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HomeMy WebLinkAbout0048 HIGH STREET - Health 48 Hi is et ---- --- - -- - - - - ---- - --- - - ` - 6 A 035' 04 � t f No. a1 t — ,.. r Fee V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftprication for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(, J`'Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. 4tb Ifi5h <A-, ( Owner's Name,Ad ss,and Tel.No. n `` Assessor's Map/Parcel 03s v`� 1 f-fsa nS Wti -sh e l �OZ C15-6 Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No. j3 d,a—o G;th Ott T►%f— 311 7�l 3�9 ��3 tr.. wv__-C�3 � —' Dvs2"/ 66 ( cu5ord`i2��33�t� Type of Building: s Dwelling No.of Bedrooms Lot Size e �e{ AtlQ,tSS 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) C6AAe%,'1 `*,nk (2s5e,a � (?o56=� , Z CQS�ead� w %-,J•, K�S �5 gel k �C.,�i� orwr ,� ��� 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 Environment de and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe c — Date Application Approved by ` ;1 Date 7 1 Application Disapproved by Date for the following reasons Permit No. � g7 Date Issued 7 — -— >� ------------------ - - - No 3J t I— .. > x y x ,,. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered,in computer:;. PUBLIC HEALTH DIVISION - TOWN OFBARNSTABLE, MASSACHUSETTS Yes` pplication for ' al *pstrm Construction jermit Application for a Permit to Construct( ) Repair(✓<Upgrade( ) 'Abandon(_ ) ❑Complete System 2<ndividual Components Location Address or Lot No. ti �1�5k1` ( Owner's Name,Address,and Tel.No. qs N`5h-A Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. /36Ac to UA t CAN% ��-'��i 3?9 tr., Type of Building: Dwelling No.of Bedrooms L Lot Size (44 sq.ft. Garbage Grinder�(a ) 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 orAlteyrations(Answer when applicable) Ce►'4o x'— S�h� es-2e\, ` T b C'ee '1 Date last inspected: t 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 Environme, t.d not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. /v 3 Signed Date Application Approved by ?t Date _Application Disapproved by U Date ` for the-following reasons - Permit No. /�� Date Issued / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(, Upgraded( ) Abandoned( )by \\ a l f► i 11 at 11 4��5� 00 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated „ -; -7 41 Installer Designer #bedrooms Approved design flow -1 `1 U and The issuance of this pe t shall not b .construed as a guarantee that the systern"`will fu ct'i as degne Date Inspector,. ----------- - - - -' - - -- -- - ---=-- - ------------------------------- 0 --------- ----=----------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstetn Construction Vermit i Permission is hereby granted to Construct( ) Repair(/j Upgrade( ) Abandon( ) System located at 2,A- -o U \ 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:C nstruc'on must be completed within three years of the date of this permit. Date Approved by �� TOWN OF BARNSTABLE LOCATION SEWAGE# c46 i VILLAGE rt�, Lk i I ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 01i SEPTIC TANK CAPACITY _ LA'A j60— yt�G �o�rG LEACHING FACILITY:(type) F ►` (size) 1000 _ NO.OF BEDROOMS OWNER J�no—IL,l PERMIT DATE: It COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1-4 At— 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 AT s i fib' TG p Print -.•-r- Page 2 of 3 SMITH, HAROLD& ELEANOR Jun 24 1970 12:00 AM 1476/483 $ 0 • Sketches-Map/Block/Lot: 035/046/-Use Code:1010 As Built Cards:1 e Constructions Details-MapBlock/Lot: 035/046/-Use Code:.1010 Building Details E Land ! - t Building value $ 180,700 Bedrooms 4 Bedrooms USE CODE 101( Total Improvements Value $225,851 Bathrooms 2 Full Model Lot Size(Acres) 0.61 Residential , Total Rooms 8 Rooms Appraised Value $ 14f Style Colonial Heat Fuel Gas Assessed Value $ 14 Grade Average Plus,Heat Type Hot Water Year Built 1870 AC Type None Effective depreciation. 20 Interior Floors .Hardwood Stories 2 Sty w/UAT Interior Walls Plastered Living Area sq/ft ; 1,830 Exterior Walls Wood Shingle Gross Area sq/ft 3,620 Roof Structure Gable/Hip Roof Cover Asph/F GIs/Cmp • Outbuildings&Extra-Features-Map/Block/Lot:.035/046/-Use Code: 1010 Code Description Units/SQ ft Appraised Value Assessed Value FPL3 Fireplace 2 story l $ 3 600 $ 3,600 htt ://www.t P own.barnstable.ma.us/Assessing/print.asp?searchparcel=035046 6/17/2011 fl j 13 1 .. COMMONWEALTH"OF MASSACHUSETTS. EXEC UTIVE,O.FFICE:OF ENVIRONMENTAL:AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS:- SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 48 Htkh Street -CotWt MA 02635' Owner's Name: Christine Cotter (n . Owner's Address: . W Date of Inspection: March 13; 2611 ` Name of Inspector: (Please Print) Janes M fiord ..Company Name: James M Ford Mailing Address: P.O.Box 49 Osterville.MA.,02655-0049 Telephone Number. (508)8624400 t . � 1 O CERTIFICATION STATEMENT I certify that I have persopallyinspected the sewage disposal system at this:address and" hat the mforination reported, below is true,.accurate and-complete as of the time of the inspection: The inspection was performed based off4hy <,j training and experience in the proper`function and maintenance of on sewage disposal systemsI..I am a CEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) The system: ' Passes Conditionally Passes Needs Further Evaluation by the.Local Approving Authority. Inspector's Signature: Date:. March 18. 2011 The system.inspectorshall su it a copy of tnis inspection"report to the:Approving Authority(Board of Health.or PEP)within 30:days.of_coinpleting this inspection...If the system.is a shared system or has a design flow of 10,000; gpd or greater,the inspector.and the systeiri owner shall submit the report to`the appropriate regional office of the DER The original should besent to:the systein'owner and copies sentto the buyer,'if applicable,and.the approving : authority: -Notes and Cominents SYSTEMHASA SINGLE CESSPOOL' ****This reporfouly describes conditions at the time of inspection and under the conditions of use at'that time. This"inspection does not address how the system will perform in the future under the`same or different' conditions of-use..' Title 5 Inspection Form 6/15/2000 page 1 .zr i 1 Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 High Street Cotuit, MA Owner: Christine Cotter Date of Inspection: March 13, 2011:' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: T have not found.any information which indicates that any of the failure criteria described in 3.10,CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not.evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components,as described in the"Conditional.Pass." section need to be replaced or repaired. The system,upon completion of the replacement or repair;.as approved by the Board of Health,will pass. . Answer yes;.no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltraiion or tank failure is imminent.. System will.pass inspection if the . existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less.than 20 years old is available. . ND explain: Observation of.sewage backup or break out or high static water level in the distribution box due t6broken 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 puinping.more than 4 times a year,due to broken,or obstructed.pipe(s).-The system will; . pass inspection.if(with approval of the Board of Health): broken,pipe(s)are replaced obstruction is removed. ND explain:. 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 High Street Cotuit MA Owner: Christine Cotter Date of Inspection:. March 13, 2011 C. Further.Evaluation is Required by t1re;Board of Health: Conditions exist-which require further evaluation by the Board of Health in-order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines'in accordance.with 310 CMR 15.303(1)(b)that the system,is not functioning in a manner which will protect public health safety and the environment: _ Cesspool or privy is within 50 feet of.a surface water - Cesspool or privy is within 50 feet of a.bordering vegetated wetland or a saltinarsh 2. System will fail unless-the Board'of.Health.(and.Public.Water.Supplier if any)determines that;th.e 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 SA&is within'100 feet of a surface water supply or tributary to d.surface.water supply: The system has a septic tank and:SAS..and'the SAS is within a Zoned: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. . Thesystem 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 dater'analysis,perforned at a DEP certified laboratory; for colifonn bacteria and volatile organic compounds indicates that the well is free from_pollution from:that facility.and ' the presence of aininonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. . 3. Other: 3 . Page 4 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'CERTIFICATION, (continued) Property Address: 48 High Street Cotuit, MA Owner: Christine Cotter Date of Inspection: March 13, 2011 I). System Fai lure Criteria applicable to.all systems: You must indicate either"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 . . d. ✓ Liquid depth in cesspool is less than.6"below,invert or,available volume is less than 'h day flow ✓. . Required pumping more than.4 times in thelast 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 wZone 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 bufgreater than 50 feet.from a private water supply well with no acceptable watpr.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 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be,attached to.this.form.] YES (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.detennine what will be necessary to correct the failure: System has a single cesspool E.' Large System: 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 iri addition to the criteria above) 'Yes No the system.is within 400 feet of a surface'.drinking.water supply _ the system is within 200 feet of a tributary to a.surface drinking water supply. the system is,located in a nitrogen sensitive area(Interiin 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.systm is considered a'significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in:accordance with.310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM- PART B CHECKLIST Property Address: 48 High Street Cotuit, MA Owner: Christine Cotter,. Date of Inspection:. March 13, 2011- 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 nonnal flows in the.previoustwo 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.faciliry 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: 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 Part C.is at issue approximation of distance is unacceptable)`[310 CMR 15.302(3)(b)]. - . 5 Page 6 of 11 ' OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE..SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 HLvh Street, Contit, MA Owner: Christine Cotter- Date of Inspection: . March 13: 2M1 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design); N/A Number of bedrooms(actual):. 4 DESIGN flow based on 310 CMR:15.203 (for example: 110 gpd.x#%of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes-or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no)s No Water meter`readings, if available(last 2 years'usage(gpd)): `Unavailable Sump Pump(yes or no): No Last date of occupancy:. Currently COMMERCIAL/INDUSTRIAL Type of establishment.- Design flow(based on 310 CMR 15.203):. pd - Basis.of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):' Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes.br no): Water meter readings, if available: Last date of occupancy/use- OTHER(describe): .:. GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part.of the inspection(yes or no): Yes If yes,volume pumped:`. gallons--How was quantity pumped determined? Reason for pumping:. Maintenance 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 systein owner) Tight Tank Attach a copy of the.DEP approval Other.(describe): Approximate age of all com onents date. pp g p installed(if known)and source of information: - Unknown. . Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE::SEWAGE`DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 48 High Street Cotuit' MA Owner: Christine Cotter '. Date of Inspection: March 13, 2011 BUILDING SEWER(locate on site plan) 1 Depth below.grade: Materials of:construction: _cast iron _40'PVC other(explain): - Distance from private water supply well or suction-line: Comments(on condition ofjoints;.venting,`evidence of leakage,etc.); SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting,as a.septic tank) Depth below grade: To rg ade Material of construction: concrete _metal fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a.Certificate.of Compliance.(yes or."no):. (attach a copy of. certificate) Dimensions: 5'W x 6'T x 7'bottorii to grade Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle. -- Scum thickness: 1 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: Measuring stick Comments(on pumping recoriunendations, inlet and outlet tee.or baffle condition,structural integrity,:hquid levels . as related to-outlet invert,evidence of leakage;'etc.): The cesspool was full up to the outlet pipe,,The.cesspool was pumped after the inspection Steel cover i'ias to grade GREASE TRAP: '.None (locate on siteplari) Depth below grade: Material of construction: concrete _metal.: fiberglass _polyethylene _other (explain):. Dimensions: Scum thickness: . Distance from top of scum.to.top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: - Date of last pumping: Commnents(on pumping recoirunendations,:inlet and outlet tee or baffle condition,structural integrity; liquid levels as related to outlet invert,evidence of leakage;,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 48 HiQh Street Cotuit.:MA Owner: Christine Cotter Date of Inspection: March-13; 2011 TIGHT or HOLDING TANK:. None (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: eallons/day Alarm present(yes or no):, Alarm level: Alarm in working order(yes�or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None' (locate on site,.plan): Pumps in working order(yes or no): Alarms in working order(yes.or no) Commments(note condition of purrip chamber, condition of pumps and appurtenances, etc.): 8.' Page 9 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM ; PART.C. SYSTEM.INFORMATION (continued) Property Address: 48 Hizh Street Cotuit: MA Owner: Christine Cotter - Date of Inspection:. March 13, 2011 SOIL ABSORPTION SYSTEM.(SAS): ✓_.(locate:on site plan,excavation not required) If SAS not located explain why: There.is anothu wipe in basement behind a wall that goes out back under the deck I could not locate this systein Type I leaching pits,number:. 6'x6'1000 a� 1.. leaching chambers,number' leaching galleries;number: leaching trenches,number,,length: leaching fields,number, dimensions. overflow cesspool,number: Innovative/alternative system Type/name of technology: Coimnents(note condition of soil,signs of hydraulic failure,level of ponding;damp soil,condition of vegetation,etc.)`._ The leach pit had 3'ofwater on the bottom. .There did not appear to be any sigm bo failure in the pit CESSPOOLS: _(cesspool must be pumped as part of inspection)(locate on-site plan) Number and configuration:. One single Depth top of liquid to inlet invert: Depth of solids layer: Depth.of scum.layer: 2'' Dimensions of cesspool: 4'x6' Materials of"construction: Metal Indication of groundwater inflow(yes of.no). Coibinents (note condition.of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The kitchen drains to this single cesspool. Steel coven ivas`to grade. Single cesspools fail in the town of Barnstable PRIVY: None(locate on site plan) Materials of construction: Dimensions: Depth of solids: . Coininents(note condition of..soil,signs of hydraulic failure,level of pond ing,.condition of vegetation,etc.): 9 Page 10 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 High Street Cotuit, M.4 Owner: Christine Cotter Date of Inspection: March 13, 2011 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two perinanent:reference landmarks or benchmarks..Locate all wells within 100 feet. Locate where public water supply enters the building. . o l o aS 10 Page I I of 11 OFFICIAL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 48 High Street Cotuit. MA ' Owner: Christine Cotter Date of Inspection: March.13. 2011 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water, 20+/-_ feet . Please indicate(check)all methods-used to,determine the high ground water elevation: Obtained from system design plans on record-If checked -date of design plan reviewed: Observed site(abutting property/observation hole within`150 feet of SAS) ✓ Checked with'local Board of Heahh-explain- topographic and water contours rnaps Checked with local excavators,installers-(attach documentation) - Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topoLiaphic and water-contours in s "theartaps were showing approx stately 20'+/-to ground water at this site. This report has`been prepared only for the septic'systeni and components described herein.. This septic system was inspected and failed as of the date of inspection..This report is.not a,warranty or:guarantee that the system will function properly in the future. There have been no warranties or guarantees,:either expressed written or implied, :.relating to the septic system,the'inspeci on, this report andlor any coiponents of the septic systein w.hich have not -been located and inspected: " ' 11 ?`, E1►7�3�� 1'OS yi�l\' 11131IO� E1J� (�O. I\TC. r JM 929 State. Road, Plymouth, MA 02360, Phofi:e 608.224-5500 Fax 508 224 8883 License No, AC00342 Mr. Thomas McKean Barnstable Health Department,,.-. 200 Main Street F Hyannis, MA 02601 Dear Mr. McKean: r We are nob m .y' g you about an-asbestos removal job to be done, at The start up, ° . . date is j °and the end date is. L 4 f close d ple ase fi n p d a copy of the Asbestos Notification Form (ANF-001) for.your files. s If you have any questions, please,contact us at (508) 224-5500. - Sincerely; , --' Paul Ilacqua c Enc: ANF-001 formCIO CIO a°�, r Commonwealth of Massachusetts ■� 100170345 Ll Decal Number Asbestos Notification Form ANF-001 Important: A. Asbestos Abatement Description . When filling out p forms on the computer,use 1. a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied only the tab key residence of four units or less? ❑Yes R] No to move your I cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: V'04— CHRISTINE COTTER 48 HIGH STREET a.Name of Facility _ b.Street Address BARNSTABLE 102635 9783945608 a Ciiy/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this RESIDENCE ��� - BASEMENT form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? Dy/ Yes ❑No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of Occupational ASBESTOS MAN REMOVAL 929 STATE ROAD Safety(DOS) a.Name b.Address notification PLYMOUTH �-� 02360 � 5082245500 requirements of 453 CMR 6.12 c.City/Town d.Zip Code e.Telephone Number AC000342 f.DOS License Number g. Contract Type: ❑Written ❑✓ Verbal h.Facilit Contact Person i.Contact Person's Title PAUL % ILACOUA JAS050350 a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number ASBESTOS CONSULTANTS JAM051114 7' a.Name of Pro'ect Monitor b.Pro'ect Monitor DOS Certification Number ASBESTOS CONSULTANTS AA000173 8' a.Name of Asbestos Analytical Lab b.Asbestos Anal tical Lab DOS Certification Number ,11 4!2013 1/24/2013 9. a.Pro'ect Start Date mm/dd/ b.End 0 7AM-1PM c.Work hours Mon-Fri. d.Work hours Sat-Sun. =0 10. a. What type of project is this? =o ❑ Demolition ❑✓ Renovation ❑ Repair ❑ Other, please specify: b.Describe 11. a. Check abatement procedures: o ❑ Glove bag ❑ Encapsulation o ❑ Enclosure ❑ Disposal only _U_ ❑Cleanup ❑ Other, specify: Q Full containment b.Describe —z Q 12. Is the job being conducted: ❑✓ Indoors? ❑Outdoors? anfO01 ap.doc-10/02 Asbestos Notification Form•Page 1 of 3 II Commonwealth of Massachusetts ■ 100170345 Decal Number i#: ! Asbestos Notification Form ANF-001 A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or encapsulated: 15 25 a.Total pipes or ducts(linear ) b. oTa o er su aces square c.Boiler,breaching,duct,tank 25 d.Insulating cement surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or layered paper 5 E= f.Trowel/Sprayer coatings- pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft. g.Spray-on fireproofing h.Transite board,wall board �- _� -- Lin.ft. Sq.ft. Lin.ft. Sq.ft. i.Cloths,woven fabrics j.Other,please specify. Lin S Lin.ft. S .ft. k.Thermal,solid core pipe ° insulation Lin.ft. Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: REMOVE ALL ASBESTOS IN FULL CONTAINMENT UNDER.NEGATIVE AIR PRESSURE 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (9): WET DOWN ASBESTOS & DOUBLE BAG USING 6 MIL MARKED& LABELED POLY BAGS 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver# e.Name of DOS Official f.DOS Official Title �N g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# _0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this-project? Yes EINO B. Facility Description W_N 0 1. Current or prior use of facility: RESIDENCE ° 2. Is the facility owner-occupied residential with 4 units or less? �]✓ Yes ❑ No CHRISTINE COTTER 1 PARSONS WALK 3' a.Facility Owner Name b.Address ° MARSHFIELD 19783945608 o C.City/Town d.Zip Code e.Tale hone Number area code and extension tL — — 4' a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address Z �Q c.City/Town d.Zip Code e.Telephone Number(area code and extension) ■ anf001 ap.doc•10/02 Asbestos Notification Form•Page 2 of 3 ■ . Commonwealth of Massachusetts ■ r Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) 5. a.Name of General Contractor ( � b.Address c.City/Town d.Zip Code e.Telephone Number area code and extension f.Contractor's Worker's Comp.Insurer q.Policy Number h.Exp.Date(mm/dd/yyy 6. What is the size of this facility? 2000 2 a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): ASBESTOS MAN REMOVAL CO 929 STATE ROAD Note:Transfer a.Name of Transporter b.Address Stations must IPLYMOUTH 02360 5082445500 comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 JOB ROLLOFF POB 6037 a.Name of Transporter b.Address CHELSEA 02150 1 16173871495 c.City/Town d.Zip Code e.Telephone Number 3. a.Refuse Transfer Station and Owner " ( b.Address c.City/Town d.Zip Code e.Telephone Number 4. ITURNKEY LANDFILL(WASTE MGT NH) a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 7 ROCHESTER NECK ROAD IROCHESTER c.Final Disposal Site Address d.City/Town NH � 03839 e.State f.Zip Code g.Telephone Number CO �O D. Certification �N The undersigned hereby states, under the PAUL ILACOUAPAUL ILACQUA �O penalties of perjury,that he/she has read the a.Name b.Authorized Signature_ �° Commonwealth of Massachusetts regulations 1PRESIDENT 1/10/2013 for the Removal, Containment or c.Position/Title _ d.Date(mm/dd/vyy Encapsulation of Asbestos,453 CMR 6.00 and 5082445500 JAMR CO 310 CMR 7.15, and that the information contained in this notification is true and correct e.Telephone Number f.Rere_sentinq ._,...� ° to the best of his/her knowledge and belief. 929 STATE ROAD �O ci.Address u_ PLYMOUTH-�� 02360 h.City/Town I.Zip Code Z Q ■ anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 ■ i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION w d O„M Sv0 TITLE 5 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAR O .-5..a., ..� CERTIFICATION PARCEL Property Address: 48 HIGH STREET COTUIT,MA 02635 3 C t—i�.p LOT Owner's Name: SMITH Owner's Address: 48 HIGH STREET COTUIT,MA 02635 Date of Inspection: 9/5/03 .� ® Name of Inspector: (please print) JOHN GRACI,INC. 6 TV Company Name: SEPTIC INSPECTIONS C� o Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 �O�BpEPS g�E Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally asses _ Needs Fu Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 9/5/03 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sha I submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the"system will perform in the future under the same or different conditions of use. Titles 5 Incna.r.tion Form 6/1 50000 1 'Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed . pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a 'Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. t _ 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 n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a 'Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE,LAST YF,AR.. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well 4 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. a 'Page 5 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 Check if the following have been done. You must indicate "yes" or"no as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage backup? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part,C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I 5 ,Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 HIGH STREET COTUIT, MA 02635 Owner: SMITH Date of Inspection: 9/5/03 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):JEAP Sump pump(yes or no): NO ©� — `ZQI V U Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR. Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 2000gallons--How was quantity pumped determined? n/a Reason for pumping: MAINTENANCE/CESSPOOL TYPE OF SYSTEM _Septic tank, distribution box, soil absorption system X Single cesspool X Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: NEW COMPONENT IN 1975 PER PERMIT 187 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 BUILDING SEWER(locate on site plan) Depth below grade: 6" Materials of construction: Xcast iron _40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage, etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 0" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: n/a Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 0" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How were dimensions determined: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): n/a GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a -Page 8of11 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX:_(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.): NONE-SNAKED THROUGH PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a R I Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a 6' X 6' BLOCK CESSPOOL overflow cesspool, number: 1 n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of Hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT AND OVERFLOW ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. STAIN LINES INDICATE LEACH PIT HAS NEVER HAD MORE THAN 2' OF LIQUID IN IT.BOTTOM IS AT 7 FT. CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert: 0" Depth of solids layer: 1" Depth of scum layer: 3" Dimensions of cesspool: 5' X 5"' Materials of construction: BLOCK Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 Owner: SMITH Date of Inspection: 9/5/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. W. PeLj rch q G - AA My in ` 'Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 HIGH STREET COTUIT,MA 02635 tr Owner: SMITH Date of Inspection: 9/5/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet ` Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: . HAND AUGER- 12+FT. e �� z No. // 7_ Fwic...1�"................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH JCA-0-�_ _0F... mac. , . Appliratioaa for Ui!ipuiittl Works Towitrurtion Urra ait Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System � tion- r or Lot No. wner �l a Address a ��l --• ... . ...................... ................. Installe Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-----3-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ------------------------- - No. of persons.....................------- Showers ( ) — Cafeteria ( ) f4 Other fixtures ------------------------------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. \ W Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depili................ x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area-._..---_-__.____-_-sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq..It. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------- -- .............................................................. Date------------------------------------ .. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-..:_--.-----.--.-.-.._- fi Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ r---------------------------------------------------------------...............................................................................................O Description of Soil---------------------------------------------•--------------•---------------•---------------------------------•-------•- --•-----------••--•-------- .................. x V --••...----•--•-------------------------------------------------•-••-••-----•--••••....-•-------------••----...------------••-------------------------------------------------------------------------- •------------------------- -- -------;� U Na tu of mJZep 'rs r Alte —A weZZa ppli ble._... 1_ �®dL C _ - .�(� regiment The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article.XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e`en ssued by board o he _ Signe !fit-------I---- Date Application Approved By__________ _______ Date Application Disapproved for ie following reasons:---•---•--------------•----------- ............................................................................ Date PermitNo......................................................... Issued.... --------------------------------------- Date No......................... Fs$. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH 4, a Apphration -for R,gpo al Works Tonfitrurtion Urrmil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �� �------ � •--,'...-- l---, =f A,d es -----or -------------------------------------------------- L, anon-A�es's or Lot No. �. ................' �..._.---- ................ �• Owner ` Address FW1 •-------•---- c I _... .._._.. Address Installe Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms------ -----------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons._-___--__-____._--.----_- Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter___-_...-_----_ Depth---------------- x Disposal Trench—No..................... Width..................... Total Length_________--______-- Total leaching-area--------.-----------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date---------------------------------------- Test Pit No. I ______________minutes per inch Depth of Test Pit.................... Depth to ground water..._--_-.-_-----_-._.... G14 Test Pit No. 2.______-•-.-____minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 9 ---------------------------------------............................................................•--------••------•----••---•---••-•--••--------......... DDescription of Soil................................................................................................ ..------------------------------------..._.--..-.--------------------- ",� W ---------------------------------------------------------------------=------------------------------- --------------------------------------------------- UNatu ofans—A swer wheACappli ble.....f �i.r?J.- -_- ----- ��- 0 ,-- 0 - -----.. . -�✓ - � �- A reement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een ;ssued by t board of,.he 1 hr) --•-• •--7 ......-• '-5 l,)) C Date ApplicationApproved BY Y l /--•---••-•-•---••••-•--•••••--••-----•--•.........................•--•-..---- •----•-•---••---------- __------------ Date Application Disapproved for the following reasons______________________________________________............................................ -•-•--•.__... ----------------------------------------------------------------------------------•---------------•------•-----•-••• ---------------•-•-•••••--•--••---•-•-•-•--•----•----------•--•••-•-••------._..... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH _ f ...................OF....... ....�'��1/1/.... ............................................ T fif" tr of Tompliaurr v THY TO RTI That the Ind' idual Sewage Disposal System constructed/ ) or Repaired ( ) / Installer ..... at- rr. -- • . -!l.. ' = ' -�' ltlf/ Y f�!�d-. ........... .................. been installed in accordance with the provisions of A g I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. .-- --- --_-- dated-----7`_.f._-...7..S.V........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE l � . --•••----- Inspector . u'�G THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH GG�t_.a /�i!i�s, ,"L C ... ........................O F.................................................... ................................ .No...... :.........•... FEE.--•-----U-•-.G........... �i��o�ttl ork,� �on�txnrtion �rrmit ;: Permission is hereby granted.............. ............................ ...� S..'p( f ' to Construct or Repair ( ) an Individual Sewage Disposal System Street _ as shown on the application for Disposal Works Construction Permit No...... ._.._ ..._. Dated---------/--`___.�._'......:....... ------------------------------------------------------ ....................... .............. T(' Board of H alth DATE...... / / --..............................----- t FORM 1255 HOB65 & WARREN. INC.. PUBLISHERS t LOCQTIOK! _ 5EWQC,E PERM IT" , :a10. IW57aLLER S 1 b, E ADDRESS BUILDER 5 Q &VAE 9ADDRE55 DIQTE PERKA T ISSUED 6 D ATE CO@APLI Wt CE ISSUED : y/ S i r :0 f y t' ZONE: p �b0 RF „ F Area (min.) 87,120 SF min (RPOD) Frontage (min) 150' Na ' Width (min) Setbacks: Fron t 30 ,�.� ;Beach, No Side 15' Rear 15' •: 1 tea, OVERLAYS: >a1,b - Resource Protection Overlay District • {r,`Ottll� i Aquifer Protection Overlay.District •` ��� �1 1 Estuarine Watershed LB FLOOD ZONE: ` .. .. _ I1 ..'0 •�C Zone C a 1 _ ,••e Community Panel No. N/F N/F July 2,01 92 8 ° LOCATION MAP: .}r Scott M Grover Scott M Grover Scale: 1" = 2,000±' ^` 18381/297 18373/147 — W ASSESSORS REF.: Map 35 Parcel 04 6 N *LZ Existing'Pipe `81 � INV= 96.33' (Unknown Destination) 0 #48 21/2 Sty Re Plumb as Required 1 I Ip w1f Dwelling / 0) CDZ x F.F.= 100' Cesspool y \ Rim= 96.19' Connect Cesspool to Block Septic ink Notes. INV= 95.84' With 4" PVC Pitched 2X Min. 4 Qn Porch Provide T'S as Required 1 `D 1.) The property line information and building $ \ \ Rim= 93.68' location shown were compiled from available \ v= 92.48 1 record information. 1000 Gal 6'x6'1 .,Conc Leach Pit s'xs' _ — _ _ - � ,• 2.) The location of the septic components are O Block Cesspool Functioning as — — per inspection dated March 13, 2011. 3 Septic Tank `� O Install T as Required 3.1 ) Invert and Rim elevations shown were N ;E determined by Sullivan Engineering, and are OFbased on an assumed datum. rasa - 4.) See Title 5 Official Inspection Form N/F . N/F Dated March 13, 2011 Clarke B Crocker. Timothy & Daniel Leveroni By James M Ford ■ 715/205 8225/016 4 (� 0 30 60 FEET k Sheet # Title: 1 Prepared For: Prepared By: Scale: 1"=30' Proposed Septic Repair Plan Christine S Cotter Trust Sullivan Engineering, Inc. 1 of Date: At 48 Hi St 48 High Street Realty Trust PO Box 659 171JUN/11 g 1 Parsons Walk Osterville, MA 02655 Pri: Barnstable (Co t u i t) MA Marsh fiel d;MA 02050 • 31005 (508)428-3344 (508)428-9617 fax ZONE. 1 RF i1 o Oa�n Area (min:) 87,120 SF min (RPOD) n Fronta e (min) 150' i Ha Width min) 1. Setbacks: �Fiooper,,s i $®AC ' ` .. 9'• Front 30' \ No Side 15' a Rear 15 OVERLAYS: gab r p � Laatfing •. • x p F Resource Protection Overlay District {riOttli Aquifer Protection Overlay District a0`• � /I tt Estuarine Watershed • T o . � z, .. e�'Y BIu FLOOD ZONE: t �, to Zone C _ -,:'1•, 1 Community Panel No. 2 0 500 1 OOi N/F N/F July 1992 8 D LOCATION MAP: .�� Scott M Grover Scott M Grover Scale: 1 = 2,000t' ^` 18381/297 18373114.7 W ASSESSORS REF.. *� Existing.Pipe p Parcel 046 p a 35 Pa INV= 96.33' r^ (Unknown Destination) V, #48 o 21/2 Sty Re Plumb as Required m w1f Dwelling / rn m Z x F.F.= 100' <'. Cess ool Rim= 96.19' Connect Cesspool to Block Septic ink B O Notes. Porch \ INV= 5.84' With 4" PVC Pitched 2% Min. Ln Provide T'S as Required: 1 `D 1.) The property line information and building $ Rim= 93.68' �' location shown were compiled.from available V= 92.48 . 1 record information. 1000 Gal 6'x6' 1 1 Conc Leach Pit s'xs' — _ _ w 2.) The location of the septic components are v Block Cesspool —' Functioning as — — per inspection dated March 13, 2011. 3 Septic Tank 1 3. Invert and. Rim elevations shown were- o Install T as Required 1 ) N ,E determined by Sullivan Engineering, and are based on an assumed datum. nsza _ F „ 4.) See. Title 5 Official Inspection Form N/F N/FA Dated March 13, 201 1 Clarke B.Crocker Timothy & Daniel Leveroni By James M Ford n 715/205 8225/016 CML 0 30 60 FEET Title: Prepared For: Prepared By: Sheet # - ' . Scale: 1 =30' Proposed Septic Repair P/an �. Christine S Cotter Trust SUII1VaI1 EnpineeTlTlpr, Inc. 1"of 1 Date: �] 48 High Street Realty Trust b At 48 High St PO Box 659 171JUN/11 y 1 Parsons Walk Osterville, MA 02655 /�/j�j Marsh field,MA 02050 iPrj: 31005 Barnstable-�Co t u l t) /V A (508)428-3344 (508)428-9617 fax