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Home My WebLink About0041 KEELA ROAD - Health 41 KEELA ROAD COTUIT Q � rl I A TOWN OF BARNSTABLE LOCATION ��0. ��C�! E#-Z�SP VILLAGE CMU t't ASSESSOR'S MAP&PARCEL I1T==Xdt!S NAME&PHONE NO. u'-f:(_0 CoMV t 0 SEPTIC TANK CAPACITY 5_00 LEACHING FACILITY:(type) `YciLQVS (size) y NO.OF BEDROOMS OWNER MOrri -trr-k/ PERMIT DATE: CO ATE:_Jr,5P /640�/O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlan ex t within 300 feet of leaching facility) Feet FURNISHED BY f r_i f f f r • r r / f f • / f • r f • f f f f f f / f / f f ! • J f 1 J f f f f f f J F f f f f f F J i f • • J f f 1 f ! f f f / - 1 J f J J ! ! J J ! / ! f • J f ! " • r ! ! f f ! f ! / f r 1 r f • r J f f f f • • ! r J f f f ! ! ! f f ! F F f ! F h R \ \ \ \ \ \ R \ \ h h \ \ h \ \ \ 4 4 \ 4 \ 4 4 4 \ 4 \;Y;P1CfK31rk;\f\ 20 28 2 : J , Commonwealth of Massachusetts Title 5-Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 every 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: A. General.Information When filling out forms on the computer,use 1. Inspector: 12, only the tab key to nova you. Pairick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name; 189 Cammett Road Company Address Marstons Mills MA 02648 ICI Cityrrown State Zip Code 508.428.1779 SI 12855 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 2,VAAf- t—x—� October 6, 2010 Job# 10-239 In pector'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. o 1 I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage sposal System•P ge 17 iL Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every page. Citylrown 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: Tank is not in need of pumping at this time, leaching system had no standing water or evidence of surcharge B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section :teed 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-09108 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 2 of 17 1_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every page. Cityrrown 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 t 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-09108 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 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 i every page. Cityfrown 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 syst6m hay a septic tack acid 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 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 ❑ R ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any>portion of cesspool'or privy is within i 00 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no'to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200.feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. l5ins•09108 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 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ f 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ro Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Unknown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 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: Tank pumped two years ago. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every 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: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1 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.): Septic Tank(locate on site plan): 1' . 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: 10.5' long x 5.8'wide- 1500 gal. 0" Sludge depth: l5ins•09108 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 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 0,1 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 Measured How were dimensions determined? . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank had liquid only, no solids. Liquid level was found at bottom of outlet invert and tees were intact and clear. 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-09/08 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 .�' 41 Keela Road Property Address Diane Moriarty Owner Owners Name information is Cotuit MA 02635 October 6, 2010 required for 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Keela Road ' Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 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): 0" 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.): No solids or high stains present. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: j Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Galleys had no standing water or evidence of surcharge. 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-09108 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 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 every page. Cityfrown 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.): r 15ins•09/0, 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 r 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for C.otuit MA 02635 October 6, 2010 every page. Citylrown 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 777,777.7 / / / / J / / / / / / / / / / /. . . . . . . . . . . . . . . 20 .� 2 28 41 V4 .. .................. , e r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is required for Cotuit MA 02635 October 6, 2010 every page. Citylrown 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 groundwater 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: Low areas of abutting property with no surface water are considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 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 41 Keela Road Property Address Diane Moriarty Owner Owner's Name information is Cotuit MA 02635 October 6, 2010 required for every page. Citylrown 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 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 )PE:.' DATE: 10/.29/98RY ADDRESS: Al K�ela Road OCT b 0 19 Cotuit TOWN OFBARNCTABLEHEALTH DEPiMass. -On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1500 gallon septic tank. ' 2 . 1 -Distribution box. 3 . 4-4 ' x4 ' Leaching gallies packed in 2 ' of 1 '-z" stone.. Based bn my Inscactlon, I cerilly the following condltlons: 4 . This is a' title five septic system. (• V'8v COci-e ) 5 . The septic system--is in. proper. worki.ng order at the present time. 6 . The house has had very little use in the past two years. .. SIGNATURE: I . Name J P Macomber Jr;,. i , . . -.- ----- - Company:_J• P .Macocober &- Son'`Inc , Address:_.g _66---_-..�-__�__ CentervilleLMa,,j, _02b32 Phone: ---SQ8_:L7S- 33a....... THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER '& SON, INC, Tinkc-C�upoolrl.e�ch(lelds . Pump+d 4 Instillyd Town Sewer Connections P.O. Box 66' Centerville, MA 02632.0066 77.5-3338 M) 412 r i ,a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT.OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02109 617.292.$500 r WILLIANI F.WELD TRUDY C Governor Seca ARGEO PAUL CELLUCCI DAVID B.STA Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commiss PART A CERTIFICATION Property Address: 41 Keela Road COtuit,Mass. Address of Owner: Date of Inspection: 1 0/2 9/9 8 (If diHerenU Name of Inspector: ,Tn-p h p Ma r•nmber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:J.P-Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass. 02632 Telephone Number: S f)R_7 7 r,_vn R CERTIFICATION STATEMENT I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accur; and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function any maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails G Inspector's Signature: s Date: The System Inspecto shall submit a copy of this inspection report to the Approving Authority within thirty(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 subm the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system ow and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.3C Any failure criteria not evaluated are indicated below. COMMENTS: 61 SYSTEM CONDITIONALLY PASSES: /f/9 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, of completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate ye!L_no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or to failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:Invww.magnet.state.ma.us/dep Printed on Recycled Paper f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) P(opcny Address: 41 Keela Road Cotuit,Mass. Owner: Richard & Susan Hamilton Date of Inspect)on: 1 0/2 9/9 8 e) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipes) or due to a broken, senled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box Is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pus inspection if(with approval of the Board of Health): broken pipes) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD Of HEALTH: A_ Conditions.exist which require further evaluation by the Board of Health In order to determine if the system is (ailing to p(oeea th public health, safety and the environment. t) SYSTEM WILL PASS UNLESS BOARD Of HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTt /bD Cesspool or privy is within 50 feet of a surface water DP Cesspool or privy is within 501ect of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD Of HEALTH (AND PUBLIC WATER SUPPLIER, If APPROPRIATE) DETERMINES THi THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFM04ND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply c tributary to a surface water supply, /!)Q The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within So feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is lesi than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for eoli(orm bacteria and volatile organic compounds indicates the the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate niuogen is equal to o less than 5 ppm. Method used to determine distance A* (approximation not valid). )l OTHER AJA 04 (revised 04/3s/17) dap• 3 of 10 SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 Keela Road Cotuit,Mass. Owner: Richard & Susan Hamilton Date of Inspection:10/2 9/98 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note i4 they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, eluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address:41 Keela Road Cotuit,Mass. Owner: Richard & Susan Hamilton Date of Inspection: 1 0/2 9/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow:} BpL�Jbeclroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_ Laundry connected to system (yes or no):Xd Seasonal use (yes or no,. V6— _ 'l Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):2M 199Y2 A0PO'o— � ei Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establish m: Design flow: a allons/day Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no),Y Non-sanitary waste discharged to the Title S system: (yes or no)'Vol Water meter readings, if available: A/,Q Last date of occupancy:_A) OTHER: (Describe) ) Last date of occupancy: 1 GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) 10 If yes, volume pumped: �� gallons Reason for pumping: A/,4 TYPE OF YSTEM 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) VA Technology etc. Copy of up to date contract? Other APPROXIMA AG of il4components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/17) ?&go 5 of 10 C�1 SUBSURFACE SEWAGE DISPOSAL •SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Keela Road Cotuit,Mass. Owner: Richard & Susan Hamilton Date of Inspection: 1 0/2 9/9 8 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron Z40 PVC_other (explain) Distance from private water supply well or suction line A Diameter 411 Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight. No evid n Through the house vent SEPTIC TANK:/Gem�OPgALOug (locate on site plan) !t Depth below grader Material of construction: I/concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: A I 1/ SIR A i Sludge depth: Q i Distance from top sludge to bottom of outlet tee or baffle: Scum thickness: -/A4,4A— Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bolt of oud t�affle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump the tank every 2_-4 1,e�s - Tnl Gt e--Qtdt I pt tees are in DlaCe_' TJ sltj rj 1 PVpl at t-ho Olit,Iet i {}�re r� The tank i c etriint Ur- l 1 . 1_G uRd and -shojes fte--3j: GREASE TRAP: / (locate-on site plan) Depth below grade: Material of construction/w_concreteA/4 metal&/ Fiberglass WPolyethylene VAother(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of sc m to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) Grease trap is not present _ (revised 04/25/97) page 6 of 10 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) nm Property Address: 41 Keela Road COtuit,Mass. Owner: Richard & Susan Hamilton Date of Inspection: 1 0/29/98 TIGHT OR HOLDING TANK:dPtt(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: AZ14 Material of construction Wiconcrete4!hmetal A14F iberglassf4PolyethyleneWAother(explain) Aw — -- AIR Dimensions: AM Capacity: AM gallons Design flow: gallons/day Alarm level:/ _Alarm in working orderNA Yes;/YA No Date of previous pumping: 44 Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks are nAt =rpgPni- DISTRIBUTION BOX:z (locate on site plan) Depth of liquid level above outlet invert: �d Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Dis ri ution box has one lateral;No eevidencP of cnlirlc carry, nvos; No evidence of leakage into nr aut—nf tho bQX. PUMP CHAMBER:AWk (locate on site plan) Pumps in working order: (Yes or No))A Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is not prespnf _ (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Keela Road Cotuit,Mass. Owner: Richard & Susan Hamilton Date of Inspection:1 0/2 9/9 8 SOIL ABSORPTION SYSTEM (SAS): " ��)942"'�� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number: leaching galleoies, number: leaching trenches, number,length: d leaching fields, number, dimension overflow cesspool, number: Alternative system: Name of Technology: -77 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to sand;NO signs of hydraulic failure or jnntjin; , All vegetation is normal. CESSPOOLS: (locate on site plan) Number and configuration: 0r 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 (cesspool must be pumped as part of inspection) Cesspools are not present. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present. PRI VY:/fh(E (locate on site plan) Materials of constructs n: /t//q Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present. (revised 04/25/97) Page 8 of 10 TOWN OF BARNSTABLE I LOCATION SEWAGE # VILLAGE �i i/ �� ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. _3,0 ' SEP11C TANK CAPACITY l LEACHING FACILITY:(type) (size) NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER� �� BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED_�� VARIANCE GRANTED: Yes No t� I 417 i SUBSURFACE SEWAGE DISP( l SYSTEM INSPECTION FORM P;.r. C SYSTEM INFOI;'— HON (continued) Property Address:41 Keela Road COtuit,Mass. Owner: Richard & Susan Hamilton Date of Inspection: 1 0/29/98 Depth to Groundwater 161'Feet Please indicate all the methods used to determine High Groundwater OeVation: Obtained from Design Plans on record observation of Site (Abutting property, observation hole, basemtrst'sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records 2 Check local excavators, installers Use USGS Data Describe in your own words how you established the High Grounclwater•Elevation. Must be completed) Used Gahrety & Miller Model 12/16/94 Shows 5 ' (ravis•d 04/25/97) Pag.` '160f 10 •rnm r+.—n'I+�.Y9—Est'rww•nt.wllTn+w'�.l�rrnlr+�r►1A+RTn nTn17J 1�17'.1n eta •• v '1'0 NN OF Barnstable BOARD OF 11EALTII SUDSA-•rn-r••.-t: —r, n�,T�� UItFACF SEWAGE I)I POSAL SYSTEM INNSHCCTION FORM - PART D .- CERTIFICATION I . ,-TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 41 Keela Road Cotuit,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 18-64 OWNER' s NAME Richard & •Susan Hamilton v� PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & S6 Inc. — COMPANY ADDRESS Box 66 Centerville Mass. 02632. Street Town or City Stat• LIP COMPANY TELEPHONE (508 J 775 - 3338 FAX (508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne ; System PASSED , The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con ted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEAL1'II. * If the inspection FAILED, the owner or" perator shall u within one year of the date of the inspection, unless allowed dortrequiredm . otherwise as provided in 3.10 CFJR 16 . 306 . ` partd .doc `4 TOWN OF BARNSTABLE lot'THE 11 nayo ?35'k# , I OFFICE OF EALTH t BOARD OF I PAM i ` 367 MAIN STREET' "�r. t619 K( � MASS P . 02601 120K �. .�a'!' HYANNI8 - fF ,j rt at August 3 , 1988 Mr. Richard Hamilton c/o Cape Cod Five Cents Savings Bank. 97 ..Cranberry Highway Orleans MA 02653 E1ML. NU1U TO ABATE. L C_IICIOU. QF_ $1ST MR_ '15 I 1 111l _b_ A-1'E- E11YI13O13t7EdTAla 1 ) ' ' E. Y..s C1iH_ 141 RE i FNTS Fst$ MF,- EUBSUREACE WJEMEAL Q. SANITARY ELMR The property owned by you located at 41 Keela Road, C( t:u.it, was inspected on August 3 , 1988 by Donna Miorandi , Health Inspector for the 'Town of Barnstable because of a complaint . The following ' vi.olations of 105 CMR 410. 00, State Sanit.ary Cade, Chapil-or II , shad yitl Grak. 15, w)j ,.A.W4 fltAW ta,l Code, Title 5, were found. .;{ $egula 1Q11 1300 Q-t ChaUter 11 and Regulali_Qa I !?, ( 19) (20) al Title ;Z: Sewage was observed overflowing onto the ground. No sanitary sewage shall be allowed to discharge or spill onto the surface of the ground. You are directed to hire a licensed disposal works construction installer within seven (7 ) days to upgrade this system to meet the requirements of Title 5 and the Town of Barnstable Health regulations. You are further directed to keep the system pumped, daily: if necessary. In the event these orders are not complied with, serious consideration will be given to the emergency condemnation of this dwelling. - .;'You may .request a hearing before. the Board of Health if written petition requesting same is received within seven (7 ) days of receipt of this notice.. Non-compliance could result in a fine of up to $500 . -Each day's failure to comply shall constitute a separate violation. You are also sub,)ect to a ticket citation for each day violations are observed. There is a $25. 00 fine for each ticket issued. Tickets will be issued daily until the violations are corrected. PER DER OF Tli BOARD OF HEALTH :.,...:.. Thomas A. McKean Director of Public Health a r, �j�� f o50�> �D �' ,�� v �� a �� a � )li �� a�-� �� i � �� a�ri�� - ^' °- .. �' +',." ��w.x�'"'�..•xm.-.'*s �� 1-�.,.i,»�ax+F::...... - r3t ` -------,....�.�`�� - _ � ea:� - -_,,.�_.-..r—•.ti.._,_. - .':.._,•.� _ „ .. f a31 e. .:�SVrj.7 ._Y�_'!�:,s�f-kcx'C�E.uf&C'.t�S_'.:$t- s.€ �.a+ _e _ _ f�"r,•. fw�3. ., R.�"e b - ". - �.. ,,. ',• ;;q _. §q" ;,}y t>K ,..c�. a�.:.. �sa ^k"u : ' ., :•: ' YYr�. r� • � S+f'.•- � -. - .� .-4 .- 1y.4 �F f �,,,rY�„1 iS. i:. � -' -+yz. - ?.7�4>]. �`3 .�1.^c' 1 e,"��.w _ :: �7 sry,h;:��e-As•x��'+}t'�° oe Ilk 4c� � sza •`a7+ ,?,f.., _ `da., _ y _xt"t 1 F7`'d��,�' ,�� ,':�• rs s� ".r.�-g ,�*"�r � 2 �`'�M1'; rF:.^ � ^*" � ,�� r-,�..».. ��- Yko a •+vza _ r "7.r :... r„. .o.:�. w �� ,�,� K%�;Yry:rrr �"t�,"" `�`'` _�`_ �,�+�`' '°"EI ^s�•r '�- ..�, -+" S r Sst� Ass..,:� ,...n -'.• '- �- ry,. `.'`v� ,e:: 'arc•-'xX �.. } � S :, �.x. x. -, . •_5 � ff�'"�+a� 4�7wL '*�' in ::..��s"'XF,�'��A4; j'i, � r�:.a4'3't-�':^ , m�,`'J ,..•r�:,u•�.�"+ - i.6.i��''�q,,�-,. -�f.�•h-=-.' ��`G.x`'�a�>� � =v�'ra �� y� .:'• '� .r- r ti��:.xi-��1�� *'a' - �• �... �s r.....,.� ice. :"` t A ✓ '' 1 ,;"'., _ _...:....._...i.�=.•:�.:. 1 - • �O � a � � , �� TOWN OF BARNSTABLE 1A ATION SEWAGE # SlO VILLAGE_ i� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 6 � SEPTIC TANK CAPACITY LEACIiING FACILITY:(tyge) (size)- �-�—`NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �/is�� DATE PERMIT ISSUED: 7 / DATE COMPLIANCE ISSUED_�� VARIANCE GRANTED: Yes No 0 THE COMMONWEALTH OF MASSACHUSETTS Dig BOARD OF HEALTH ......................... Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal 000 Own Address Ins er Address U Garbage Grinder Dwelling—No. of Bedrooms---- .......Expansion Attic Z Other Distribution box (4-�— Dosing tank ( ) �4 ;X -- ----- ----- - The undersigned agrees to install theuforedescribed Individual Sewage Disposal System in accordance with the provisions of TAIL TALE5 of the State Sanitary Code— The undersigned further agrees not no place the system in operation until Application Certficue fC laoc 6d of-health. ~'*--- ------' ----.—.-----'--- »°e � Aoo1cudoo Approved 8y-.------. ' ~ -------------'�~ ----��-�'^��c-Is��- o*° - ort6x rousows:------_-------------------------.---.----_---------'- � ---------------------'_----.---'-----'----------'----_------------.--_--------------------------_- � Date � Permit a�.tc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................-------------...... ...OF.............................................. ApphrFatinn for Uisvoii al Workii Tnnitrttrtiun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System /...t_ ............................................ . •. - -- ...................----------- Lo tion-Addre � ' ......... ....................... ......................................... " Own Address W ... .. �::: . �., Ins er Address d e of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........................ .Expansion Attic ( ) Garbage Grinder ( ) a~ Other—Type' of Building ............................ No. of ersons.............._............. Showers — g p (----)-------Cafeteria ( ) dOther fixtures ---•----•-•------•------•-----•---------- -•-•-----------•------------••••--••-------------------•---•-•---•. _....•..... w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/,Q-(•._gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (L--y- Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date-------------------------------------- ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water•--._-.---______--__---. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ x ---- Soil __ � o Description of __ .._ w ----------- -- -- V 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 TT`: ._: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the board of health. Signed ••--- . •...... -------• --------------------------•--••- Date Application Approved By................. _________ --t,�- j. - --•-------• -- r� = !,D.a_.t_e'.. c Application Disapproved for the following reasons:-----•---------•-----------•---------------------------------------------------------------••--•••--........._.. -•-------•----------•--......----•-------...-•--------•...........................••---•--•-----•----••••---•--`•-----•--•--.....••-----•-----•--•-------•--••-•••-•----••---••-•---•--•-••------•-.--- _ Date r Permit No....... .C6-----�•6 0...................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS' BOARD OF HEALTH . 1(..i/.{.............OF.... ................................... %-Entif irFatr, of TD1ntpifttnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired --...1 - --.• .... -------------------------------------------------------------- •- staller at 1. _� ....................... ------•--------------•------•---------••----------•--------------------------------------- has been installed in accordance with the provisions of T I TIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......S?`h-_-___�_6.6._....... d-ated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ^ DATE........................7..`.-_l.0.----.6X-•----•-------•------...._. Inspector....................... D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL�-Tff�H_ �{ / .............%'tct-...........OF............ A! t' ..................................... �] /� No....6 V..... .tl... FEE......#L.!-......... Kiopsal nrkr Tnn#rnr�ion rrntit Permission is hereby granted......... Y ...._._,. ? t� -•-•.. •. _ to Construct ( ) or Repair (� an ividual Sewage Disposal System at No.----------- -------�c��.�P, P-6A � PStre ermit O 1[" ! as shown on the application for Disposal Works Construction Permit No...___'..��_.._ . Dated.......................................... -----------------•---------•- ;A.W'D...................................................... DATE_ Board of Health -------•--•-.`�--- ��..... ` -------•-----------------•----.... - FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS f Commonwealth of Massachusetts ,P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� 41 Keela Road • Property Address Scott&Laurie Blizard Owner Owner's Na e information is Cotuit Ma 02635 3-12-2021 tom? required for 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5� Sa3 on the computer, Daniel Hawkins use only the tab key to move your, Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code rasa: (508)477-0653 S114324 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins Date:2021.03.1607:55:46-04'g0' 3-12-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts r .. .. , Ti Sewage tle 5Official Inspection Form Susurface p System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is required for every Cotuit Ma 02635 3-12-2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont:): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑'Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts .. .-.._- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 41 Keela Road u' Property Address Scott&Laurie Blizard Owner Owners Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ E Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ O Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] 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. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ E] The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each.of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - � 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ El 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) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components,excluding the SAS, located on site? 0 ❑ 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? ❑ El 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: El ❑ 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)] 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t � . � 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town Slate Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 4 Number of bedrooms(design): Number of bedrooms (actual): NA DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: No design plans or permits were on file with local Board of Health. 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes,0 No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes Q No Seasonal use? Yes ❑ No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2019- 24,000gallons. 2020- 27,000gallons Sump pump? ❑ Yes 0 No Last date of occupancy: August 2020Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? , ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 2 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is required for every Cotuit Ma 02635 3-12-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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: 1988 per town Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 216" Depth below grade: feet Material of construction: ❑cast iron X 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts ------ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owners Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'6" 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 1 Dimensions: 000gallons 4" Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 11f Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1611 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: NA Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day . t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 1a 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): OilDepth 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): NA If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: 0 leaching galleries number: 4 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. No standing water or evidence of past backup was observed when viewed. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration NA 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 i Commonwealth of Massachusetts 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately oaf`�sl'�*'�*fi�il"�N��"'A�^s,�'s�xe��"�®;�\��"��iq��+``mr�ai�w,•�,�. VA 10. IN r fr• ,s " -e+ ,� �• r.,, .,� ;. VwF4,"'IN '3A.edNdd*, .<w_.� r.a .«-,01, s�qi a�y 90 `1 14, «'e ONO kik' I .. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..... / 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is required for every Cotuit Ma 02635 3-12-2021 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑� Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells Estimated depth to high ground water: NoGW@15'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 0 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: A dry, low neighboring property elevation shows ground water is greater than 5" below bottom of SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 41 Keela Road Property Address Scott&Laurie Blizard Owner Owner's Name information is Cotuit Ma 02635 3-12-2021 required for every St page. City/Town ate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: �■ A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed& Dated and 1, 2, 3,or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed 0■ D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18