. l r Centerville, MA . Telephone Number: _(508) 775-8776 CERTIFICATION STATEMENT. r 'o r. 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 Zeasses tion 15.340 of Title 5(310 CNIR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: w i L Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I f Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Grove Street Cotuit Owner: Karen Dale Date of Inspection: Jsr—/G,O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S71haVe asses: 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 Condition ly Passes: One or more syste components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upo completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not dete fined(Y,N,ND)in the for the following statements.If"not determined"please explain.. The septic tank is me I and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substanti infiltration or exfilration or tank failure is imminent.System will pass inspection if the existing tank is replaced wi a complying septic tank as approved by the Board of Health. •A metal septic tank will p s inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is le s than 20 years old is available. ND explain: Observation of sew ge backup or break out or high static water level in the distribution box due to-broken or obstructed pipe(s)or due t a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Hea th): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system r quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if( ith approval of the Board of Health): broken pipes)are replaced obstruction is rcmoved ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Grove Street Co.tuit Owner:_Karen Dale Date of Inspection:. 0110-0 G Further valuation is Required by the Board of Health: Condit ns exist which require further evaluation by the Board of Health in order to determine if the system is failing to pro ect public health,safety or the environment. I. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is of functioning in a manner which will protect public health,safety,and the environment: _ Cessp of or privy is within 50 feet of a surface water _ Cessp of or privy is within 50 feet of a bordering vegetated wctland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is funcl ning in a manner that protects the public health,safety and environment: _ The s stem has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surface wa cr supply or tributary to a surface water supply. The ystem has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. _ Th system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a privat water supply well'• Method used to determine distance "Th s system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bact ria and volatile organic compounds indicates that the well is free from pollution from that facility and the p esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failur criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4orlt OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddress: 68 Grove Street o ui Owner. Karen Daley Date of Inspection: Q le oj' D. System Failure riteria applicable to all systems: You must indicate' es"or"no"to each of the following for all inspections: Yes No . Backup of ewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge r ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S or cesspool _ Static liqui level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid dep in cesspool is less than 6"below invert or available volume is less than IA day flow Required p ping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times p ped _ Any portion f the SAS.cesspool or privy is below high ground water elevation. Any portsuion f cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water ppl . Any portion of a cesspool or privy is within a Zone 1 of a.public well. Any portio of a cesspool or privy is within 50 feet of a private water supply well. Any portio of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply wel with no acceptable water quality analysis. (This system passes if the well water analysis, performe at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates hat the well is free.from pollution from that facility and (tic presence of ammonia nitrogen nd nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trigg red.A copy of the analysis must be attached to this form.] (YeslNo)Th system fails. I have determined that one or more of the above failure criteria exist as descri in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health o determine what will be necessary to correct the failure. E. Large Syste s: To be consider a large system the system must sere a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indi ate either"yes"or"no"to each of the following: (The follo%vin riteria apply to large systems in addition to(tie criteria above) yes no ttte sys cm is within 400 feet of a surface drinking water supply the syst is within 200 feet of a tributary to a sarfacc drinking water supply the syste is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of 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 ab ve the large system has famed.The cmmer ar operator of arty large system considered a significant threat unde Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o%% er should contact the appropriate regional office or the Department. 4 Page 5 of 1 I zt OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Grove Street Cotuit Owner: Karen Daley Date of Inspection: ?'/6-A Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ umping information was provided by the owner,occupant,or Board of Health V Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? (/Have large volumes of water been introduced to the system recently or as part of this inspection?. Were as built plans of the system obtained and examined?(If they were not-available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? V — Was the site inspected for signs of break out? r/ Were all system components,excluding the SAS,located on site? _�_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition' of the b'affl/es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ LW as 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 _ Existing information.For example,a plan at the Board of Health. _L_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CUR 15.302(3)(b)) 5 Page 6 of 11 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Grove Street o ui owner: Karen Daley Date of Inspection: g-/G-G FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. . Number of bedrooms(actual): o DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms): 360 Number of current residents: l Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):,&0[if yes separate inspection required] Laundry system inspected(yes or no):zA_-'0 Seasonal use:(yes or no): U Water meter readings,if available(last 2 years usage(gpd)): 2004 - 3 7,0 0 0 Sump pump(yes or no): 2003 - 25, 000 Last date of occupancy: COMMERC NDUSTRIAL Type of establi ent: Design flow( ased on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sqft,etc.): Grease trap resent(yes or no):_ Industrial ste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water me er readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Al- A Was system pumped as part of a inspection(yes or no): iL v If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYlaiEIOF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(i( ow )and source of information: /7 4 Were sewage odors detected when arriving at the site(yes or no) 6 1'agc 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAItT C SYSTEM INFOI(A ATION(continued) Property Address: 68 Grove Street Cotui Owner: Karen Daley Date of Inspection: BUILDING SEWER(locate t site plan) Dcpdi below grade: Materials of constructi n:_cast iron _40 PVC_other(explaut): Distance front priva water supply well or suction IutC: Comments(on c dition of jouils,venting,cvidcncc of Icakagc,eic.): SEPTIC TANK: ✓ `(Ivcatc on site plan) Depth below grade:�— Material of construction: ✓concrete metal fiberglass_pol}•ethylene _otlacr(explain) — If tank is metal list age:+ Is age confinned•by a Certificate of Compliance(),es or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet Ice or bafllc: Scum thickness: Z d Distance from top of scum to lop of owlet Ice or baffle: L Distance from bottom of stunt to button of outlet ice or baflic: 3 , I low were dimensions determined: Comments(on pumping reeomntenda►Gons, inlet and outlet Ice or baflic condition,structwal integrit}',liquid levels as related to outlet invert,evidence of leakage,etc.): CREASfRA P: (locale on site plan) Depth bed ._Material coon:_concrete_metal fiberglass polyethylene__otlier (explainDimensiScum IhDistanceop of scum to top of outlet tee or baffle:_Distanceottom of stunt to bottom of outlet tee or barite: Dale of ping:Conunepumping recommendations, inlet and outlet Ice or baflle cunditiu:t, structural integrity, liquid Icvcls as rclalcllct invert,cvidcncc of leakage,cic.): 7 'age 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORA-IATION(continued) Property Address: 68 Grove Street Cotuit Owner: Karen Dale Drtte of laspcctloo: TIGHT or HOLD G TANK: (tartk must be pumped at time of inspection)(locate on site plan) Dcpth below gra e: Material of cons ruction:_concrete_metal fiberglass___polyethylene other(explain): Dimensions. Capacity: gallons Design Flow- gallonstday Alann presc t(yes or no): Alarm level Alarm in working order(yes or no):_ Date of as pumping: Comment (condition of alann and float switches,etc.): DISTIUBUTION BOX: + (if present must be opened)(locate on site plan) Dcplh Hof liquid level above outlet invert: 0 Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Ieakag:e into or out of box,ctc.): f PUAIP CHA ER- (locate on site plan) Pumps in working rder(yes or no):— Alarms in workin order(yes or no):— Conunenls(note ondition 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: 68 Grove Street Cotuit Owner: Karen Daley Date of Inspection: g�-f G=—6 S� SOIL ABSORPTION SYSTEM(SAS): �/(locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number:!� tn h leac ' chambers,num_ber: g - leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): / 7 o - iy P c tL�.el < !fa .�u.✓i CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and con guration: Depth—top of I' uid to inlet invert: Depth of solids ayer: Depth of scum layer: Dimensions o cesspool: Materials of onstruction: Indication o groundwater inflow(yes or no): r Comments ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:/(note te on site plan) Materialction: Dimensi Depth of ; Commenndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Grove Street o ui Owner: Karen Daley Date of Inspection: $-f0-G-5 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ° l f5 Es 3 _ 10 Page l l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Grove Street Cotuit Owner._karen Dale Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water O -U feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 `t x� ki ? t DATE; 5/12/01-_-- PROPERTY ADDRESS; 68. Grove-Stregt_...... ---Cotuit-JW-$-•---------- ---------------- On the above date, I Inspected the septio ,ayotorl at the above address. This system consists of the following: 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3. 4- infiltrators packed in 4" of stone. saved on my In3pectlon, I certify the following conditions: 4. This is a title five 'septic,system. I 5. The septic system is in proper working order at the present time. S I G N AT U R Company; b Son , Ync , Address ;_ Box-66---------- C•nrorville � Nay-02632-0066 Phone ___ ------- THIS CERTIFICATION OOES NOT CONSTITVTE A OVARANTY OR WARRANTY • JOSEPH P. MACO:77 BER & SON, INC- ER Pumpild Instilled Town stwoonn�vtions P.O. Box 66 Clnt1111, MA 02632-0066 775-33385�6412 .\ COMMON M WEALTH OF ASSACHUSETTS EXECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Grove Street Cotnit Maas Owner's Name: Supri Dahn Owner's Address: Same Date of Inspection: 01 Name of inspector: (please print) TnG�P M ciomber Jr. Company Name:J P MaComher R Gnn Inc. Mailing Address: Rnx FF rontepri 1 t o 14a&s Telephone Number: 508-775-3338 CERTIFICATION STATEMENT 1 certify that 1 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 t Section 15.340 of Title S(310 CMR 15.000). The system: F Passes �' Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: r Date: — � The system inspector chat s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of c mpleting 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 -- '**'This report only describes conditions at the time of inspection and under the conditions of use at that I ._time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 6/15/2000 page 1 Title 5 Inspection Form Pape 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 68 Grove Street Cotuit,Mass. Owner: RnGan Dahn Date of Inspection: 5 f 1 2 f n 1 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A .System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or to 31 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: 2 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 t s� � r � ► Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Grove Street o ui ,Mass. Owner: Susan Da n ` Date of Inspection: 5 1 2 01 C. Further Evaluation is Required by the Board of Health: ,4)6 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: AThe system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of surface water supply or tributary to a surface water supply. �pl 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. /IJ� The system has a septic tank and SAS and the SAS is less than 10 feet bu 50 feet or more from a private water supply +-ell••. Method used to determine distance 1Sj�J4�� "•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: ► 3 I Page 4 of l 1 ` OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Grove Street Cotuit,Mass. Owner: Susan Dahn Date of Inspection: 5/1 2/01 D; System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes YXackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ���,?,�llorS iquid depth ir� is less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q. Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface _ water supply. Any portion of a cesspool or privy is within a Zone I of a public well, ny portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 (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 _ Vthe system is within 200 feet of a tributary to a surface drinking water supply ;--t/he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped. Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a ' significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 .. Page 5ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Grove Street Cotuit,Mass. Owner: Susan Dahn Date of Inspection: 5/1 2/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No umping information was provided by the owner,occupant, or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? Were all system components,-ekluding the SAS, located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the b fles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no 1 Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of I I t 4 ; OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-NI PART C SYSTEM.INFORMATION Property Address: 68 Grove street Cotuit,Mass. Owner: Susan Dahn Date of Inspection: 5 1 2 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):__.� Number of bedrooms(actual): DESIGN (low based on 310 CMR 15.203 (for example: 110 gpd x a of bedrooms):�j_z; � Number of current residents: Does residence have a garbage grinder(yes or no):Ale) Is laundry on a separate sewage system (yes or no):/ (if yes separate inspection required) i,7 Laundry system inspected (yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage(gpd)): Sump pump(yes or no): � ,�� Last date of occupancy: D� COMM ERCLAUINDUSTRIAL Type of establishment: ,(J Design flow(based on 310 CMR 15.203)_ gpd Basis of design now(seats/persons/sgft,etc.): A Grease rrap present(yes or no): dd Industrial waste holding tank present(yes or no)4?,I' Non-sanitary waste discharged to the Title 5 system(yes or no)4 Water meter readings, if available: Last date of occupancy/use: _ OTHER (describe): yfl GENERAL INFORMATION Pumping Records , Source of information: r�0r.'a 'A`as system pumped as pan of the inspection(yes or no): _ l es. volume pumped: O allons •• How was quantity pumped determined?'_ Reason for pumping: TYP OF SYSTEM optic tank, distribution box, soil absorption system Single cesspool gOverflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) lnnovatiYe/Allernatiye technology. Attach a copy of the current operation and maintenance contract (to be obtained tom system owner)' ,Night Wik 4,0 Attach a copy of the DEP approval Other,(describe): Ap ro.rimate age of all ompo nts,date installed (if wn)a rce of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 68 Grove Street Cotuit,Mass. Owner: Susan Dahn Date of Inspection: 5/1 2/01 BUILDINC SEWER (locate on site plan) Depth below grade:-_�� Materials of construction: cast 'von 40 PVC mother Sexplain): •CJ/¢ Distance from private water supply well or suction line: le Comments (on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: Zlocate on site plan) Depth below glade: 1.L Ma terial of construction: t/concrete�metaltilDfiberglass4polyethylene /-Cdothcr(explain) !i tan.k is metal list age:Wb Is age conrLrmed by a Cenificate of compliance(yes or no)e�j(atuch a copy of certificate) Dimensions: lecr�,,x7 Sludge depth`j.,� L� _ Distance from top of udge to bonom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee o baffle:�y Hoµ Acre dimensions determined: /111`A4 Aa 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 septic tank every 2-3 years. Inlet & outlet tees ' are in p ace;T a tank is structurally- sound and s owsno evidence of leakage. GREASE TRAP (locate on site plan) Depth below grade:/' Material of construction:-if4 concrete,,&metal 1&fiberglass 4I_polyethylenc4!±other ;e.xpIain): ,Vy4 Dimensions: 414 Scum thickness: _ - Distance from top of scum to top of outlet tee or baffle: ' Distance from bonom of scum to bonom of outlet tee or baffle: to Date of last pumping: A� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inven, evidence of leakage,etc.): Grease trap is not present- 7 9 Page 8 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Groue Street Cotuit,Mass. Owner: _Susan Dahn Date of Inspection: 5/1 2/01 TIGHT or HOLDING TANK4 !&(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: AM Material of construction: concrete/ i metal Aj&fiberglass AZ polyethylene42,6 other(explain): NV Dimensions: Capacity: gallons Desien Flow: gallons/day Alarm present (yes or no): z0 Alarm level: 04 Alarm in working order(yes or no): Date of last pumping: A)1? Comments(condition of alarm and float switches,etc.): T ghttor holding tanks are not Aresent DISTRIBUTION BOX: Z(ir,resent must be o coed Ica p )( o to on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Di Stri hilt i nn hnx has one 1 atera 1 Nn em'i dtznc-P of col i dG carry near No ell drone-P of 1 eakage intn nr niit- of the hnx PUMP CHAMBEP4)d1 (locate on site plan) f Pumps in working order(yes or no): th Alarms in working order(yes or no): j),!f Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not present _ 8 0 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: 68 Grove Streetr Cotuit,Mass. Owner: Susan Dahn Date of Inspection: 5 1 1 2/01 SOIL ABSORPTION SYSTEM (SAS): (locate on,site plan,excavation not required) If SAS not located explain why: Located Type leaching pits,number:Q � leaching chambers,number:�'• 4 y�leaching galleries,number: V,!)_ leaching trenches,number, length: d �leaching fields,number, dimensions: A&AL overflow cesspool, number: O 4 L 4& innovative/alternative system Type/name of technology:/�` � �Gl Comments(note condition of soil, si<_ns of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamt sand to fine sand.No signs of hydraulic failure or ponding.Soils are dry. Vegetation is normal. CESSPOOL(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 laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):dA Comments(note condition of soil, sins of hydraulic failure, level of ponding,condition of vegetation, etc.): Cesspools are not present. PRIVY locate on site plan) Materials of construction: Dimensions: Ate' Depth of solids: Comments(note condition of soil, s ns of hydraulic failure, level of ponding, condition of vegetation,etc.): Privy is not present_. 9 Page 10 of 11 OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Grove Street Cotuit,Mass. owner: Susan Dahn Date of inspection: 5/12/01 . 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. ?7,FZ Ti O� ri !p� t4 y.t.� !�tr l'.�'f�ha t i �-Irn.��.:�::•J t. OF 10 k y TOWN OF BARNSTABLE LOCATION A I SEWAGE-# VILLAGE Cam ASSESSOR'S MAP & LOT Oa6. 1 d INSTALLER'S NAME&PHONE NO. -�� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �1' !,s./ (size) ��— NO.OF BEDROOMS - - B:UTi DES.OR 0 V,'NER a PERMIT DATE:..-2— 7 COMPLIANCE DATE: ^ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and LeachingTacility (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 ... �:.. _ ._...v ' .. _.. t � ._ ! 'L.i.._.._. • . .�.0 C.aS"'.Y ,.3....I�Cx+S wi!tJ-Y'.'°i..E{CY��S.d''' -' _ LP ' I r,� 4a g e I I of I I '' r •" OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ProperT Address: 68 Grove Street Cotuit,Mass. Owoer: Susan Dahn Date of Iospectioo: 5/12/01 SITE EXAM Slope Surface water Check cellar Shallow wells r _sumated depth to ground water.&Yfeet Please Indicate (check) all methods used to determine the high ground water elevation: to ed I s on record - If checked,date of design plan reviewed: ` served site abut;09a 7roop bservation hole whin ISO feet of S) ecked wit local th-explain:ljfj¢1,I'J �/ ,/ $ /,� Checked with local excavators,installers.(anach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used water contours map aAhret-v R Mi 1 1 Ar Mnrlal 1 2 /1 ti /9 4 • iE f • II w►•nlr+M�-.w1.wwww.1-r.+w�.1/w1.RwR n'T1u n►w�w�T ART-�-+.- .. ,- TOWN OP Barnstable BOARD OF IIEALTII SUIISHFACF SFWAOF 1)I9r'OSALSYSTEM INSPFCTION FORM PART D •- CERTIFICATION ••�nT••.•'.:t-�.I i11-�TTI..r7ww.A Tw1PI.IRwS r7n��Aw-Taw-wI w�ww-w��I� ww y,��r....�.�. _. -TYPO 0A PAINT CI.CAALY- PROPERTY INSPEC7'CD STREET ADDRESS 68 Grove Street Cotuit,Mass. ASSESSORS HAP , BLOCK AND PARCEL # OWNER' s NAME Susan Dahri PART D - CERTIFICATION NAME OF INSPECTOR _ Joseph P. Macomber Jr, COMPANY NAME Joseph P. Macomber &"Son, Inc. COMPANY ADDRESS Box 66 Centerville MA. 02632-0066 Str••t Tovn or City itat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dieposa`1 system nt >r1ecoinmendaL' Ions his nddress and that the information reported is true , accurate , and omplete as of the time ot - inspection . The inspection was performed and any regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems , Che,ck�ne ; � SY stein PASSED The inspection ►+h'ich I have conducted has not found any information which indicates that the system fails to adequately protect public (health or the environment as defined in 310 CHR 16 - 303 . Any failure criteria not evalunted are as stated in the FAILURE CRITERIA section of this forin , System FAILEUx The inspection which I have �conticted has found that the system fails to protect the E)ublic (health and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection fo m . Inspector Signature Date On e copy of this. Vtirication must be provided to the OWNER , the BUYER ( whe re appl ioable ) and the BOARD OY HBAL'I'll, • If the Inspection FAILED , We owner ors'operator shall uperade ' the eyetem . within one ,year of the dote of the inspection , unleaa allowed or required otherwise as provided in 3.10 CHR 16 306 partd , doc TOWN OF BARNSTABLE 7 LOCATION ✓fit S� SEWAGE# / VELI:AGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY �yr00 5 7' LEACHING FACILITY: (type) (size) y S NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by FT V,TY T� 0 TOWN OF BARNSTABLEWO— f �7 .fit SEWAGE# / VILLAGE 'h- ASSESSOR'S MAP& LOT Q6 f d INSTALLER'S NAME&PHONE NO. i�ss, SEPTIC TANK CAPACITY /�®® i 7'. LEACHING FACILITY: (type) {��,�.E' (size) .NO.OF BEDROOMS BUILDER OR OWNER PERMI TDATE: COMPLIANCE DATE: �6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply.Well and Leaching Facility (If any wells exist-, on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands eicist within 300 feet of leaching facility) Feet Furnished by - - 1 �� _ C TOWN OF BARNSTABLE :,OCHTION SEWAGE # VILAGE 1,8 ASSESSOR'S MAP &LOT© D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS a BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 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 n III 1'�� ��o`1 � o ��o� ��� �. '!Y'AT�JN SEWAGE M VILLAGE � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) //l/�/7/ `•��' u) NO.OF BEDROOMS 13 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 (I-f,any wells exist Fat on site or within 200 f t of leaching facility) Edge of Wetland an ng Facility(If an wetlands exist within 300 fee ci ' Feet Furnished b ° �� ��9�s � ��� :'a�_ � __ter . _. _ ,� _ e • � lie a d o� C1�j••yc � � / / � � ��� ..— ' ��� j � i 1 � .� b'"' � �$, ,s°` a rT f No. — V93- Feet/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pprication for �Digpool *pgtem Congtruction permit Application for a Permit to er/ruct( )Repair(✓)/Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No.��qSr-6je_,5% CO -Nk Owner's Name,Address and Tel.No. Assessor'sMap/Parcel ()'r o ly °\e'v�"b1O102 IInnsttal�ler's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 2-3o gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank -- nn -_­, Type of S.A.S. 1-4 Eg Description of Soil Nature of Repairs or Alterations(Answer when applicable) MV-sV-04k� .,S-w Cc pc 54`rrt-9_ Co-, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ' this B Signed Date Application Approved by Date — Application Disapproved for theYollowA reasons Permit No. 7" L- —5 Date Issued '''j `�ji• �. * No. 1— 1� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION 7 TOWN OF BARNSTABLE., MASSACHUSETTS Yes F 2pplication for Migaar *pgtem (Construction Permit Application for a Permit{to Construct( )Repair(f)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 5F G r o-e-5 7 CG'CV'�� Owner's Name,Address and Tel.No. Assessor's Map/Parcel D 41 v a 4, /� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. - 2 lS lv teV Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ``(�( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank l r!"D C,ra.IG Type of S.A.S. 14 c C,.7/n Description of Soil ym,—y 5 Ar-n v Nature of Repairs or Alterations(Answer when applicable) _:ry_CV`1Nk� l`5;(4) t7- iY ti. C Vic;, t,� 1 C� ` i o we. c��. s _s -r ! r y t�-cf ,--r��✓ �, u , �a C. r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the"afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place thet.system in operation until a Certifi- cate of Compliance has beesq-InUC this B .af)4ealtlt, Signed Date 1� 7 -Application Approved by'�`. _ Date - Application Disapproved for the, ollow' reasons F^ Permit No. ~" V t Z Date Issued' ——————————— �-------------- --` ————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER that tbLe_O.n`_site.S wage Disposal System Constructed( )Repaired-( )Upgraded Abandoned( )by od✓� at _ s9 G r'o J C �5 T r f e+ C ca�� U,i 0A-�\ c has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 dated Installer Designer . The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date '' j 0 Cf Inspector I --G------------------------------------- No. !�, Fee ^THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migo5af *p!5tem (Construction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at re,-I- and as described in the above Application for Disposal System Constriction Permit. The applicant recognizes`his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date:` �9 - �7 Approved by NOTICE: This form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION UC SKETCH ANl) APPLICATION FOR A DISPOSAL 1VOIZ10 WNST'ItUGHON 1 10111 I' (1V1'1'IMU 1 llESIGNEU PLANS hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at J�8 zw C.OTLJT�— meets all of the following criteria: • There arc no wetlands within 300 feel of the proposed septic system • There are no private wells within 150 feet of the proposed septic system The observed groundwater table Is 14 feet or greater below the bottom of the leaching facility • There is no increase in now and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan, this plan should be submiticdl. G a 0