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HomeMy WebLinkAbout0118 HOPEWELL LANE - Health �- III HOPEWELL LANE, COTUIT -� A=040-065 -All C A 1 II R , i+ a WrIll J ------------ Prj � , r Du ------------------------------------ s C0 f UTI .0 �Q a JA\ RREN �, �1 (b 6 SCS -'COHd O-WYIJAU� ' ISTEii OIT RI b � _ ( IV vp Dui ------------- UTIL � A\ DARREN M. M d LT OZ 60 AUK � 40 '��NItAR�Aa _ (( �cjo(, w nnrnvnri-I� l 7r\11S1d�//� i I I I I I I I i X 1 , i (Z •. I I � I I i I I 1 I �v I i I : _ i i I i 66 rh ! :--------------- I 1 I I , I I , I I I I I : I l i : I �Yl I I i I I • i I _ I I I : : � I I i I � I ' :' I I i .. '�f}�►� _l.YU . � i I i i I I I j _ I L. ! I : I : I : I I . i ��h`� I I , : C�l�LN i i. i i I v N� i 66 +13 '.,��,,,"/ter � -- .. ...... .. ..... _ ...... _. .......... ..� ;3_6.165 8l 1 : : r � l bo R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma` 02635 12/21/11 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return key. B & B Excavation,lnc. - Q Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town q State. Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and•that they.) --A 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 15.346 of Title 5(310 CMR 15.000).The system: = ® Passes ❑ Conditionally Passes ❑ Fails ❑ eeds Further Evaluation by the Local Approving Authority 12/21/11 I nspecto r's#Signa re 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. C/ W t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments �^M 118 Hopewell Lane (main house) , Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma •02635 12/21/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure'is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal-septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank.is less than 20 years old is available. ❑, Y ❑ `N ❑: ND(Explain below): t5ins•11110 Title 5 Official,inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection- Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Lane (main house) J Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or•uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ., ❑ Y *❑ N ❑ ND (Explain below): El -obstruction is removed „ ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the�Board of Health 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 . i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 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. y° 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 El ® 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 1/day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M s 118 Hopewell Lane(main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1tof a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑' ®. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This -system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-' 10,000gpd. ❑ ® The system fails. I have determined that one or more`of'the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to.determine what will be_ necessary to correct the failure. _ E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the ' questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within.200 feet of a tributary to a surface drinking water supply ' ❑ the system is located_in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)_or amapped Zone`II of a public water supply well' j If you have answered "yes"to an Y y y y 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•11110 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspectiori' Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 4 °M 118 Hopewell Lane(main house) Property Address r Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11- page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"Yes" or"no"as to eacl .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): ' 4 Number of bedrooms(actual): 3 DESIGN flow:based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11110 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 .12/21/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last•2 ears usage d n/a 9 ( y 9 {gP ))� Detail: Sump pump? El Yes ® No Last date of occupancy a current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No. Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 -- page. CityrFown State Zip Code Date of Inspection D. System Information .(cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: - ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ., ❑ Shared system-(yes_or no) (if yes, attach previous inspection records, if any) El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 117 Commonwealth of Massachusetts = Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 _, ' page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.)_ Approximate age of all components, date installed (if known)and source of information: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: . >20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in good condition no sign of leakage. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete' El-metal ❑fiberglass ❑ polyethylene , ❑ other(explain). If tank is metal list age: years Is age confirmed by a Certificate of Compliance? (attach a copy.of certificate) ❑ Yes. ® No Dimensions: t 5'8"x5'8"x10'6" Sludge depth: 611 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11, page. Cityrrown 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 31„ Scum thickness 411 Distance from top of scum to top of outlet tee or baffle , a 14 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? scour stick - ^ Comments(on pumping recommendations, inlet-and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection, septic tank appears to be in shape no sign of back up. ` Grease Trap(locate on site plan): k: Depth below grade: feet Material of construction: F' ❑ concrete ❑metal ❑ fiberglass �❑ polyethylene ❑ other(explain): ' Dimensions: Scum thickness' 46 Distance from top of scum to top of outlet tee or baffle Distance from bottom„of scum to bottom of outlet tee or baffle - Date of last pumping: • - Date • - t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection• Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 118 Hopewell Lane (main house) ' Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 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.): t . • e 4. �2 a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow:' gallons per day Alarm present: ❑ Yes ❑ No , Alarm level." - Alarm in working order'. ❑ Yes ❑ No Date of last pumping: Date Comments (condition'of alarm and float switches, etc.): *iAttach copy of current pumping contract(required). Is copy attached? El Yes ❑ No t5ins•11/10 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 G M , 118 Hopewell Lane(main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma - 02635 12/21/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate•on site plan):,. A j Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition no sign of carryover or'leakage. Pump Chamber(locate on site plan): ,y Pumps in working order: ❑ Yes. ❑ No Alarms in working order: El Yes ❑ No Comments(note condition of.pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is Cotuit Ma 02635 12/21/11 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 25 bio-diffusers 12.1502 El leaching galleries r number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching was dry no sign of staining or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction f Indication of groundwater inflow ❑ Yes ❑ No k t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane(main house) ~ Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 page. City/Town 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.): Privy (locate on site plan): Materials of.construction: Dimensions _ Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i5ins•11/10 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 ,M 118 Hopewell Lane (main house) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 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_1 00 feet. Locate where public water supply enters the building. Check one of the boxes below: -- ® hand-sketch in the area below ❑ drawing attached separately JA '3 e V S'o y® .f= (p7, t5ins•11/10 1. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ,r. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Lane (main house) Property Address Steven Gemborys ' Owner Owner's Name information is required for every Cotuit Ma 02635' 12/21/11 ' page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) z Site Exam: - ® Check Slope _ ® Surface water p ® Check cellar ® Shallow wells k + Estimated depth to high ground water: >12,feet Please indicate all methods used to determine the high ground water elevation:' i ❑ Obtained from system design plans on record -If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ' ❑ Checked with"local excavators, installers-(attach documentation)' ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: ; • R 1 e e. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11/1 o t Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments M •°'F 118 Hopewell Lane(main house) < Property Address _ Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 Inspection Ins page. CitylTown State Zip Code � Date of p 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 (Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 µ Commonwealth of Massachusetts. r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Main house" Property Address Cil v Debra Traugot r Owner Owner's Name/ information is required for every Cotuit V Ma 02635 3/11/16 r ►+ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information u on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain reb Company Name s 8 Johns path ' ' Company Address S Yarmouth Ma 02664- City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number 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 ❑ Needs Further Evaluation by th Local Approving Authority 3/13/16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 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. /� VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste 17 . j Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments g: 118 Hopewell Ln. " Main house" Property Address r` Debra Traug of Ow ner Owner's Name rm infoation is requ�red for every Cotuit Ma 02635 3/11/16 page^< Cityfrown 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 passes and contains a 1500 gallon septic tank as well as a dbox and 5 rows of 5 High Cap Infultrators. S.A.S. was dry at time of inspection. Pumping is recommended at this time B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I ' Commonwealth of Massachusetts - Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Cityrrown State Zip Code Date of Inspection B. Certification(cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled-or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): .. ❑ obstruction is removed '❑ Y ❑ N. ❑ ND (Explain below):. ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ . broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): f4 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 t5ins•3/13.� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1. Commonwealth of Massachusetts Title5 Official Inspection ecti on Form s .Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 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 Y2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 it Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is-required for every Cotuit Ma 02635 3/11/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or .tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence ' of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd.' ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a . design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. . Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of atributary to a surface drinking water supply El, ❑ 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page. Cityrrown 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 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 ,M 118 Hopewell Ln. " Main house Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma. 02635 3/11/16 page. CityfTown State Zip Code Date of Inspection D. System Information Description: System passes and contains a 1500 gallon septic tank as well as a dbox and 5 rows of 5 High Cap Infultrators. S.A.S. was dry at time of inspection. Pumping is recommended at this time. Number of current residents: - 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No 219 gpd Water meter readings, if available (last 2 years usage (gpd)):' Detail: ; Sump pump? ❑ Yes ❑ No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): - Gallons per day(gpd) Basis'of design flow(seats/persons/sq.ft., etc.): Grease trap present?' ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes.❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑• No Water meter readings, if available: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Pumping is recommended Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form y. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 118 Hopewell Ln. " Main house Property Address Debra Traugot Owner Owner's Name " information is required for every Cotuit - Ma 02635 3/11/16 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: 11/28/09 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): ` 1.5 Depth below grade: feet Material of construction: ®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.): No evidance of leaking, Vented at roof Septic Tank locate on site Ian Depth below grade: feet Material of construction: ® concrete : ❑ metal ❑:fiberglass ❑ polyethylene ❑ other(explain) 1500 GI If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy.of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: ' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4�M 118 Hopewell Ln. " Main house Property Address Debra Traugot Owner Owner's Name information is-required for every Cotuit Ma 02635 3/11/16 page. Cityrrown 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.): Tees are in place and levels are normal. ' Tight or Holding Tank(tank must be pumped at time of inspection) (locate on'site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No i Date of last pumping:, Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 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 and at normal 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r �. Commonwealth of Massachusetts W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M ,•''v 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: leaching galleries number: 5 rows Of 5 ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S.A.S. was dry at time of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ' ❑ 'Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 - page. Cityffown 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.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection 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 yt 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Cityrrown 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 o �3� t t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 L Commonwealth of Massachusetts iz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page. Cityrrown 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 t 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 118 Hopewell Ln. " Main house" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every 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: 10+ ft 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: 11/28/09 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan shows NGE at 132" 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 118 Hopewell Ln. " Main house Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/1.1/16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information- Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 n Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" Property Address �+ Debra Traugot v Owner Owner's Nam information is required for every Cotuit Ma 02635 3/11/16 page. City/Town State Zip Code Date of Inspection ,ff• Inspection results must be submitted on this form. Inspection forms may not.be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: C7( (P key to move your ; cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain ,Q Company Name 8 Johns path Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number 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 ❑ Needs Further Evaluation by the -ocal Approving Authority - 3/13/16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^,M 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page; Cityfrown 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 passes and contains a 1500 gallon septic tank as well as a dbox and two h10 500 gl dry wells Pumping is recommended at this time. 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 r h r • r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` M 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3111/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) - ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): f ❑, Observation of sewage backup or break out or high static water level in the distribution.box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ .Y ❑ N [] 'ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑.Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health 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 Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 �. Commonwealth of Massachusetts . Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln. " Cottage Property Address Debra Traugot Owner Owner's Name - information is required for every Cotuit Ma 02635 3/11/16 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: r- ❑ ® Any portion of the SAS, cesspool or privy,is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® - Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or-privy is within 50 feet of a'private water supply well. ❑. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.,- E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in-addition to the questions in Section D; Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat,, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Cottage " Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Cityrrown 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 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System passes and contains a 1500 gallon septic tank as well as a dbox and two h10 500 gl dry wells Pumping is recommended at this time. Number of current residents: 2 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? a. ❑ Yes ® No Water meter readings, if available last 2 ears usage(gpd)): 189 gpd 9 ( Y 9 - Detail: Sump pump? EJ Yes ❑ No Occupied Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present?'. ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner. Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Dat e Other(describe below): General_Information Pumping Records: Source of information: None provided Pumping is recommended Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma. 02635 3/11/16 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: 4/3/96 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5. feet Material of construction: ® 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.): No evidance of leaking, Vented at roof Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 GI If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Citylrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM '< 118 Hopewell Ln. " Cottage" Property Address Debra Traugot " Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. CitylTown 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.): Tees are in place and levels are normal. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons ` Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached?' ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma 02635 3/11/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal 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.): Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma . 02635 3/11/16_ required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2 500 gl dry wells ❑' leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): S.A.S. was dry at time of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer " Depth of scum layer Dimensions of cesspool Materials of construction e Indication of groundwater inflow ❑ Yes ❑ No i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form p o a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 118 Hopewell Ln. " Cottage " Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 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.): No ponding no break out Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-iNot for Voluntary Assessments ,M 118 Hopewell Ln. " Cottage" Property Address Debra Traugot Owner Owner's Name information is Cotuit Ma • 02635 3/11/16 required for every page. Cityrrown 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 - t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments G1M 118 Hopewell Ln. " Cottage " Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft 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. 11/28/09 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan shows NGE at 132" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 3/14/2016 Assessing As-Built Cards TOWN OF BARNSTAB E LOCATI3N (0 SEWAGE# VILLAGE C7 L!5r ASS E SSOR'S MAP&LOT oYD-G% INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY_IS-Od 6rd_ LEACHING FACILITY:(type)fdv bat Drlws��1 _(size) NO.OF BEDROOMS BUILDER OR OWNER � Lf/d441 PERMITDATE: " 3' COMPLIANCE DATE:Z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility —5-7f Feet Private Water Supply Well and Leaching Facility (If any wells exist On site or within 200 feet of leacbing facility) tl Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) # Feet Furnished by i 39' 1 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=040065&seq=1 1/2 f Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Ln. " Cottage" P Property Address Debra Traugot Owner Owner's Name information is required for every Cotuit Ma 02635 3/11/16 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i,• Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 ' 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. Important:When filling out forms A. General Information , on the computer, use only the tab 1. Inspector: v �� key to move your cursor-do not Ricky L. Wright r use the return key. B & B Excavation,lnc. reb Company Name _ 14 Teaberry Lane Company Address r Forestdale MA 02644 City/Town State Zip Code ' 508-477-0653 S14595 Telephone Number License Number 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 , ❑ Needs Further Evaluation by the Local Approving Authority 12/21/11 , Inspector's Signature`" Date The system inspector shall submit 6 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 f the same or different conditions of use. i t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 s' Y 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form , j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 118 Hopewell Lane (cottage) {' Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR.15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: t El 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 exp4n. 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. 0 Y ' ❑•N 0 ND(Explain below): •t5ins•1 U10 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) i B) System Conditionally Passes (cont.): f ❑ 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 F1 ,ND (Explain below): . ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below) ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s): The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y IEJ 'N ❑ ND (Explain below): ❑ obstruction is removed. ❑ Y ❑ N ❑ ND (Explain below): k 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 ,r 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ` P f Commonwealth of Massachusetts. R W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name . information is Cotuit Ma 02635 12/21/11 required for every - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,. safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface_water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ , The system has a septic tank and SAS and the SAS is within 50;feet of a private water, supply well. ❑ The system has 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 DER 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: ' ' 1 D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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. 0 ® 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-1 1/1 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 v ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is Cotuit Ma 02635 '12/21/11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ` 4 Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is-below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion,of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined.that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of-Health to determine what will be necessary to correct the failure, E) Large Systems- To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to_15,000.gpd. For large systems, you must indicate either"yes"or"no"to each of the following; in addition to the questions in Section D. Yes- No F ❑ ❑ 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. t5ins•11/10 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 118 Hopewell Lane (cottage) Property Address r Steven Gemborys Owner Owner's Name information is Cotuit Ma 02635 12/21/11 required for every 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 r available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,'Opened, and the interior of thertank 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. ® El 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 t Residential Flow Conditions: .' Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 1.5.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System"Page 6 of 17' Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments_ ^M 118 Hopewell Lane (cottage) Property Address Steven Gemborys A, Owner Owner's Name LL information is required for every Cotuit - Ma 02635 12/21/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes E No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last? ears usa a n/a 9 ( Y 9 (gpd))� , Detail Y Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type-of Establishment: g Design flow(based on_310 CMR 15.203): _ Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑' Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available:. - t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts' . AmmW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 118 Hopewell Lane (cottage) '1.1. yV•y`• . a Property Address Steven Gemborys . Owner Owner's Name - information is Cotuit Ma 02635 12/21/11 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: _ Source of information: Was system pumped as part of the inspection?-. ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: y Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool y" . ` ❑ 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): i P t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 8 of 17 l : i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane (cottage) Property Address Steven Gemborys t f Owner Owner's Name information is Cotuit Ma 02635 12/21/11 required for every j page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No f Building Sewer(locate on,site plan): `. Depth below grade: 2 feet F Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - Distance from private water supply well or suction line: >20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in good condition no sign of leakage. Septic Tank(locate on site plan); _ Depth below grade:., feet Material of construction: . ® concrete ❑ metal ❑,fiberglass ❑ polyethylene Elother(explain) f t . If tank is metal, list age: ,years Is age confirmed by a Certificate of Compliance? (attach a•copy of certificate) ❑ Yes ® No Dimensions: 5'8"x5'8"x10'6" Sludge depth: , no sludge t5ins•11/10 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is Cotuit Ma 02635 12/21/11 required for every page. Cityrrown 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection, septic tank appears to be in shape no sign of backup. k Grease Trap(locate�on site plan): Depth.below grade: feet Material of construction: b ; ❑ concrete ❑ metal El fiberglass ❑ polyethylene` ❑ other(explain)- Dimensions: ° w 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 �3 Date of last pumping: Date t5ins•11/10 F Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 118 Hopewell Lane (cottage) Property Address r Steven Gemborys Owner Owner's Name information is Cotuit Ma 02635 12/21/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) ; Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: e gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date ' Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 { i 1 Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit . Ma 02635 12/21/11 page. Cityfrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids'carryover, any evidence of leakage into or out of box, etc,): At time of inspection d ,box appears to be'in good condition no sign of carryover or leakage. 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.): a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why- t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owners Name information is required for every Cotuit Ma 02635 12/21/11 page. City/Town State Zip Code _Date of Inspection D. System Information (cone.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500-gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching was dry no sign of staining or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes `❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is required for every Cotuit Ma 02635 12/21/11 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.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids , Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, . etc.): t5ins•11/10 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 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owners Name - information is required for every Cotuit Ma 02635 12/21/11 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 i i i3/:17`P 33;: % Yo I R C f.✓z! Ln . t5ins•1 1/1 o Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments M 118 Hopewell Lane (cottage) Property Address Steven Gemborys Owner Owner's Name information is Cotuit Ma . 02635 12/21/11 required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: r ® Check Slope ® Surface water ® Check cellar ® Shallow wells >12 Estimated depth to high ground water: 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: pate ' ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe howyo6 established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Lane (cottage) ) Property Address Steven Gemborys Owner Owner's Name information is Cotuit Ma' 02635 12/21/11 .required for every ' page. Cityfrown 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 i t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I { 4r �oFTT , Town of Barnstable Barnstable Department AHmeaieaCffy Regulatory Services anxrrsrAs�.e. � t' F "`A a Public Health Division At�Q MA'S m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 Thomas F.Geiler,Director Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205008611 9/25/2009 Today Real Estate c/o David Holt 1533 Falmouth Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 118 Hopewell Lane(Main House), Cotuit MA was last inspected on September 15,2009 by Shawn McElroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to.the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace.the septic system within the deadline period will result in future enforcement action. PER ORD THE B ARD OF HEALTH Kean, l f Agent of the Board of Health s OnD ' l UNITED STATER,_:QL.. ass TGy s • Sender: Please print your name,.address, arjoZIP+4 it 4 is bad• Town ofBarnstavlc_ co (fl� `° Health DIVIsi0r11. ax' G00Main`Street N -m III 3 fill ii [ 1411 q1 }} 1111f tt �tt I die IIIf211J firi�ftlltt1 n M.111tiih,11is ,1141 l.er�itt�t� lti L i �ENDEF�)COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. S' atu item 4 if Restricted Delivery is desired. ❑Agent • Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Rec ived by(Printed Name) Date of Delivery ■ Attach this card to the back of the mailpiece, �� I or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No VId +461+/ —rada K2a i �I-a�-2, �33I�oU-�v� 3. Se ice Type Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number t t 17 0 0 8 .183400,027'Oi5 O l s 8 8 9 5' ! (Transfer from service label) a r y y v a f l p r PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I CD 0 ul Postage $ ��%S O C3 Certified Fee nj Post ar y O Return Receipt Fee Qcuf oss �Oog O (Endorsement Required) C3 Restricted Delivery Fee O (Endorsement Required) m 'b Total Postage&Fees $ ra y cD Sent da o --------- - •... ----------------- � Street,Apt.No.; f3 or PO Box No. rl U... ----.....-- City,Sfate,Z/P+4 Certified Mail Provides: .T o A mailing receipt o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. e Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the. fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with tliA endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. . PS Form 3800,August 2006(Reverse)PSN 7530.02-000-9047 7 Commonwealth of Massachusetts -' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments ,M s 118 Hopewell Ln (MAIN HOUSE) Property Address P Y Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 . every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form._ Inspection forms may'not be altered in any way. A. General Information I 1. Inspector. Shawn Mcelroy e Name of Inspector Upper Cape Septic Services ; Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification f ro , 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 i ElNeeds Fu Valuation aluation by the Local.Approving Authority ran S. 9-15-09 Inspector's Signature Date ^� The system inspector shall submit a copy of this inspection report to the Appro ing Authc�ta'ty (EArd of Health or DEP)within 30 days of completing this inspection.If the system is shared WsteA 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 y 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. This roe has a main house and a cottage each with its own septic stem. property rtY g P Y 118 hopewell(main house)cotuit-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 118 hopewell(main house)cotuit-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Tj Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.' -,-, ;•.ro wM 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name - information is required for Cotuit,; - MA 02635 9-15-09 every page. City/Town State 'Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): s , ❑ 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): r ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 d ❑ '' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. y, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board'of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 ® ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than.6°below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 �. Commonwealth of Massachusetts . s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (MAIN HOUSE) - y Property Address Bank Owned contact David Holt @ Today Real Estate}1-800-966-2448 , Owner Owner's Name information is required for Cotuit i MA 02635 9-15-09" every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to AII.Systems (cont.): Yes No ❑ Z 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 CM 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to'correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. , For large systems, you,must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ :the.system is within 400 feet of a surface drinking water supply ❑ ` ❑ `the system is within 200 feet of a tributary to a surfaceArinking 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every 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 CM 15.302(5)] t5insp official document-03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �( 118 Hopewell Ln (MAIN HOUSE) Property Address r ; Bank Owned (contact David Holt @ Today Real Estate, 1-800-966-2448) Owner Owner's Name information is required for Cotuit �' MA 02635 9-15-09 F'r every page. City/Town . J State Zip Code Date of Inspection i D. System Information Residential Flow Conditions: u Number of bedrooms(design): 4 Number of bedrooms(actual): . 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd.x #of bedrooms): 440 Number of current residents: . 0 Does residence have'a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? a ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No 6-09 Last date of occupancy: Date Date Commercial/Industrial Flow Conditions:. s Type of Establishment: Design flow(based on 310 CMR 15.203): " Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? .• El Yes ❑ No Industrial waste holding tank present? . ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if avvailable:' _ Last date of occupancy/use: Date Other(describe): t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit - MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_... M 118 Hopeweii Ln (MAIN HOUSE) Property Address "4 Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) ., Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 30" F' feet Material of construction: 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.): Good condition. Septic Tank(locate on site plan): ; Depth below grade: 24,.feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gal Sludge depth: 12" rr Distance from top of,sludge to bottom of outlet tee or baffle 20 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every 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.): Tank is in good condition with water at working level. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not{for Voluntary.Assessments { °�M 118 Hopewell Ln (MAIN HOUSE) r, "Property Address Bank Owned (contact David Holt @ Today Real Estate. 1-800-966-2448) Owner Owner's Name information is Cotuit. MA 02635 .9-15-09 required for every page. yCitylTown State Zip Code Date ofanspection D. System Information (cont.) i t. 4 Tight or Holding Tank (cost.) Dimensions: Capacity: gallons Design Flow: gallons per day` `� • Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: ,. i pate Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required).Is copy attached? 0 Yes ❑ No Distribution Box (if,present must be opened) (locate,on site plan): ;b; 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.): D-box in good condition with.stain lines above inlet invert. Pump Chamber(locate on site plan): " ' ' � "' `=• `� Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System s Page 11 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had clear signs of hydrolic failure with stain lines above inlet invert. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments. °,M s 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow , ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids = Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document-03r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (MAIN HOUSE) Property Address Bank Owned (contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. e h 0 � �Lc ITP 7�_p_ ��, �_p_ �3r D A t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln .(MAIN HOUSE) Property Address Bank Owned (contact David Holt @Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans.on record If checked, date of design plan reviewed: Date ® Observed site (abutting,property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at greater than 20'. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 f Commonwealth of Massachusetts - Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , v1M , 118 Hopewell Ln -(COTTAGE) Property Address , Bank Owned(Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 - every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information `- 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr „ Company Address E. Falmouth MA - 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number 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 maintenan9,of opAite sewage disposal systems. 1 am a.DEP approved system inspector pursuanm Section".34 f Title 5 (310 CMR 15.000).The system: ; vs d ® Passes ❑ Conditionally Passes•. El it ❑ Needs Further Evaluation by the Local Approving Authority 9-15-09 W rn Inspector's Signature Date n 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,th.e 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. lee ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not add the system will perform in the future under the same or different conditions pt / This property has a main house and/a cottage each its own septic system. t5insp official document•03108 - .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 , r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments, , ,M 118 Hopewell Ln (COTTAGE) - Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): - ❑" distribution box is leveled or replaced o ND Explain: ❑ The system required pumping more than 4 times a year due to broken.or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ` ❑ obstruction is removed ND Explain: 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. r 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a'surface water ❑ Cesspool or privy is within 50'feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, - safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and;the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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. t5insp official document-03138 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 1/ day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. , 4M , 1.18 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit- MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection a B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No t ❑ r ® 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. ❑ ®• zAny portion of a cesspool oryprivy'is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence ' of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ®, The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ' ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. " E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 1..5,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ,:❑• , the system is within 400 feet of a surface drinking water supply ❑, . ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area= IWPA)or a mapped Zone If 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 1 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M al 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every 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 CM 15.302(5)] t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts s Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments 118 Hopewell Ln (COTTAGE) "#'•• - Property Address BankOwned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection r } 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: 110 330 p gpd x #of bedrooms}: Number of current residents: - 0 Does residence have a garbage grinder? ":ti ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 6-09 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) .. a 1.• . i... s. Basis of design flow(seats/persons/sgft-, etc.)' Grease trap present? ❑ .Yes'❑ No Industrial waste holding tank present? f ❑ Yes ❑ No Non-sanitary waste discharged to the.Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection .Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons M How was quantity pumped determined? Reason for um in : P p 9 Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Priv y . ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w.. 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate' 1-800-966-2448) Owner Owner's Name information is required for Cotuit ,: MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ;. Building Sewer(locate on site plan): Depth below grade: w 14" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet ` r Comments(on condition of joints, venting, evidence of leakage, etc.):. Good condition. Septic Tank(locate on site plan):. 6" ' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500gal 101, Sludge depth: Distance from top of sludge to bottom of outlet tee or bafFle- 22" Scum thickness .0 6" Distance from.top of scum to.top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp official document-03108 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection `Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass '❑ polyethylene ❑ other(explain): t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments . 118 Hopewell Ln (COTTAGE) t Property Address Bank Owned (Contact,David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09` - every page. City/Town State . Zip Code Date of Inspection - D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day` • Alarm present: ❑ Yes El -No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level. r ' Pump Chamber(locateon site plan): Pumps in working order: ❑ Yes . ❑ No. Alarms in working order: ❑ Yes ❑ No t5insp official document-03108 u Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page it of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real'Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . _ . } Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition with stain line at 12"below inlet invert. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments;, 118 Hopewell Ln (COTTAGE) Property Address Bank Owned Contact David Holt @ TodayReal Estate 1-800-966-2448 ) Owner Owner's Name information is required for Cotuit MA . 02635 9-15-09 , every page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) , Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,•level of ponding, condition of vegetation, - etc.): t5insp official document•03/08 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. to � a G � O D t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Y Title 5 Official . Inspection, Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Hopewell Ln (COTTAGE) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Cotuit MA 02635 9-15-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on.record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ®. Accessed USGS database—explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. t5insp official document•03108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 - t Town of Bamstabye P# f / o Department of Regulatory Services 1 � P_Olie Health.Division Hate �A1161q ��6� 200 MaiwStreet,Hynnnis N1A''02601,- ED µAl Date Scheduled Time. Fee-Pd. 0 v -- Soil.Suitabi-, A�ssessrnent f Sewer` e:Dzs or. g posal Performed By: GyY.>✓'Z✓J J " _. Witnessed Bytalid ��. LO CATION-&GENE ' Location Address v 'OAVIATION S 2a8r 5� --zeT� 17'0^'WG Owner's Name l Address, j�•�p yy, /i/1( %�'`f Assessor's Map/Parcel: . 04(rl1 - tS `V O , NEW CONSTRUCTIONrren - REPAIR Ergtpeer's Name /der T,:elephone;#" 7 8 l', + Land Use slopes,(qo) tL l- - `Surface Stones Distances from: Open Water'BodY >- _V ft Possible Wet Area 'ft Drinking Water Well Drainage Way ft. Pr- e w t oP" Line'------_ft' Other ft S 'TCII:(Street name dimensions of lot exact locattiions of test boles&perc tests,Iocate wetlands in proximity to holes) S. Ibie It I 1 I1Z � :XIS?ING i� �G T GE.29 / Parent material(geologic) Depth to Bedrock. Depih.to Groundwater--Standing Waterin Hole: /V A ,.:Weeping ftn.1plt pace., Estimated Seasonal HIgh Groundwater_ '" ) r ON FOR SEASONAL A WATER TABLE Method Used: HIGH Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: In, Depth t0=soil mottles ' Index Well# In, arbundwaterAdjtist' In. Reading Date: Index Well level y ft. . - Adl.factor Adj.`drnundwgter Levei, PERCOLATION TESx Observation 1 bgtp Hole# ( xlmn Depth of Perm Tlme at 9° '' '� Tlm 6'eat '. Start Pre-soak Time @ L 20 -71 j t.r - End Pre-soak �.� tb i Rate Min./Inch Site Suitability Assessment:' Site Passed /l x Site Failed: Addidonal Testing Needed.(Y/N) Original: Public Health Division m Observation Hole-Data.To'Be:Cornpletetj on Back----------- *If percolation'test is to be conducted.within 100' of wetland ou must first notifythe Barnstable'Conservation Division at least one (1) week prior toibeogui m ng. QAS EPTICIPER CFO RM.DOC rFSurface(in.) DEEP..OBSERVATION`FIOLE�a `, Soil Horizon LOG Hole_# Soil Texture' Sdi1 Color Soil (USDA) Other (Munsell) Mottltn g" (Structure,Stones;Boulders. q c to on •ivel 3Y. - s /4 of �/" }* DEEP OBSERVATION 730LE LOG — Dcpth`from Soil Horizon Hole Surface(in.), ,•.Soil Texture Soil Color Soil (USDA) Other (Munse{1) Mottling (Structure,Stones,Boulders. ' R j nsi to 0% revel Ate. url e a.) N rA • _ w . sA Wed- :DE-FP`OBSERVj ATION HOLE LOG Hole# Depth from Soil Horizon 'Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Muusell) Mottling (Structure,Stones,Boulders. / i , ZOAM: alie b 3l 1e v g'r 3 a mot. S ytcP 2. j3 DEEP OBSERVATION HOLE LOG Hole# FUL th from Soil Horizon Soil Texture face(in.) Soil Color Soil Other (� (USDA) (Munsell) Mottling (Structure,Slopes,Boulders. ( r' >� C s' to 3�/ '' 3 s g Z, 7 3 Flood Insurance Rate itilao' !-.bove 500 year flood boundary No Yes within 500 year boundary. `No X Yes Within-tooyearfloodUoundary No x Yes Dent!of Nnfurally Occurrine Pervious Materiel _ Does at least,four feet of naturally occurring pervious material existin all areas observed throughout the area proposed for the Soil absorption system? -- 4 JS If not,-what is ttie'depth of naturally occurring per iod us material? Certificatioi' I certify that on L 1 I have passed p the soil,evaluatorexamination approved by the Department of,Environmental Protection.and; hat the above analysis was performed by me consistent with .the.requir inin ,experdse.and experience described in 10 CMR 15.017. Signature ` Date Q:\.S•BPTIWERCFORM.DOC TOWN OF BARNSTABLE LOCATION _d �`LC1C,r/ SEWAGE#. VIT-;LA.GE ASSESSOR'S MAP&PARCEL,!!:�)YCO•-JZL� INSTALLER'S NAME&PHONE NO. /�Illavo SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /t(size / NO.OF BEDROOMS ii OWNER eAm . bMot�yl „( PERMIT DATE: Q COMPLIANCE DATE: !� Separation Distance etween e: 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 f FURNISHED BY •3 A.y &y ���,� Gl 41 S V TOWN OF EARNST LE LOCA'FION II � �`,f N L(0#-r-ge) SEWAGE# ----..-_... VILLAGE c3��� ASSESSOR'S -MAP& LOT AN E&PHONE NO. SEPnC TANK CAPACITY LEACHING F.ACILTTY: (type)_ V.IL (size) loon NO.OFBEDROOMS A, ,_... ( bUILDER OR OWNER. ;( PERMITDATE?: COWUANCE DATE: ' Separation Distance Betweep the; Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching facility (It any wells exist oa site or owitWn 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If,any wetlands exist within 300 feet of leaching facility) 1<�eet Furifted by � l✓h =�/� Li /4 r w-_,_..�.. 4 A -E-mod- ==3 ' A-r- 5s' a-�- y� o � v � pp TOWN OF BARNSTAB E ,O,CATION �0 ffd C.1( L n a Pn ��se SEWAGE # - ✓11b.LAGB ASSESSOR'S MAP di LOT' ;EPT dC TANK CAPACITY S� XAtwWNGTAC11 I TY: (type) C4 (size) -SW �g 40,OF-BEDROOMS WILDER OR OWNER 'E I'TDA7'k?: COWLIANCE DATE: separation Distance Between the: vlaximurn Adjusted Groundwater 3�ble to the Bottom of Leaching Facility eet 'rivtate Water Supt.ly W01 and Leaching pacility (If any wells exist on site or within 200 feet of leaching facility) Wge of Wetland and LeacWng Facility(if any wetlands exist within 300 fer ja, ea �n j�aci! ) Feet utnished by ee f evt keAi 6ok1sjd. A �uuCe�- because ooc Dc vp - t �E �_Z_ 17 % t D- 3 3 to' t �10. J ��� �� ��:. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ltlfcation for Disposal 6pstem Construction VPrmitIle z r 0 Application for a Permit to Construct( ,) R�air Upgrade( ) Abandon( ) El Complete System El Individual Components Location Address oo�rrrL�oot No. J L L Owner's Name Address and Tel.No,5—�'v Assessor's Map/Parcel ©� Installer's Name,Address,and Tel No. �/f�/ f��' Designer's Name,Address,and Tel.No. t��l �'R!z/I��l� j�0 is-k�/ i/, O ,/�� ��/ o �5✓�i/d�ut/�/�t/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) j�C7 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) , iG� ��U /y —/� Q v Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Application Approved b Date Application Disapproved by Date for the following reasons Permit No. laoeq Date Issued l d .r .� � �.,.-. a A^'+.r;::,;.r�y.- -w+r.�......,r•-n....R_v+�r..+w. ..+.*+v.-,rhnstqlrw.wri..w.r-u*.-yA.ra.«,r.*..wMi^.^'�...rM � r.. v:...,,.,a�a,�y�a:�+N*•N++'✓r"p'"`y`..,-.�..,,,,q,,.}••, Fee �;+ THE COMMONWEALTH OF MASSACHUSETTS- Entared in computer. V " Yes -Fhi LIC,HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS IF Yication for Misposar Opstern Coustrurt orr 3permit _ Application for a Permit to Construct( ) Re air Upgrade( ) Abandon( ) ❑.Complete System ❑individual Components Location Address or Lot No. �% jCG �1_L—VDesi e,Address,and Tel.NoE7/.�/1/�'.�iL( S Assessor's Map/Parcel ( 41Z! > 0 S Installer's Name,Address,and Tel.No. ;�j/�/j //f]� �, me,Address,and Tel.No ��C/�h/I/!G!�/ :,e'_co Type of Building: - Dwelling No.of Bedrooms Lot Size qC2 sq.ft. Garbage Grinder( ) r Other Type of Buildings No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �j b gpd Design flow provided � �, yE gpd Plan Date Number of sheets Revision Date - Title Size of Septic Tank Type of S.A.S. 4 Description of Soil - S Nature of Repairs or Alterations(Answer when applicable) 0�GU Date last inspected: . Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sipe i—�r �C Date Application Approved b 7 Date i Application Disapproved by Date for the following reasons f p t Permit No. � � 7 — � � Date Issued jd � ...�,�r-.- --_.-c... __,_-.-._,___._._._----_.___.__._._.- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed$ p y ( ) Repaired ) Upgraded( ) Abandoned( )by at,. Cr2 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Ad dated / 3D�b Installer C�i//lllal._As Designer r Q VP,yam- #bedrooms Approved design flowf\ ! j�'J 4�) gpd The issuance of this permit shall not be construed as a guarantee that the system wil(�l'funct ion/as designed./� Date �la P I t) 1 Ins ector ------- No.(�� ''��- -- r-- ..v,. - --.,�_._--__�----------- - -------•-------------------- ----.Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction J)ermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at Z/0- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/h.-r duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of chi' s permit. Date �. ' /0-9 APProved-by-- m6 - ' Lq, CMP, � �' � � p bv Ij K-A�_ vp Doti,, r � po OARREN M. M 40 �FGliT L ��NITAR\ l L Hv PE w auL, L Q COTU I �;1 LA L L ----� . 1 . S T" itµ OF AfA E cy� MEYER No. 1140 ANf TARN (�130161* APPLICANT: �Gt ✓�L✓1 �-J[� ADDRESS: LA K e DESIGN FLOW: SSA gPd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)) Locus Provided [310 CMR 15.2204 t Plan proper scale? (1"=40' for plot plans, P'=20'or fewer for components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)J System located totally on lot served [310 CMR 15.405(1)(a) for ? upgrades]- i not, a variance is required 310 CMR 15.412(4) Location of impervious surfaces (driveways,parking areas etc.) 310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)) ✓ Location and dimensions of system components and reserve areas [310 CMR 15.220(4)(e)) System Calculations [310 CMR 15.220(4)(f)) daily flow ' septic tank capacity (required andprovided) soil absorption system(required and'provided) whether system designed for garbage grindet North arrow [310 CMR 15.220(4)( )J " Existing and ro osed contours [310 CMR 15.220(4)( )J s Location and log of deep observation holes(existing grade el: on each test) 310 CMR 15.220(4)(h) Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)) Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)J Percolation test results match loading.rate?[310 CMR 15.242] Certification statement by Soil Evaluator 310 CMR 15.220(4) ')) Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)) Location of every water supply,public and private, (310 CMR 15.220(4)(k)) Address 1q t4!' 4wt t 1 JW �pOV F" . �, Sheet 1 of 7 within 400 feet of the proposed system location in the case of surface water supplies and grayel packed public water supply within 250 feet of the proposed s stem location in the case within 150 feet of the proposed system location in the case of private water supply wells Al' Location of all surface waters and wetlands located up to 100 ft. / beyond setbacks listed in 310 CMR 15.21 l and any catch basins ✓/ located within 50 ft. 310 CMR 15.220(4)(1)] Water lines-and dtWkibsurface utilities located [310 CMR 15.220(4)(m) if water line cross see 310 CMR 15.211 1) 1 ) Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR15.220(4)(o)] Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as approved for an upgrade under LUA at 310 CMR 15.405(1 Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103 4 Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)]4° Benchmark within 50-75'of system 310 CMR 15.220(4)( )] Materials specifications noted? [various sections of 310 CMR 15.000) System components not>36" deep(unless Local Upgrade Approval or LUA requested)f 310 CMR 15.405(l(b Address 6 I+opeW E (ATV L.7- Sheet 2 of 7 Town of Barnstable Regulatory Services "~' : . r �. Thomas F. Geiler,Director F'' qT"� Public ]Health Division Thomas McKean, Director 200 Main Street,Hyannis,INL4 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: ` Sewage Permit# Assessor's MaplPareel 06S Designer: Installer: Address: X Address: On 'issued a permit to install a . ( 10, date) (Installer) septic system at *Y1245")E—-- based on a design drawn by (address) _�� �.. i�br..>? ✓� Vt4P i_. e� dated (designer) l I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. 4F. .'k�s 4 DARR N M. s' / ME (Installer's Signature No: 1�t�� 4 5 1 �NITAIt�a� � (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BAI2� STABLE PUBLIC HEALTH ''DiVIS10N. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU Q:Health/Septic/Designer Certification Form 3-26-04:i I doc i { `Se w Size OK? -[310 CMR 15.223(1)] Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14" +5"per foot for increase ft depth [310 CMR 15.227(6)] ✓ Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid ,depth) 310 CMR 15.227(2) Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - " middle access at least 8" (b 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade one port for system s<I_000gpd, / two fors stems>1000 gpd 310 CMR 15.228(2) V All at-grade covers secured to unauthorized access? .[310 CMR it 15.228(2)] ✓ > 10 ft from building foundation[310 CMR 15.211(1)] Buoyancy calculation Required/Done 310 CMR 15.221(8) H-20 Where appropriate?-[310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211 r Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)] ; First compartment 200%daily flow; Second compartment 100% , daily flow 310 CMR 15.224(2) and (3)] "U"pipe through or over baffle, outlet of each compartment with as baffle or approved filter[310 CMR 15.224(4)] . ICI '' '.. - • .. `- - - e Address GAu• 6EVIT- Sheet of Located atNOW leastten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18"below water line(when water and / sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided ? 310 CMR 15.222 8)] Thrust blocks specified in force mains?310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs?(.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] V Siphonproblem/ leachfield below pump chamber) Endca s or vent manifoldspecified? Size and orientation of discharge holes specified?(not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] V Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2)and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity server) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd);waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency.storage above working=design flow)? [310 CMR 231(2) Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE 310 CMR 15.231(5)] Service components accessible (not too deep,with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [31 Q.CMR 15.231(6)and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)] Address o �` W-e 6TU L r Sheet 4 of 7 Calculations correct? 4 feet of naturally occurring material demonstrated?[310 CMR 15.240(l)] / Re uired separation-togroundwater? 310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] : Breakout requirements met?(No violation of breakout elevation / within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] w Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must / be tograde) 310 CMR 15.253(2)] V . Aggregate I'minimum-4'maximum. 310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 s .ft. [310 CMR 15.253(6)] Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] . 100 feet-maximum length 310 CMR 15.251(1)(a Minimum separation 2x effective depth or width whichever eater(3x if reserve between trenches) [310 CMR 251 1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] E minimum 2 distribution lines 310 CMR 15.252(2)(a)] Maximum separation between lines 6' 310 CM R15.252(2)(d Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e) Aggregate depth below discharge pipes 6"minimum, 12" maximum. [310 CMR 15.252(2)(g)] r Separation between beds 10' minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only 310 CMR 15.252(2)(i)] Address w e tl LN 60 n-..�r. F `� -J *a '` : Sheet 5 of 7 1 Pressure Dosed System ? Provided pump and piping calculations as re uired, 310 CMR, 15:220 4 r)] X Pressure dosing required on all systems>2000gpd or alternative systems undavftmedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface[Guidance Document] x Inspections once per year(systems<2000 gpd)or quarterly (>2000 d)good to'note on plan 310 CMR 15.254(2)(d)] Construction in frll -Did the plan specify that the fill shall meet the specification of310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] x Retaining wall must be designed by Registered Professional 71 Engineer[310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ?,r3l0 CMR 15.255(2) Breakout requirements met? [310 CMR 15.252(2) and Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [3J0 CMR 15.255 (2)(e)] �( Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? �( Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? An alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a co y of a maintenance Are the variances listed on the plan ? [310 CMR 15.220 (4)( ) RLS Stamp necessary on plan if a component is within five feet of property line F310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] Address Sheet 6 of 7 Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR.15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] V Is the system proposed on the same lot as served by private well,F? / [310 CMR 15.214(2)] v Are the nitrogen loads proposed in compliance? [310 CMR 15.216(l)] .Pumping to septic tank? 1310 CMR 15.229.] Shared System [310 CMR 15.290 Address /p L AO �l �� _ Sheet 7 of 7 T - . .' TOWN OF BARNSTABLE LOCATION L�<!/r/i C6��t SEWAGE # r /ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. D/ Go /C��'c 5�`" 7 7/ 4`3�P SEPTIC TANK CAPACITY 1Soa LEACHING FACILITY: (type) J-d d Gr t X,we U1 ( (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 1'ti'" 3—�IQI? COMPLIANCE DATE:Z '` J?�� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist y, on site or within 200 feet of leaching facility) N Feet O Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i No. ;� O I�+Z- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplitatton for Mtgpoeaf *raem Con!gtrurtton Vertu Application is hereby made for a Permit to Construct( )or Repair(V)an On-site Sewage Disposal System at: Locatild ss or Lot No. Owner's Name,Address and Tel.No. t4& Ins aller's Name,Address,and Tel.No. �/V��� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3® gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) X 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 issued b i eal �� Signed Date Application Approved by Application Disapproved for the ollowing reasons Permit No. Date Issued T 3 <.,.� .� ��`a. _� .. �� Ems '. 7��,�•t fr. .. No. Z Fee 'J C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS` ZIppYicatio.-n for Migoga[ *pgtem Congtruction Permit Applic tion is hereby made for a Permit to Construct( )or Repair(V)an On-site-Se'wage Disposal System at: FL, ocati4d .ess or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. '7/_ 173� Designer's Name,Address and Tel.No. , �67Gr/O/�� : ✓ �Q/Sf4�5 Ali�f +` Type of Building: '� �R pit" �- Dwelling No.of Bedrooms 4t "" Gatlzage_Csripder-( Other Type of Building gZ51 e l e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 35,0 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Naturetof Repairs or Alterations(Answer when ap licable) fell �O D /f/O ✓l�9 j� e � X f 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 issued s-B. and ealtil" Signed '' Date 3 �/ Application Approved by Application Disapproved for the ollowing reasons 3- Permit No. 7 �0 Date Issued T _- __ _ _ THE COMMONWEALTH OF MASSACHUSETTS 041 O6S PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installe ( )or r paired/re aced( on by &1-)`D7LO/,�_/ l' e,-77 for Jd v, f�p�i./�, as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated 2. Use of this system is conditioned on compliance with the provisionswset forth below No. � a c/a Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS a Miq gaf *pgtem (Congtruction Verntit Permission is hereby granted t ,for l� % to construct( )repair( an On-site Sewage System located at 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. All construction must be completed within two years of the date below. \� Date: T2) !2 6 Approved by � j � j oo0 C7. ------------- I h CEIt11'IFICAnON OF SKETCH AND APPLICATION FOR A DISPOSAL 1VUH110 CONSTItUCTION I,EIt51l l' (1V1'l'IIUU'1'DESIGNED PLANS) 1 (oQt4 5—,-J7 , hereby certify that the application for disposal works construction permit signed by me dated concerning 6 the property located at I (F LtA- c meets all of the following criteria: i✓ There arc no wetlands within 300 feet or the proposed septic system There are no private wells within I5o rector the proposed septic system T-lie observed ground«vater table is 14 rect or greater below the bottom or the leaching racility ,i 'There is no increase in flow and/or change In use proposed �✓ r no variances requested or needed. There are SIGNED: DATE: 7 LICENSED SEPTIC SYS EM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IA(lach a sketch plan or the proposed system. Also Irthe licensed installer posesses a certified plot plan, (his plan should be submi(tcdi. - yl CERTIFICATION OF SKETCH AND..APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION 1'E1t119('1'(WITHOUT DESIGNED PLANS) 1, �Gd�r J, 4i'faZo6ereby certify that the application for disposal works permit signed b me dated �/Z� concerning the construction p g y property located at //g /F��el� 1/9 i �o f��'r meets all of the following criteria: /There arc no wetlands within 300 reel of the proposed septic system /T icre are no private wells within 15o feet or the proposed septic system • he observed ground«vater table is 14 feet or greater below the bottom orihe leaching facility ro • ,?here is no increase in flow and/or change g In use proposed There are no variances requested or needed. SIGNED: DATri: 317 5/ LICENSED SEPTIC STEM INSTALLER IN 114E TOWN OF BARNSTABLE NUMBER IAttach a sketch plan of the proposed system. Also irthe licensed installer posesses a certified plot plan, this plan should be submitted]. 1 ` N ,�v1U•n W �E P R M T N0. LOCATIO , , SE AGE E 1 'PILLAGE INST 1L NIS _ NAME & ADDRESS VV OR OWNER Ot l7 . DATE' PERMIT ISSUED = �, DATE COMPLIANCE ISSUED J -- � 1 7 1. y�'� � 1 � � s�� � r ��,. rr Fus.. �� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ------....��J.G4/1-I...........-OF.........6 .. ................................... C7)? Allp iration for Uiipniia1 WorkB Tomitrnrtinn ramit Application is hereby m de for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 10 Ca�.S.9rr►�f'0•v) `�/g' -•• - -.,C'!_'�..-. ..Wa L-------------- eL-�---•--------...._. ..................... ...... _�... 4, L n. old ss or LA-TV o. xlc ... ` -•-- ------------------ �� .. .. � - • _.....�...._. �n �� O Address W .................................. Installer Address Type of Building r Size Lot. ��4✓__¢__'_Sq. feet V Dwelling No. of Bedrooms_________________ ______ ._ Expansion Attic ( ) Garbage Grinder �+ -------- `� Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ....... - ---•------- --- Design Flow --- allons per person per day. Total daily flow "� dons. WSeptic Tank Liquid capacit . _ . allons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ................... Width____ _--- ....... Total Length.....___.. ._____... Total leaching area........__._....................sq. ft. 3 Seepage Pit No.../-------------- Diameter........�Qd.... Depth below inlet._.. Total leaching area.:�.�4�;.,sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1..�;)--minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ---- - • ... �---- 6 �escrpono Soil........ - . �--`.......... -- / W ••----------------------------------------------------•---------------......._..-----•-------•----------••-••-•--------------------------------•---•---•-•-•----•--•------------------. ----..........-- U . Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------•__-_....................................... •-------•-------------------•---••--•-----•--...---------------------------•--------...............-----•---•-----------------------------------...----•---------------------------......__....--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TH'I TIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board h. fined ... = "�,��-----•---------- / D to Application Approved BY v L �r -�-- - Date Application Disapproved for the following reasons_________________________ __ _______________________________________________________________________________ ---•-----------•-•---•--•---------------•-----•---------------- -------------• --------------'..-----------•---•--------------------------•^--------------------•------------------------------ fP Date Permit No....................... .....--•--------.._... �@ Issued._.._.�..__ll_n r�G� No: • •��--� -- a „ ' FRs............................. ' THE COMMONWEALTH O F,MASSACHUSETTSCf B ,gF . P( W_ L. OF..... ,���firtt�ilan��ur �i��ia��a1 lark, C��tt��r�r�iun rruti� Application is hereby de fora Permit to Construct ( or Repair ( ) an Individual 'e a e I. o4al System at: C 'l7S .��sbti� �+t`�/�( - -- A --- - - s. ..:.� . ._. • - 9 L on-A41d ess or No. S� w er Address W ---•-....'•-•--?c'l_f!/ .- -•................... ........-----------------------------•------ ---..-.-------......................••-•...... �` Installer Address ro� � Type of Building,.,' Size Lot______ ___________________Sq. U Dwelling No. of Bedrooms................ .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other-kxtures -----------------------------------------------------------.------..................................... allons per person per day. Total daily flow____.__. W Design Flows ___:�....,,�_____________ ..�j�. _._gallons. W Septic Tank—Liquid capacit-AW*91]tons 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 (r ) Dosing tank ( ) Percolation Test Results Performed bY............................................................----------_... Date....................... ............. L,aa Test Pit No. . >'minutes per inch Depth of Test Pit.....................Depth to ground Water........................ Gr, Test Pit No. 2................minutes per inch' Depth of Test Pit.................... Depth to ground water........................ P4 .. ... o . . �---'-�--- �--.------._�_.;�..Via..--------J-�� --�� ��/, Description of Soil---------;...................... .....V------._..............-------------------•......-•--`-------------------......... `l---................ .................. W -----------•------------------••-••------••--------------------•----------------•-------------------•--•----------------•-------------••-•------------------------------------•----••-••......----...... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreerpent: The The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.:L 5'"of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by the boar h. igne ................ .ve- {� Application Approved B .............. Date PP PP Y-------`- -- "-_-. .. •- ---=-- ---�/'�----- Application Disapproved for the following retasons-.....................-------------•••--•••--•-•---•-----•----------------•------••......-------•----.....------ ...................................---------------•-----......---------------------..........--•--------••---------------------......---------------•--•-----------•--•--------------------.....--•-- .. " w- Date PermitNo....................'--.. .... Issued--------------------•..-------•-------•-------- ---------------•----•------• --- Date THE COMMONWEALTH OF MASSACHUSETTS j B®ARD. OF HEALTH a tOF.........../ . . .. . ..... ...... t�. Tr ifiratr of Tompliatta jrr THIS I -T0 CE IF at at ,Individual Sewage Disposal System constructed 4-) or Repaired ( ) :........ :: .� ............... (rW �. nstall� at---- ------•-------------•------ -------- --------- ---... - ----- a- has been installed in accordance with the provisions of �r pkj �tate Sanitary C+Weh.a1Awrj&�in the application for Disposal Works Construction Permit No......................................... date d_...._........................_................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,CONSTRUED AS A GUARANTEE THAT THE SYSTEM;10VI�L FUNCTION SATISFACTORY. ' DATE........... `............................................................... inspector..', ---...�. . `........................... ............. a THE COMMONWEALTH OF MASSACHUSETTS BOARD OFYEALTH . ..... .. ....OF................... ................7...---- •• _...................... .... No........................ �.. FEE...:.t .................... Disposal Vrk - ey ant ' T�e/Permisson Y" n isosat � I � � �� at`No... --- rmi r ------rr-� •. Stre't ., �� i as shown on the application for Disposal Works Construction i t No... _... d r .� ." I Board of Health ................7,*..............- DATE�-.,/...................................................••-•----•-------........ I FORM 1255 HOBBS & WARREN, INC., PUBLISHERS � 4 1 i Lo �' I i 60 ol Ab j L i^ A fiooi r_ aALT.+.t' lt'�i ce".- ��f• , �'`� '� , �c ow Na F tit iNG.SCA �f s . ' t' w 53. 0 �"0 N ors-'•Jc.Sd:;( ;J [Q;ST.�.77r Aim o0o CIA'-. -_or•:c j ; y -- ! I �, n 4� jr 9, I G 7t-,, ; I GCaI� �l 4. ,( �.` -� .�-� s ,-. ,(J� D -79 tiSE c000 r - ri r LZ In .. _.-.....i....,.. ..�- ..;._.. -. ��. ;.�_... SURVEY REFERENCE: '~ MAP.040 ' PLAN OF LAND BY CHARLES- N. SAVERY, PLS LOT. 065 DATED: cEBRUARY 12, 1968' • _ \`1 �) LCCA.•128610 - 40 SITE �a I `'•�\,�` _ �`_ _ :/ �s \\\ i� "•\,\ { ,lam \� � i / 1 ���Q���'i �'L�`� •. r �_ _ Tld-1 ``�. /u 90 f/ '\ -4,qv, ; it r ' LOCUS MAP N'.T.S. y� \ of t5, �•� �, ! 1 "` \ BT.LEACH PIT s \ , GENERAL NOTES: s \ (SCE NOTE 10) �y O \I 1 \ {{ LOT 1 % ` - / I c 1 1 J �r �\ ?,. � ,� 1 C J � � 1 1 \ ' 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL �� _`_ BOARD OF HEALTH AND THE DESIGN ENGINEER. l I AREA, = 1 .90. cc 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V,.AND ANY APPLICABLE LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: 310 CMR 15.405 (1) (B): am Q / \• 1 \r I 1 \ i c 1, - �• s \1 ` 1) A ..1.0 FT. VARIANCE FROM 310CMR 15.221(7) TO ALLOW LEACHING '�n '•, �,; - .\ ��\�, ,• � \ �I � i 1 \\ TO BE 4.0 FT BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) o �� '. �,% �`�\ \,` \ r�`f�� \f �!\ ;` , j I, �\ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE 13ACKFILLED PRIOR f \ TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE `'\ DESIGN ENGINEER. I `\ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING I \ T�! fJh' I t.LLt i i ��\, FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. i C) '� ► \ rS'" \.✓� \ I ' 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. . 16. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF \C, I j THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. it 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. \ / • it I-'J S I` I i t 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED C \ I i TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR, BENCH M AR K Y7 ', � � -���- / tl � � / Il �';' 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PAINT POT ON STER THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 1 ELEVAnoN = 65.72 ,` \ i .��r CONSTRUCTION. BARNSrABLE GIS DATUM ��✓``l ��' aa4 I! \-�-��\ \\ \ //. ���� 10. EXISTING LEACH PIT TO 8E PUMPED, CRUSHED AND FILLED. i, 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING TEF. L l 14..ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC.) AT;`• z 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW j 1a Of FOR THE USE OF A GARBAGE GRINDER 16. NO WETLANDS WITHIN 100 FT. OF. PROPOSED LEACHING DA E�I� rSh� s s , I � �' -�- I , �. - J 17. PROPERTY IS WITHIN A ZONE OF CONT. TO ESTUARIES j rCi o - MEYER PROPOSED SEPTIC SYSTEM UPGRADE PLAN NITAR\aN 1 - ,fir \� 118 HOPEWELL LANE, COTUIT, MA Prepared for: Mike Dedecko Engineering by: Surveying by: SCALE DRAWN ,. _ I DARRENM.MEYER,R.S. Eco-rec6 Bnvironmentel 1" 30, DMM ,_ PO BOX 881 DATE: CHECKED SHEET NO, �.-.._. _. _ I (508) 364-0894 EAST SANDWICH,MA 02537 -_"-- 50B�B2-2922 1 1/28/09 DMM T of 2 , '> REAKOUT, THE PROPOSED DESIGN CRITERIA NOTE: MAGNETIC TAPE T01.E3E PLACED OVER ALL COVERS DIE SHALL NOT BE < EL:60.54 FO`RA @@STANCE OF 15' AROUND THE NUMBER OF BEDROOMS: 5 BR DESIGN (PROPERTY IS IN ZONE-OF CONT. -T3.ESTUARY) PERIMETLOF THE S.A.S. SOIL TEXTURAL CLASS: CLASS 4 SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. DESIGN PERCOLATION RATE:. <2 MIN/IN INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION FrJg'' OVER Lim-Y 4-LCYr '� g"'i`1 G.Pa7 �BR T.O.F. "EL".=66.28 ... OUTLET AND SET TO 6' OF FINISH GRADE SET TO 6 OF GRADE ONE CHAMBER (MIN.) AND SET TO 3' OF F.G. 4+w,.; `"' DESIGN FLOWN 550 G.P.D. (Min. F.G. EL.=6OUT r ) F.G. EL=64.50t F.G, EL: 64.5tF.G. EL: 64.50(MAX.) VENT GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) PROPOSED SEPTIC TANK: 550GPD X 200% _ 1,100GPD USE NEW 1,500 GALLON TANK 9" MIN COVER/ LEACHING AREA REQUIRED: (550) = 743.24 S.F. L m 10'"t L 45' L 15'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) ® S-1% (MIN.) 36" MAX COVER ® S=iX (MIN.) ® S=lX (MIN.) .74 4"SCH40,PVC 4"SCH40 PVC 4"SCH40 PVC DISTRIBUTION BOX: 5 OUTLETS (MINIMUM) 10" " e 11.3" TO PRIMARY S.A.S. u" INVERT USE 5 ROWS OF 5 - 16" ADS BIODIFFUSER H-20 UNITS NO STONE \IN = 6 1.26. • 48'LIQUID INV.=61.01 AND EXTENDED 0.75 FT WITH CONTOURED WEDGE. LEVEL INSTALL • GAS BAFFLE .25 .75 PROPOSED INV.=60.30 5 ROWS OF 5 UNITSIAT 6 '/UNIT + 0 ' WEDGE 32.0'/ROW BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) D-BOX (BIODIFFUSERS) 25 UNITS' x 6.25 LF x 4.70 SF/LF = 734:38 SF INV.=60.50 DB-3(H-10) INV. 80.15 SOIL ABSORPTION SYSTEM (PROFILE (BIODIFFUSERS) 5 UNITS..x 0.75 LF x 4.70 SF/LF 17.62 SF .' m PROPOSED 1,500 GALLON SEPTIC TANK DESIGN FLOW PROVIDED: 0.74GPD/SF(752 SF) = 556.48 GPD > 550 GP req'd RESTORE,VEGETATIVE COVER EXISTING SEWER OUTLET I BACKFILL WITH CLEAN PERC-SANG 75" TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING - e. :. • •. .:,.• PLACE FILTER FABRIC PIPE INVERTS PRIOR TO CONSTRUCTION OVER ALL UNITS 2) SEPTIC TANK AND D-BOX SHALL BE SET LEVEL AND BREAKOUT=TOP ELEV.=60.54 (RECOMMENDED) TRUE TO GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 60.15 . t•,.':: INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 59.21 EXISTING SUITABLE 310 CMR 15.221(2) 2.83' MATERIAL 3) INSTALL INLET & OUTLET"TEES AS REQUIRED 5' MIN. ABOVE BOTTOM OF T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH 5 x 2.83' = 14.15 r (7.11' PROVIDED) USE 5 ROWS OF 5-HIGH CAPACITY PROFILE ` BOTTOM OF TESTHOLE EL.=52.10 - ADS BIODIFFUSER UNITS-NO STONE W/ CONTOURED' WEDGE SEPTIC SYSTEM PROFILE : TYPICAL- IS CTION N.T.S. KTS. 6.35' SOIL LOG P#: 12760 �- 34" DATE: NOVEMBER 18, 2009 SOIL EVALUATOR:.. DARREN M. MEYER, R.S., CSE. #1614 _ ��� Of �lgsf9c �� SECTION END CAP WITNESS. DAVID STANTON, BARNSTABLE B.O.H. D�N y� 16 ADS 160OBD BIODIFFUSER UNIT (H20 LOADING) Elev. TP-1 Depth Elev. TP-2 Depth Elev. TP-3 Depth Elev. TP-4 Depth M ER NOTE: INSTALLER TO FIELD VERIFY, H-20 LOADING PRIOR TO USE. 64.10 0" 63.10 p" No. 1140 � 63.80 A 0" A A •64.0 A i 0" . MODEL 16" HI�CAP LOAMY SAND LOAMY SANG LOAMY SANG LOAMY SAND f 'f1161 4 LENGTH Z6 tOYR 3/2 10YR 3/2 10YR 3/2 NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT 63.30 B 6„ 63.35 9" 62.43 8„ 63.25 10YR 3/2. I 9" NITAR�P� °TO CHANGE WITHOUT"NOTICE. PRODUCT DETAIL MAY LOAMY SAND e e e101EFFECTIVE LENGTH 75 LOAMY SAND LOAMY SAND � Zg .DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. 10YR 5/8 LOAMY SAND SIDE WALL HEIGHT 11.2" 10YR 5/8 10YR 5/8 10YR 5/8 � , OVERALL HEIGHT 16' 60.97 C1 34" 61.35 C1 33" 60.27 C, 34" 61.25 C1 33" OVERALL WIDTH 34" MHHLr 4640 rRUEMAN BLVD MEDIUM SAND MEDIUM SAND MEDIUM SAND HILLIARD, ,OHIO 4,3026 2.5Y 7/3 MEDIUM,SANO 13.6 CF 4 2.5Y 7/3 2.5Y 7/3 2.5Y 7/3 CAf ACITY (101.7 GAL) AovAftcEo oRAlrtacE sysreMs, INC. PERC ®59.63 PERC ®58.89 PROPOSED SEPTIC SYSTEM SITE PLAN • t 52.80 132" 53.10 132" 52.10 - 132 53.0 a 132" 1 1 8 HOPEWELL LANE, COTUIT, MA PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) 1 - Prepared for: Mike Dedecko NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED ' Engineering by: Surveying by: SCALE DRAWN DARRENM.MEYER,R.S. Eco-Teed FwvZ onmentel NTS D.M.M. _ • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MQEP pursuant to SI D CMR 15.017 pO BOX 981 508 to conduct soil evaluations and that the above analysis has been performed by me consistent with the EASTSANDWICH,MA02537 ( ) 364-0894 DATE: CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Evcl. Exam in October, 1999. ) 508•362-2922 1 1/28/09 D.M.M. 2 of 2 I 40/ - ---- ------------------------------------------------------------------------------ ----- ---------- -- ------------------------_ 'r----- -- -----^--------------------- _ .. .. .. :. :: 30' Window 30' Window EXISTING STAIR I � , SCM ' Down, to Basement � _ I _ NEW STAIR, UP . to Living. Area I I _ o � I -L. I i . I I I r 3 NOTES; - .3 1, Existing Concrete Steps 2; New.. Steps to Second .Floor <.Existing Living -Area) NEW 3 C AR GAR A G E I _ - i a. Stringers KD 2x12 reads KD 2 T _ x12 , -3. First Floor Walls Will be 16' _ I o,c, 2x6 KD _ I 3 4. Headers for Garages :will be o ; 11-7/80 LVL (Triple) 5. Headers for windows/door MR loe KD 2-x-1p a, (Dble .w/Plywood) Garage Door Garage Door Garage Door 1 �, , IL---------- ------------9-----_---_-- ------------- ------------9------------= ---�__------- ---=- 9 I 66n gow:�LTOZ 130 Au. I ' I , ORWG.NO. PREPAREDFOR SCALE DRAWN:BY NO. DATE DESCRIPTION BY NON — PUBLIC I:NF'ORMATION t _ BC218-032217-002 Seth & Jennifer Cassidy (Owner) 1/.4• = 1' B,Ca rio _ _ '"°" r P t ma w A epa ft**qua men a«r u,.Rm.v a mr unamwra.a w., tkn«�rrowr.r aaen.e er b..nr SETH&JENNIFER CASSIDY TITLE DATE APPROVED BY SH erw n.-weo ba�aaon ur Ma¢ 218 Hopewell Drive 3,.CAR GARAGE Exterior Balls 03/20/17 m..►,w a capes er..ewaa«mab waaw.w 9.y am.p..* « Cotuit,MA 02638 3 - .uiy aaw�e n.o�.wRe. cm..ne w'weq 40 t lo 30' Window 0' Window 30' Window r NEW STAIR, U SCM j o From- E ist ng House N4 �v STAIR UP, From Garage to - Dds Ing House . N MASTER CLOSET O � EA - - _. _ - o N a CD -w MASTER BEDROOM E3 B❑Y'S ROOM ,TV ROOM. c � , J O M 30' Window 30' Window 30' Window DRWO..NO. PREPARED FOR SCALE DRAWN BY NO. DATE DESCRIPTION BY NON — PUBLIC INFORMATION BC218-032217-004 Seth & Jennifer Cassidy (Owner) 1/4' 1': B.Caprlo 1, _ _. s►1 W dbd��� 00 _ — { SETN&JENNIFER CASSIDY TITLE DATE APPROVED BY I 218 Nopewell:Drive, 3 CAR GARAGE — New Upper Level 03/20/17 3 - .a�ia° n�„ 'Maft awe°�m.:�rw.v Cowls,MA 02635 SH 40/ ol ol Existing House Foundation cc Cross Section .of New Foundation Not to Scale) .. - .. W: p Anchors - - cc c NEW : 3 CAR GA RA G E 3 O LL- O - O) F' a to X - W DRWG.NO. PREPARED FOR SCALE DRAWN BY NO. DATE DE$CRIP7ION ' BY NON PUBLIC INFORMATION ' BC218-032217-001 Seth & Jennifer Cassidy (Owner) 1/4 V B.Caprio _ _ S„ rtgf. anlai.mti0ntd IM�nwPm tlwl 6 YN pnpRlr d NCR. . Aef wa"Id a... a d6wld,u.Y prchOtbO D�1 Wn'IFb :. SETH&JENNIFER CASSIDY TITLE DATE APPROVED BY a 9I 218 Hopewell DNve U M .6 e.oyM0.4r�ab4.,nM.—*dA-i ap,MA„pr.m., 18 Ho 82835 3 CAR GARAGE — Foundation Plan 03/20/17 a - + .wr Mnw�W.pro..ne. m..n 0 na 33 lb Q0 y $g@gy a6 116$ is q � 6 gL IL g ;9 Z 1. Garage watts insulated with R-21 Hurricane Clip on Every Rafter z Simpson. Hs,5A on.:Inside .4 2. Garage ceiling insulated with R-30 (Not to Scale? 3. Garage walls finished with 8' fire rated dry wall Z 4. Upper Level watts, insulated a .with R-21 5. Upper Level. ceiling :insulated _1 1 with R-48 6 - Upper Level walls finished with 1/2' dry 'wall L Simpson Strong 'Ties: 11-7/8' LVL Ridge U c. Over Ridge 1,75' W �' a o fU Plywood :a o .. .. :. :. y. ,••1: .G 2x12 Rafters 16' o.c. 2x12 K'D Collar Ties 16' o,c. Make 11.25° o oc b U m 1 U ` m W QQQ 'T/ ,- tr iv .11-7/8' TJ.I 'o I-Beam 40'x12'x7.5' o a =..;. a (D f O 8 Concrete Exposure- from Gr.ound ;to Si'din y •� _. i 11-7/8' Ledger Rim_Board around perimeter of structure Q New Walls) 2 @ 11-7/8' LVL 4n.. J F _ Single 11'4' TJI -Hangers on 11-7/8' LVL 2 @ 11-7/8' LVL 11-7/8' LVL .. Double Hanger 2 @ 11 /8' LVL 5 @ 2x6 KD Post (2) a I- Underneath . Beam NOTES 1. I-Beam 40'x12'x .5' FLITI T .:a .I S , I (Not to Scale) 7.5 G rag D or G Ior a rage Dior 2. 11-7/8' .TJI Joists @ 16" o.c. • 3. T%G S:wlo Floor with • construction adhesive \ I .. " . DRWG.NO, PREPARED FOR SCALE DRAWN BY NO. DATE DESCRIPTION BY NON PUBLIC . INFORMATiON BC218-032217-003 Seth & Jennifer.CassidyOwner 2017.m mpaYwn work eN MR N flrlb.rM6 TM ) 1/4 = 1' B,Caprlo 1 _ sH tM-Odf d m�nenta eat b = y— z .. .. .: .. .. •nr uwtnomw ww o,p�mmo>awo�un r Thm Qrt om�Uwe are W .. + SETH 8 JENNIFER CASSIDY TITLE DATE APPROVED BY p - _ 91 Mod"°w" a .n W— b*Q Mrt e W= "11, ft/ bcw.tnb ea T t+tmnWm 218 Hopewell Drive 3 CAR'GARAGE - Floor $ tem _ .e a mpw awwnt aba=Mua awes"to ay WW P..—a Cotuit,MA 02635. :. ➢e 03/20/17 9 - .aer.en.ut e.a�•�tm mart ar xa