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HomeMy WebLinkAbout0096 GROVE STREET - Health 96 GROVE STREET , _ , �i r 1 / I - I A 11 �j Fee ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: u� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLotion for -mispoBof *pstem Construction Permit Application for a Permit to Construct Repair( Upgrade Abandon Complete System ❑Individual Components s Location Address or Lot No.90 &rou e,-5Vr*-e-4- Owner's Name,Address,and Tel. Qsm sb4g n Assessor's Map/Parcel 61 cr g °d 39, / Installer's Name,Address and Tel.No3Gf Designer's Name,Address,and Tel.No. ! 'v n6uu on.xf_Y1 0014ox " Ov. XkE;S 11WA .A. toV r 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)Q (Y_X_A C E 3e'l, 4 r'_ Lfb M4 '46 6 snnos (fxie,d�Yl� 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 Envir tal Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. n Si Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. &r7 Date Issued t No. Ei' �� a :. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: c/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Disposal *pstrm Construction Permit Application-for a Permit to Construct( ) Repair(V) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. � G-rtiv � r s� Owner's Name,Address,and Tel.No._;��}4 �j . eve. n t T c� Assessor's Map/Parcel 6 t .� U, Installer's Name,Address and Tel.No'3pC4� i Designer's Name,Address,and Tel.No. ,i "C1f15trut�iO�..TYY, ibex 70 . x/ �'�' /1//A 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(min.required) gpd Design flow provided '' gpd Plan 'Date Number of sheets_ Revision Date Title f Size of Septic Tank Type,of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Oo , ,�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in !• accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. _ --- — �(i i, Sigpedrr Date f:? (f r Application Approved by Dater} �� Application Disapproved by Z Date - # for the following reasons i 1J /' Date Issued Permit No. j - -------------------------------------------------------------- -------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Z Upgraded( ) Abandoned( )by at (n (Y-cn e t- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit a. ; i dated '` Installero 1 )jt � Designer — #bedrooms _ Approved design flow gpd The issuance off this 1permit shall not be construed as a guarantee that the system wi 1 fi nc ' n as ted.,,,, Date ?1 S6/�o Inspecto---------------------------------------------------------------------------------------------------------------------------------------- No. .-^r Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal �6pstpw Construction 'Prmit Permission is hereby granted to Construct( �),, Repair( �/ Upgrade( ) Abandon( ) System located at i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction/must be co• pleted within three years of the date ois permit. [ . Date / ? Approved by Y i r Town of Barnstable Department Inspectional Services De v p sAfW$TAet.r~, KASS Public Health Division 1639. 0Ys 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 1456 February 27, 2020 CLARKE, LOGAN III TR 74 OLD COUNTY ROAD EAST SANDWICH, 02537 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 . The septic system located at 96 Grove Street, Cotuit, MA was inspected on 02/19/2020 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Needs Further Evaluation by the Local Approving Authority" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: 0 Single Cesspool. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. t Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\96 Grove Street Cotuit.doc Town of Barnstable ,16 9 0.00 Inspectional Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last.year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). T O 2 YEAR DEADLINE CRITERIA _ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe(per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc t Commonwealth of Massachusetts D�q' Dag (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every COtuit / MA 02635 2/19/20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. A. Inspector Information 51Ir Lt3��- Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ® `Needs Furthe[Evaluation by the Local Approving Authority 4. ❑ Fails <hez6a 2119/20 lnspectort8ignatbre Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 96 Grove St. Property Address Hagenstein Owner Owner's Name information is required for every Cotuit MA 02635 2/19/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The ❑ Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insP.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,to Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: ""'There are 2 systems serving this property. The laundry and kitchen sink go to a single cesspool which is 600g and of precast. The rest of the house is served by a block cesspool to an overflow block cesspool. The laundry/sink system is in violation as Barnstable does not allow single cesspools 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owners Name required for every COtuit MA 02635 2/19/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool- ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No the system is within 400 feet of a surface drinking water supply ❑ ❑ Y 9 Pp Y ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts l-F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: No design plan in file Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 162 GPD 9 ( Y 9 (gP ))� � Detail: Cotuit Water District readings Sump pump? ❑ Yes ® No occ Last date of occupancy: Date upied t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 l Commonwealth of'Massachusetts TO Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / 96 Grove St. Property Address Hagenstein Owner Owners Name information is required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 6 months ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9- 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every COtuit MA 02635 2/19/20 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Cesspools per age of home, laundry system later per materials used Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 2, Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) No septic tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �. ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ ,fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every COtuit MA 02635 2/19/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): - I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Owner Hagenstein information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Overflow cesspool depicted as"C"on pg. 16 is of block construction and 6'x6'. Bottom of overflow is 9' below grade, it has 3'of effluent in it at this time, no indication of past hydraulic failure, cover is 2' below grade. It has a 2nd inlet pipe which I ran a camera through and it dead ended. This line appears to be abandoned. It presumably used to be from the laundry system but was abandoned when the newer precast pit was installed The SAS for the laundry system is depicted as"X. It is a 600g precast pit, effluent level is currently 6" below the invert, the pit shows signs of hydraulic failure including charged soils and high staining. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration cesspool to overflow Depth—top of liquid to inlet invert 6" Depth of solids layer 6" Depth of scum layer trace-1/4" Dimensions of cesspool 4x6 Materials of construction block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The cesspool is depicted as"B"on pg. 16, no indication of past backup t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 • Commonwealth of Massachusetts �n ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every COtuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C� qo� 30 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � •� 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >13' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: n/a Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Previous inspection report augered a We to 10'with NGW ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping puts the site at 26'msl and nearby surface water at Tmsl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts o� Title 5 Official Inspection Form ll° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every Cotuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 96 Grove St. Property Address Hagenstein Owner information is Owner's Name required for every COtuit MA 02635 2/19/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 © r O2,? Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this addaess and that`�he o information reported below is true, accurate and complete as of the time of the inspection. The inspe tion was performed based on my training and experience in the proper function and ma nt mance,gf on si sewage disposal systems. I am a DEP approved system inspector pursuant toection 15:340 of+ Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fail ❑ Needs Further Evaluation by the Local Approving Authority C 11/4/14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 da�of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. llSI�I t5ins•3/13 Title 5 Official Inspectio orm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Property has 3 Cesspools 2 Pipes exit house and go to 2 differnent cesspools both cesspools tie in to a overflow cesspool. All cesspools were dry at time of inspection B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health ih order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 96 grove st M Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public 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 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on:. ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 part time Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: occasional Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is Cotuit Ma 02635 11/4/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 grove st M Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1957 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 24 feet Comments(on condition of joints, venting, evidence of leakage, etc.): 1 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number.- leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): 2 Main 1 overflow Number and configuration Depth—top of liquid to inlet invert Depth of solids layer 8 at bottom Depth of scum layer Dimensions of cesspool 6'x6' block Materials of construction cocrete block Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): both main cesspools have stain line up to botttom of outlet to overflow cesspool . Overflow cesspool has a stain line 2'10" below invert. All 3 cesspools are were dry at inspection Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 C aka of Massachusetts Official Inspection Form Sewage Disposal System Form -Not for Voluntary Assessments wMEss st VMEm Johnson Jr. - Micheal Beier Owner ommel�s pine infolTk1?=15 Ma 02635 11/4/14 requia €ate ` Paw- mown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal.system,including-ties.to. at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately w_L'12 > W &A �. 3( t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: no G/W at 10'at bottom comer of yard , feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: . You must describe how you established the high ground water elevation: back yard slopes downward to abutting property. hand augered hole near property line 10' deep no GM encountered. Lowest cesspool is overflow and is 8' below surface. see attached drawing Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 grove st Property Address Willem Johnson Jr. - Micheal Beier Owner Owner's Name information is required for every Cotuit Ma 02635 11/4/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 3 T I G�per I ho b -43 T J ASSESSOR'S MAP NO. (::)19 PARCEL L 0 C A T ' - N SEWAGE PERMIT NO. �g Gr&je, VILLAGE 1 J' NAM A ADDRESS u t� �tij 1 8UILDER OR OWNER 0 A T E PERMIT ISSUED _ 0ATE COMPLIANCE ISSUED r �(�S C- f uto ��RI: t� 0 �y 7 �atitR�/u Postal CERTIFIED MAIL@ RECEIPT Ln Domestic Mail Only For delivery information,visit our website at _ 7 , '. CO Certified Mail Fee Er i g� $ Jai . Extra Services&Fees(check box,add fee as appro date ❑Return Receipt(hardcop» $ O ❑Return Receipt(electronic) $ p' ark t= ❑Certified Mail Restricted Delivery $ 0 ❑Adult Signature Required — $❑Adult Signature Restricted Delivery$ _ - r CLARKE, LOGAe��I^I�TR `'� a 74 OLD COUNTY -Ge)- o EAST SANDWICH, 02537 :�� .rm 0r rrr•r• I Certified Mail service provides the following benefits: e A receipt(this portion of the Certified Mall label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders: Adult signature service,which requires the ■,You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which E■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. ) and provides delivery to the addressee specked I'■Insurance coverage is Available for purchase by name,or to the addressee's authorized agent with Certified`Mail`service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mallpiece,you may request Certified Mail item at a Post Office'for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy.retum receipt, - complete PS Form 3811,Domestic Return Receipt,attach PS Form 3811 to your mailpiece; IMPORTAN11 Sava this receipt for your records. IPS Forth 3800,April 2015(Reverse)PSN 7530-02.000-9047 i P8 Form 3811.July 205pawrsxo-0u-0no-9os Domestic Return Receipt USPS TRACKING# First-Class Mail USPS9e&Fees Paid Permit No.G-10 9590 9402 5357 9189 1906 92 United States I Sender:-Please print your name,address,and ZIP+4®in this box* Postal Service - - - - _--- - — -- -- a^'roy Town of Barnstable s Health Division I 200 Main Street Hyannis, MA 02601 I of Massachusetts TRIe 5 Official Inspection Form Sewage Disposal System Form -Not for Voluntary Assessments 9 U G rave_ S+ '0.04 r-i chnson Jr. - Micheal Beier Owner :w.-ems s Name r� informaiior:_ (z+ Ij f.t Ma 02635 11/4/14 required;tf, -^ .` per_ Zt.i own State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately dd I i '. 3(0 d f t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17