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HomeMy WebLinkAbout0080 GUIMQUISSETT ROAD - Health 80 Guimquissett Road Cotuit - A.= 019.. 108 Commonwealth of Massachusetts Title 5 Official Inspection Form -,. ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Guimquissett Road, Cotuit M -.19 P-108 Property Address Marjorie Wallace_clo Liza Feldman Owner Owner's Name information is 40 Brown Street, Maynard MA 01754, Aril 7, 2015 required for every P page. Cityrrown 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. t Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector..key to move your cursor-do not Troy Williams _ use the return t f I Name of key. N . . _ Troy Williams Septic Inspections. IL�I Company Name — 19 Hummel Drive _ Company Address South Dennis MA 02660 City/Town State Zip Code (508) 385- 1300 S1682 Telephone Number ri License Number r B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑. Fails 1, :t f ❑ Needs Further Evaluation by{the Local Approving Authority April T, 2015 „ Inspector's Signatur "' 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 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. i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M •''t 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street Maynard MA 01754 Aril 7 2015 required for every � _ p , page. City/Town 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Guimquissett Road, Cotuit M -.19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman _ Owner Owner's Name information is 40 Brown Street, Maynard MA 01754 Aril 7 2015 required for every _ P 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 (cost.): ❑ 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 ❑ AND (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 existwhich 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street Maynard MA 01754 Aril 7 2015 required for every � p , page. Cityrrown 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 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. 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 %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form „ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Guimquissett Road, Cotuit ; M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street, Maynard MA 01754 April 7 2015 required for every p 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. El ® 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 consideredd-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 §,urface 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•3113 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 ° M 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street Maynard MA 01754 April 7 required for every � Y p �il , 2015 page. City/Town 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): 330 t5ins-3/13 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 80 Guimquissett Road, Cotuit M - 19 P- 108- _ Property Address Marjorie Wallace c/o Liza Feldman , Owner Owner's Name information is required for every 40 Brown Street, Maynard MA 01754 April 7 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information ` Description: Number of current residents: 0 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 14=28,000 gals. Water meter readings, if available(last 2 years usage(gpd)): 13=32,000 gals. Detail: :. Sump pump? _ ` ❑ Yes ® No v,14 with Last date of occupancy: � N6 No occasional after Commerciallindustrial Flow Conditions: Type of Establishment: N/A _ Design flow(based on.310 CMR 15.2013): , N/AGallons per day(gpd) . Basis of design flow(seats/persons/sq.ft., etc.):. N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ "Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No c . Water meter readings, if available: N/A t5ins-3113 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 �w 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street, Maynard MA 01754 Aril 7, 2015 required for every Y p page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/ADate Other(describe below): N/A General Information Pumping Records: Source of information: No pumping info available. 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-3113 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 80 Guimquissett Road,Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman _ Owner Owner's Name information is 40 Brown Street Maynard MA 01754 Aril<7 2015 required for every Y p - 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: i Tank, d-box and leaching were installed on 12/23/02 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: ffi w 18"+ feet t _ . Material of construction: f ' ❑ cast iron ®'40 PVC ❑'other(explain): Distance from private water supply well or suction line: , feet Comments(on condition of joints, venting, evidence of leakage, etc.): 1 Lines were found clear at the time of inspection. t r Septic Tank(locate on site plan): Depth below grade: .. W.feet Material of construction: . . ® concrete, ❑ metal ❑ fiberglass'.. ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearsv Is age confirmed by a Certificate of Compliance? (attach a.copy of certificate) El Yes ❑ No , 00 gallon 6'X10.5'X6' 15 _ Dimensions: ,' . . K _ 4„ Sludge depth:' t5ins•3113 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ----- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street Maynard MA 01754 April 7 2015 required for every — � y P page. City/Town 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 2' 8" Scum thickness none Distance from'top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r .. Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Guimquissett Road Cotuit M - 19 P- 108 _ Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is required for every 40 Brown Street, Maynard MA 01754 April 7, 2015 page. City/Town 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): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): `Dimensions: N/A N/A Capacity: gallons N/A' Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A "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 — 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street required for every , Maynard MA 01754 April 7, 2015 page. City/Town 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 level 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.): D-box was found level and in working order. No evidence of solid carry-over or backup in the past was found at the time of inspection. 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.): N/A * 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Guimquissett Road, Cotuit - M'- 19 . P 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street, Maynard MA 01754 Aril 7, 2015 required for every p page. Cityflrown State ' Zip Code Date of Inspection D. System Information (cont.) Type: 5 ❑ leaching pits number:- 2 -500 gallon ® leaching chambers-. number: with 4' stone Elleaching galleries number: 25'X 12'10"X 2' ❑ leaching trenches " `. number,length: - ❑ leaching fields number, dimensions: -= El overflow cesspool number: ❑ i 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.): Soil was sandy. Chambers were dry at the time of inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. • r Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): - Number and configuration N/A Depth-top of liquid'to inlet invert ' N/A _ Depth of solids layer f N/A N/A Depth of scum layer — Dimensions of cesspool ; N/A Materials of construction N/A _ Indication of groundwater inflow, ❑ Yes ❑ No 6 t5ins•3113 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street Maynard MA 01754 April 7 2015 required for every Y p , 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.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 80 Guimquissett Road Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman _ Owner Owner's Name information is 40 Brown Street, Maynard MA 01754 April 7, 2015 required for every -- page. City/Town 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 e � , L! - — — — — - tA' � 'Z�i � , 3y! 3 3y ►�- ►ort .r O O-. t5ins•3/13 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 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is 40 Brown Street Maynard MA 01754 Aril 7, 2015 required for every � Y P page. Cityrrown 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: 11.0'+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: 10/2/02 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: MIW 29 Zone A 8.1' 1.6'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 11.0'. Hand augered 5.2' below bottom of leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection was 1.6'. Bottom of leaching at 4.8'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �y 80 Guimquissett Road, Cotuit M - 19 P- 108 Property Address Marjorie Wallace c/o Liza Feldman Owner Owner's Name information is required for every 40 Brown Street, Maynard 'MA 01754 April 7� 2015 _ — 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 t t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION � 0 G UZAIO U 1 S.Sel'r RU2 SEWAGE # �bo 2-1/76 VILLAGE C o fJl-f ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. .T AI A CCU,/mil lss'eX r S O / SEPTIC TANK CAPACITY 1 S-Q 0 LEACHING FACILITY:,(type) If$ u U e LL S (size) NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: I� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist .on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6u"vv�q, 1Se f c� w . C TOWN OF BARNSTABLE � may.' . � � LOCATIONIJ(/ l � SEWAGE # VILLAGE ASSESSOR'S MAP & LOT &PHO �//Di� f SEPTIC TANK CAPACITY �� r �r LEACHING FACILITY: (type)�� � (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE- COMPLIANCE DATE: —� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of WetVan, ping Facility(If any etlands exist within 30 cili Feet Furnished b o 60 CZw�w�o�v`SSe'� 2oa� Co Evt�' I ' \ i \ I � 1 Fra1.f of �S¢ I I t ' No. '� (�/ Fee50. 00 6 66l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppfication for Migogal 6petem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( )XX&Complete System ❑Individual Components Location Address or Lot Nc8 0 Gu i mqu i s s e t t Road Owner's Name,Address and Tel.No. Cotuit Mass. Marjorie Wallace Assessor's l�ap/Pazcel Loff Same Installer's Name,Address,and Tel.140.5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No-5 0 8—2 7 3—0 3 7 7 J.P.Macomber & Son Inc. JC Engineering, INC. 5 Round Hill Blvd E. Wareham,Mass. Type of Building: 02635 Dwelling XX 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Omitting cesspools. Installing - 1 -1500 gallon tank 1 -Distribution box and 2-500 gallon leaching chambers packed in ot 112 s one. 25 'X12 ' 10"X2 ' 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 issuld by this oar of i th. SignedMIS@ ate 1 0/1 5/ 2 Application Approved by L;M� ate Application Disapproved for the ollowing reasons 0 Permit No. Date Issued IN SON, 4 -.... / >.' F 5 0.0 0 No. / � t Fee THE,COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes -PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 3-ppr cation"for Digool *pztem Conotruction Permit Application for A Permit Construct( )Repair( ')Upgrade( )Abandon( Complete System El Individual Components Location Address or Lot&A 0 Guimquissett Road Owner's Name,Address and Tel.No. Cottlit,Mass. `` �:� Marjoleie Wallace Assessor's Map/Parcel, ./ Ot .,Same e Installer's Name,,Address,and Tel.No.5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—2 7 3—0 3 7 7 J.P.Macomber & Son Inc. JC Engineering,INC. f 5 Round Hill Blvd E. Wareham,Mass. _ ,` Type of Building: 02635 Dwelling XX No.of Bedrooms 3 ke .Lot Size sq.ft. Garbage Grinder( ) Other Type of Building i No.of�Persons 'Showers( ) Cafeteria( ) Other Fixtures r' / Design Flow gallons per day. Calculated daily flow I gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank t Type of A.S. r Description of Soil , Nature of Repairs or Alterations(Answer'wuhen applicable) Omitting Ce pools. Installing 1-1500 gallon tank 1-Distrib_ution boo an 2- 00 gallon Ieaching chambers packea in 4g o ; s one. 25'X12' 10"X2' 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 issu d by this -o of alth. Signed Date 10 15 2 Application Approved by ate L Application Disapproved for the ollowing reasons / 1 # " d Permit No. Date Issued J _ ——————— ————— ———————�`---- ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance . THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded'(XXJ Abandoned( )by J.P.Macomber & Son Inc. at 80 Guimquissett Road Cotitit Mass. Fq h b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N e ated Installer J.P.Macomber & Son Inc. Designer JFtnWq1Ae4r4!fig,Inc. The issuance of this permit shall not be construed as a guarantee'that the system w ill function as designed. Date lei a3!D Inspector -•- --- No. / ©t� *41 1101-76—� ------------------------Fee$50.00 THE COMMONWEALTH OF MASSACHUSETTS �,. . PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 4 lwizpogar &p.5tem Contruction Permit Permission is hereby granted to Construct( )Repair( )UpgradKXX)Abandon( ) System located at 80 Guimquissett Road Cotuit,Mass. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ; Provided:Constructio must b� conleted within three years of the date of this e t Date: Approved l � by y � ' TOWN OF BARNSTABLE LOCATION C7 iJ 1/1/I LJ SEWAGE # 260 VILLAGE G U%U/� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. T/ W/ SEPTIC TALK CAPACITY / LEACHING FACILITY.: (type) (size) , >2' •`c' '` ?? A NO.OF BEDROOMS J - BUILDER OR OWNER r PERMITDATE: ID �' y COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Q i �SZ 6 6u"Mq�NIse f cl DATE:8J31192_____ �t A j-C PROPERTY ADDRESS: 80_Quii guissett Road Cotuit,Mass. ------------= ---------- 02635 --------=--------------- ti On the above date, I inspected the septic system at the abo odre�ss, This system consists of the following: ATT9�Z 1 . 1 -5 'X7 ' block cesspool. Based on my inspection, I certify the following conditions: 2. This is not a title five septic system. 3 . This is a sewage system. 4 . Cesspool is in proper working order at the present time. 5. Cesspool is not large enough to handle a three bedroom house 6 . A new title five septic system should be installed. 7. Waste water & waste is 37" below the invert pipe. SIGNATUR - ---'-- - -- _-_ - Name :- J .- P . -Macomber-jr . ____ Conjpany : ,7osepl P,_ Macomber & Son, Inc. Address:__Box _E_k ___________- ---Qen-t-e Yi1-1-e,-aa -Q.2632-0066 Phone: 5 0 8-7 7 5-3 3 3 8 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 ,per t -\ COMMONWEALTH'OF M.ASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART.A CERTIFICATION i Property Address: 80 lRuimquissett 'Road - Cotuit,Mass. Owner's Name: Marjorie Wallace Owner's Address: 8/31 /0 2 Date of Inspection: Same . Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name:J_P_MacomhPr RR Son Inc. Mailing Address:gnX FF Telephone Number: 608 776 $ 2632 t 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. l am'a DEP appt'oved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) The system: Pases 'Co nditional1v Passes Needs Further Evaluation by the Local'Approving Authority Fails Inspector's Signature Date: �=3 The system inspector sha �ubmit 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 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 - - i ****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. - Jitle 5 Inspection Form . .6/15/2000 page Page 2 of 1 ] OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Quimquissett Road Cotuit,Mass. Owner:Marl orie Wallace Date of Inspection: 8 31 /02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D y A. S stem Passes 42 I have not found any information hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The e system is in proper working order at the present time. nnP nt-her hPdrnnm ; s added a new title five septic system nas to be installed. B. System Conditionally Passes: xl�) 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. X&le-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: /L Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 4 ND explain: Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 0i rn ri ssPt i Rnar3 Owner:Marl rig Wa11arA Date of Inspection: $/-t 1 /n 2 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the • system is not functioning in a manner which will protect public health,safety and the environment: AA Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS iswithin a Zone 1 of a public water supply. 'gjQ 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 bu 0 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform . bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and' the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. QThis is a sewage system. System consists of 1 -5 'X7 ' block cesspool. When addition for another bedroom is done. A new title five septic system will have to be installed. 3 Page 4 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Ouimcruissett Road cotui t;Mass _ Owner: MA}nri g Wa 1 1 aria Date of Inspection: 8r31-/02 D, System Failure Criteria applicable to all systems: You must indicate "yes" or"no" to each of the following for all inspections: Yes No ackup 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 y _ztev-L Static liquid level in the distribution box bove 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 ''A day flow _ Required pumping more than.4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ny 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 ater supply. portion of a cesspool or privy is within a Zone 1 of a public well. y 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 eater than 50 feet from a private water — greater supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no.other failure criteria are triggered.A copy of the analysis must be attached to this form,) /1/j (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 n the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped+ Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 ' Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:80 Quimquissett Road Cotuit,Mass. Owner: Rorie Wallace Date of Inspection: _8131 f 02 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 — ��'ere any of the system components pumped out in the previous two weeks ^ �-' as the system received normal (lows. in the previous two week period ? T Have large volumes of water been introduced to the system recently or as pan of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as /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 se tic anholes 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 facilityy 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. Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)J d 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR V OLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 80 Quimquissett 'Road Cotuit,Mass. Owner:Mari orie Wallace Date of Inspection: 8/31 /0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): k Number of bedrooms(actual): o DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): .%t'1�°/ = d Number of current residents: Does residence have a garbage grinder(yes or no):,C 'J Is laundry on a separate sewage system (yes or no): (if yes separate inspection required) T- Laundry system inspected (yes or no): %�,' Seasonal use: (yes or no): t, y �� �1,0 Water meter readings, if available (last 2 years usage(gpd)): Sump Pump(yes or no): e e �4�/��d�e� i�t✓ y/�_�� ��� Last date of occupancy: COMMERCIALJ"USTRIAL E Type of establishment: WW Design flow(based on 310 CMR 15.203): i9 gpd Basis of design flow(seats/persons/sgft,etc.)--_12 Grease trap present(yes or no): t2)j Industrial waste holding tank present(yes or no): 1St Non-sanitary waste discharged to the Title 5 system(yes or no):,,eO Water meter readings, if available: Last date of occupancy/use: AJ OTHER(describe): ,(J� GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no):�If yes, volume pumped: _gallons How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 4v1single eptic tank, distribution box, soil absorption system cesspool 44 Overflow cesspool ,(,O 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 &)ob ained from syst m owner) Tight tank Attach a copy of the DEP approval Other(describe): .Approx'mate age of II componen s date inga led �i known) and source of information: l C� Were sewage odors detected when arriving at the site(yes or no): J 6 Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Quimquissett Road Cotuit,Mass. ry `' Owner: Marjorie Wallace Date of Inspection: 8/31 /02 BUILDING SEWER(locate on site plan) Depth below grade: .....-I Materials of construction: cast iron �V 40 PVC /other(explain): Distance from private water supply well or suction line: /D y` Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight-No Pyidpnne of 1eakagp ThP -CP44�� is vented through the house vents. SEPTIC TANK4&� (locate on site plan) Depth below grade: Material of construction 4 concrete44metaL10 ftberglass.?/ olyethylene 4 other(explain) ,(J If tank is metal list age:, Is age confirmed by a Certificate of Compliance (yes or no)Y1 (attach a copy of certificate) Dimensions: Sludge depth: X Distance from top of slue 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.): Once the new system is installed Pump the septic tank every 2-3 years. GREASE TRAPt�Vlocate on site plan) Depth below grade: tX Material of construction 4,kconcrete,l meta L Xfiberglass�polyethylene,/,�9 other (explain): Dimensions: - Scum thickness: Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle:_� Date of last pumping: ,�/� - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Grease trap is not present. 1 7 Page 8 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert) Address:80 Ouimqui sc;(-tt Road C'ntni t� Mess. Owner:Mai nri e Wa llasa Date of Inspection: 81131-1/02 TIGHT or HOLDING TANW,;kL4'i;tartk must be pumped at time of inspection)(locate on site plan) Depth below grade: 16/0 Material of consrmction:;60 concrete ,,lO metal fiberglass.&_polyethylene.,��other(explain): Dimensions (/ Capacity: ,U gallons Desien Floe: gallons/day Alarm present (yes or no): Alarm level: _X Alarm in working order(yes or no): ,40 Date of last pumping: t Comments (condition o(alum and float switches, etc.): Tight or holding tanks ar not present DISTRIBUTION BOX4,,�c,Y. (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.): DiGtrihutinn hnx iG not nraaant PUMP CHAMBER4o4j,,,,E(locate on site plan) Pumps in working order(yes or no) Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chambpr is not nrespn+ t 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:80 Ouimquissett Road Cotuit.Mass. Owner: ce Date of Inspection: 8 31 02 SOIL ABSORPTION SYSTEM (SAS): /(locate on site plan, excavation not required) _1-5 'X7 ' block cesspools If SAS not located explain why: r n[`af Pf�' �PP gP 10 Type 2M leaching pits, number: leaching chambers, number: d leaching galleries, number:_Q leaching trenches,number, length: 0 leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Limy sand to fine coarse sand No signs of hydraulic failure Or nnntii nQ Soi 1 s are dry Vegetation is normal CESSPOOLS: // (cesspool must be pumped as part of inspection)(locate on site plan) NurRber and configuration: / Depth—top of liquid to inle �t�vert: Depth of solids layer: _-lam Depth of scum laver: Dimensions of cesspool: n Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Same as above PRIVY41Z(locate on site plan) Materials of construction: �,+A Dimensions: Depth of solids: y Comments(note condition of soil, signs of hydraulic failure, Level of ponding, condition of vegetation, etc.): t y Privy is not present. t - . 9 Pagc 10 o/ 1 I OFFICL.A,.L fNSPECTION FORM — NOT FOR VOLUNTARY ASSESSMEN-rS SUBSURFACE SEWACE DISPOSAL, SYSTEM INSPEC 1(DN FORM PART C SYSTEM fNFORMATlON (coniinvcd) ' P'opfrn A00fCI,:80 Quimquissett Road (`ntt�i 'Mass Orotr:8/31 /OZ Disc o1 Inlpmioo:Maja le Wallace SK,f'TCH OF SEWACC DISPOSAL SYSTEM v Ao.ioc iksicn 011nc iawilr diipoiil iyltcm inclvdIng 11c1 to it Ica71 two permincm rcfcrcncc ILnc/n1rkf o, oanrnmvki to<i,c iII wili� w;in' ocric wn,<rc pvb is wrtcr lvpply cnim inc pviloinj. s • 4` MQ � µt I � I � Fra1f c �o�� Page I 1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Guimquissett Road Cotuit,Mass. Owner:Marjotie Wallace Date of inspection: 8/31 /02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Jfeet Please indicate (check) all methods used to determine the high ground water elevation: No Obtained from system design plans on record - If checked, date of design plan reviewed: NA yg,(; Observed site(abutting properry/observation hole within 150 feet of SAS) No Checked with local Board of Health-explain: NA ; yes— Checked with local excavators, installers- (anach documentation) y�g Accessed USGSdatabase-explainhf-t-n• //tnwn harnst-able.Ma.Us. You must describe how you established the high ground water elevation: Used: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level. Used; USGS; ohs -rva ion well data, June 1992 Used: USCR- Tpchnical htillatin 9 -000-1 Plate #2 Annual ranges of around water Al Pvai--i nnz_ .Tani anry 1992 roun77 Leaching Pit Groundwater reet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per FrimP ter Method Therefore, the vertical separation distance between the bottom 7 Of the leaching pit and the adjusted groundwater table is feet. r i 11 f n i•r:--ram— rr. mr•ntr-rrs-mtrr.rr-r.:-.rr+^mrr:-+n.Trt�mntts +av-rsT rrn ... �.��.�r-..-. ._... t'" •r, Barnstable F TOWN OF BOARD OF HEALTH 1 S0IIS(1ItFACF SEHAOF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION ,..-•.••r••-•.:r—-.t z^.-.--n.r.-n•rt:rr rZrr trsTr errrr r.•.�r-sin•*-s.r.nmr-t'+n++�e4a� •rt mn r•�*sn-mtiv, ,� -TYPE OR PRINT CLEARLY- PROPERTY .INSPECTED STREET ADDRESS Guimquissett Road Cotuit,Mass. ASSESSORS MAP , BLOCK AND PARCEL # � OWNER' s NAME Marjorie WAllace PART D - CERTIFICATION Y NAME OF INSPECTOR Joseph P,Macomber Jr. COMPANY NAME J.P.Macomber & Son Ini°'. COMPANY ADDRESS Box 66 Centerville Mass. 02632 Street Town or City Stet• iIP COMPANY TELEPHONE ( 508 ! 775 - 3338 FAX ( 508 1 190 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate , and omplet•e as of the time of inspection , The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check�Zystem: one ij PASSED The inspection which. I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or- the environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* a The inspection which I . have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE "CRITERIA of this inspectio f rm . Inspector Sgnatur - Date e copy of thi c t.ification must be provided to the OWNER, the DUYER On where applicab and the BOARD OF 11EAL7'II, * If the•, inspection FAILED , the owner or"" perator shall upgrade ' the eystem within one. year of the date of the inspection , unless allowed or required otherwise- as provided in 3.10 CMR 16 . 305 , partd . doc 5" DIA. OUTLET(S) FINISH GRADE OVER CHAMBERS = 97.8'- 98.9' GENERAL NOTES SLOPE 2% MIN. OVER SYSTEM REMOVABLE COVER @ FINISH GRADE OVER D-BOX- 98.3' I 4" SCHEDULE 40 PVC MIN SLOPE 1% 3/4" TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE - ( 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE @ FND. EL.= 997 FINISH GRADE OVER TANK EL.= 98•6 + 2" OF 1/8" TO 1/2" DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. -._____ _.-__------__..___ ___ ___.�__ , PLACE RISERS ON ALL CHAMBERS 20" MIN. ACCESS COVER TOP OF SAS = 96.83 TO 6" OF FINISHED GRADE 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD (TYPICAL FOR 3) 36"MAX. 9" MIN. EXISTING 4" //f 96.00' 36' MAX. BREAKOUT EL = 96.50' OF HEALTH AND THE DESIGN ENGINEER. C.I. PIPE V 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL 2" DROP MIN. PROVIDE WATERTIGHT BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. - 6" 3" 3" DROP MAX. 3" 9 � JOINTS (TYP.) o 0 0 0 0 0 0 oo ' 4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN 4" PVC IN FROM o0 � 14" `\�-96.50' SEPTIC TANK 4" PVC OUT TO o 0 0 0 o ELEVATION = 96.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS 9 9'1'± LEACHING FACILITY o0 00 o A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF oo THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. o 96.75' + 12 2' o 00 0 00 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. OUTLET TEE 96.30 MIN. 96.13 � oo � i 48" � � � � � � � � � o 000 � � � � � oo i 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 6" CRUSHED STONE o 22.9' - 22"ZABEL FILTER OVER MECHANICALLY o 0 MODEL#A1801 HIP 4' I 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED COMPACTED BASE 8.5' I (� 3.55' 3 55' PRIOR TO BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND (GAS BAFFLE ON - -- 25.0' - 4.9' READY FOR INSPECTION. SYSTEM IS NOT TO BE BACK FILLED BOTTOM) 5 OUTLET DISTRIBUTION BOX 87 27' (2 P.) WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH. TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.- PROPOSED 1500 GALLON CONCRETE SEPTIC TANK BASE. FIRST TWO FEET OF OUTLET 94.00 - PIPES TO BE LAID LEVEL. 5' MIN. 8. ELEVATIONS BASED ON ASSUMED DATUM OF 100.0' MSL OBTAINED LENGTH 10'-6' WIDTH 5'-8„ DEPTH 5'-7" CROSS SECTION VIEW FROM TOP ON NAIL IN FENCE AS SHOWN ON PLAN. DISTRIBUTION R Is_- .k ,: rNHAMPER. DETAILS I � � � II~ .,: SEPTIC TANK PROFILE ' 'T '' NOT TO SCALE 9 CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION NOT TO SCALE NOT TO SCALE THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE - - - AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY - - TEST PIT DATA -- - -- - DISCREPANCIESO H DESIGN ENGINEER. 1 p 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE STRUCTURES SHALL BE MADE WATERTIGHT. INSPECTOR: SOIL EVALUATOR: Samuel Philos Jensen f 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR �r �� h� �� ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN DATE: October 2. 2002 N. � SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. Jf - y TEST PIT#: 1 �1, 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS ELEV TOP = 98.2T _ _ * LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH ELEV WATER= >11' BGS CASE THEY SHALL WITHSTAND H-20 LOADING. ,t ;� , � PERC RATE _ < Min/In (Assumed) 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. G� a DEPTH OF PERC= N.A. 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND 4o 40 �}/ TEXTURAL CLASS: 1 UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT ON ALL SIDES o OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN EXISTING CESSPOOL TO BE m° COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN ... s'° pw r �► � PUMPED AND FILLED WITH 0 98 2T I ACCORDANCE WITH 310 CMR 15.255(3). CLEAN SAND s. f ter'.° & �, 2 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES } � 2x FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. 8 97.6' 16. PROPOSED PROJECT IS LOCATED WITHIN: CA �� ' dr . ,�} �#i .� Loamy Sand A 2.5Y 3/1 ASSESSORS MAP 19 PARCEL 108 INTERIOR PLUMBING TO REPIPED J CLEANOUT TO GRADE 0 0- 12 17. OWNER OF RECORD: MARJORIE R WALLACE PRIOR TO 90 0 FI.. 16" 96.94' t ADDRESS: 148 NOBSCOT RD. LONG SWEEP ' f: �' � L 10YR 4/6 ny d C.P � � F r' ` SUDBURY, MA 01776 B _ * • 0 - PLAN REFERENCE: BOOK 94 PAGE 47 Nail in Fence V� y a+ 24" 96.27' j 18. _ Sand Elev. = 100.00' F M-C 3� p•` Assumed tp 1 �.� :. _. ,�� :al i � 2.5Y 7/4 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. r i I' ___ _......,��.. ..m C 1500 GALLON ''�`O� / ", �" No Groundwater or SEPTIC TANK <101 r"J _'1 ? Weeping Observed 20. THIS PLAN IS TO BE USED ONLY FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT S� HED , -, .m LOCUS PLAN 132" p 9 87 27' ASSUME ANY LIABILITY FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. �w"6b. r l 2-500 GALLON y `�, ,�ii 4 LEACHING CHAMBERS---,,.. #80 ����� � N � SCALE: 1" = 1000' EXISTING 2 OM DWELLBEDRING .:: : DESIGN DATA DISTRIBUTION BOX-�_ C) fi LEGEND DECK EXISTING SPOT GRADES O v 5 EXISTING CONTOUR NUMBER OF BEDROOMS 3 (MIN. PER TITLE V) 50 PROPOSED SPOT GRADES NUMBER OF PERSONS 3 DESIGN FLOW 110 GAUDAY/BEDROOM PROPOSED CONTOUR N TP 10 -- - EiT1C - -'~ - EXISTING ELECTRICAL UTILITIES TOTAL DESIGN FLOW 330 GAUDAY 98x27 v' DESIGN FLOW X 200 % - 660 GAL/DAY ' moo- GAS EXISTING GAS LINE USE PROPOSED 1500-GALLON SEPTIC TANK - EXISTING WATER LINE TEST PIT LOCATION INSTALL 2- 500 GAL. CHAMBERS /Vg o ti PROPOSED 1500 GALLON SEPTIC TANK 93340„ MAP 19 PARCEL 108 SIDEWALL CAPACITY 2g�8o �V 4" SOLID SCHEDULE 40 PVC PIPE 19,633 SQ. FT. (LENGTH + WIDTH) (2) (2' HIGH) (.74 GPD/S.F.) = GAUDAY I] DISTRIBUTION BOX (25.0' +12.0') (2) (2') (0.74 GPD/S.F.) = 109.5 GAL/DAY 500 GAL. LEACHING CHAMBER BOTTOM CAPACITY i (LENGTH x WIDTH ) (.74 GPD/S.F.) = GAUDAY 1 11/08/02 JLC JLC SEPTIC LOCATION (25.0'x12.0') (.74 GPD/S.F.) = 222 GAUDAY REV. DATE BY APP'D. DESCRIPTION PROPOSED SEPTIC SYSTEM UPGRADE TOTALS: PREPARED FOR: MARJORIE WALLACE TOTAL NUMBER OF CHAMBERS: 2 TOTAL LEACHING AREA: 448.0 SQ.FT. LOCATED AT TOTAL LEACHING CAPACITY: 331.5 GAL./DAY 80 GUIMQUISSETT ROAD COTUIT, MA 02635 SCALE: 1 INCH = 20 FT. DATE: OCTOBER 7, 2002 P 0 10 20 40 80 FEET JOHN PREPARED BY: JR. JC ENGINEERING, INC. CR15W 5 ROUNDHILL BLVD. Na 41507 EAST WAREHAM, MA 02538 SITE PLAN- r � 508.273.0377 SCALE: 1"=20' Drawn By: BMB Designed By. BMB Checked By: JLC JOB No 299 ___E_.---.__