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HomeMy WebLinkAbout0007 LEWIS POND ROAD - Health 7 LEWIS POND RD. COTUIT A = 035 036 0 K r�I� I�1 I'I i�' c Commonwealth of Massachusetts F Title 5 Official Inspection Form 1..s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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. ImpoWhen filling A. General Information When filling out 11 forms on the I I O computer,use 1. Inspector: only the tab key , to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 n City/Town State Zip Code (508)428-4028 S14454 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 1 " 12/18/2009 Inspe r ign a 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. ****Tl s 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. LiI � �Ifit5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Page Commonwealth of Massachusetts Title 5 Official Inspection Form Nj Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VA 7 Lewis Pond Rd. Property Address Sarah Mol neaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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: The septic system is in proper working order at the present 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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 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-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,.•''y 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every 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 a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''r 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owners Name information is required for req Cotuit Ma. 02635 12/18/2009 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 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•09/08 Tifle 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 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every 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 ® 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 2008:1,000 g ( y g (gp ))' 2009:3,000 Detail: 2008:3gpd 2009:8gpd Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5. 0fficial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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: 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 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•'y 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " Depth below grade: 31 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.):. Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 21 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: 1500 gallon y 211 Sludge depth: t5ins•09/08 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 M 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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 30" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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: 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 M 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every 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 No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 GM 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators. ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Infiltrators were 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 l - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every 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.): t5ins•09/08 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 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately U X 36' S t73'p' .Z4'b X 8 ..r z6 4" n s 3 34.'9 Z4'GM Cn o o 4 47-�c' zd'- ��" • z I � S 73'4 36 LEW]5 POwb RD. t5ins•09/08 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 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 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: Bottom of leaching 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 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17' n y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Lewis Pond Rd. Property Address Sarah Molyneaux Owner Owner's Name information is required for Cotuit Ma. 02635 12/18/2009 every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION_ "P O'�� RECE VED i,RCEI. �_ DEC 1 4 2004 LOT TOWN O LT NST.BLE TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7 Lewis Pond Road } Cotuit.MA 02635 Owner's Name: Garry&Nancy Hopkins x� Owner's,Address: r Date of Inspection: December 6, 2004 ' L a:l CD Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 In Telephone Number: (508)862-9400 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs F rther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: December 8. 2004 The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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 o_r different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6. 2004 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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nana Hopkins Date of Inspection: December 6, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore.the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 Lewis Pond Road ` Cotuit. MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6, 2004 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. t ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2004- 73,000 gals.:2003-118,000 a� 1 Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank,present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 6129199-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6, 2004 BUILDING SEWER(locate on site plan) ) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade:- 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scrum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring 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.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&NanCE Hopkins Date of Inspection: December 6, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade:. Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 level and clean. No solids were present. The D-box was H-20. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: S-high capacity infiltrators 11'x 36'(per as built card) 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.): The leach field was dry and clean. There did not appear to be any signs of failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis.Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6. 2004 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. F-1 ❑ 3 d a$$ a8y 0 0 3 37 a&/ A From' y y� ag S -73 y 366 ' 10 Page 11 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 7 Lewis Pond Road Cotuit, MA Owner: Garry&Nancy Hopkins Date of Inspection: December 6, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showingypproximately 20'+1-to ground water at this site. Using the Cape Cod Commission technical bulletin, the high ground water adjustment for this site(MIW 29.Zone A. 10104) was 2.2'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11' S Ila ` DATE: 1 2/4/01 - -- PROPERTY ADDRESS:_Lewis _Pond _Road Cotuit,Mass_----__-__- --- -- D 02635------------------------ r 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 . 5-Infiltrators packed in stone. See as built. Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. 5. The septic system is in proper working order at the present time. - 6. SAS is dry at this time. r SIGNATURE- _ Name:_, P-_ Macomber J- Company: Jose_ph_P_ Macomber_& Son , Inc . �EC EIV Box 66 ---= s DEC 07 20 DD 01 Address: ____________ Centerville , Ma . 02632-0066 TOWN OFBARNSTABLE ------------ ------- HEALTH DEPT. . Phone: 508-775-3338 ' � ------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped,& Installed Town Sewer Connectlons' ' 'P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 �--\ COMMONWEALTH OF MA.SSA,CHUST,,TTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION"FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7 Lewis Pond Road CC)tlli t ,MaSs_ Owner's Name: Robert St. Thomas Owner's Address: Same « Date of Inspection: 01 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber, & Son Inc Mailing Address: P.O. Box 66 1'Ant-arvi_Lle Ma 02632 - Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: - Conditionally Passes Needs Further Evaluation by the Local Approving'Authoriry, _ Fails //,, Inspector's SignatureOmi4ta t Date: 1 7_U - The system inspector shall copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments T This report only describes conditions at the time of Inspection and under the con`dltlons of use at that � } time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ; CERTIFICATION (continued) NAY, � .. • 1• Property Address: 7 Lewis Pond Road Cotuit,Mass. Owner: Robert St. Thomas } Date of Inspection: 12/4/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. ystem Passes: I have not found any information hich indicates that any of the failure criteria described in 310 CMR 15.30 or to 31 R exist. Any failure criteria not evaluated are indicated below: Comments: The septic system is in proper 'working order at r the present t-i mg B. System Conditionally Passes: ,60 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 distribution box is leveled or replaced F 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: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Properry Address: 7 Lewis Pond Road Cotuit,Mass. Owner: Robert St. Thomas Date of Inspection: 1 2/4/01 S 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 /,,V 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: �f10 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. /j,0 The system has a septic tank and SAS and the SAS is within a Zone I 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,1100 feet ut'50 feet or more front a private water supply well". Method used to determine distance 'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form. 3. Other 3 Y Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 Lewis Pond Road ° Co ui , ass. Owner:Robert St, Thomas Date of Inspection: 12 4 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No = V ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool I.,6-�fi/ �yA1•'�?�' ,cr/ ilT�vo,�nt �iquid depth in eessp"I is less than 6"below invert or available volume is less than i4 day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 417? , 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. " y portion of a cesspool or privy is within a Zone 1 of a public well. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia . nitrogen and nitrate nitrogen is equal to or less than,5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 6/he system is within 400 feet of a surface drinking water supply 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—1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question,in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST Property Address: 7 Lewis Pond Road t " • , Cotuit,Niass. . - Owner: Robert St, Thomas Date of Inspection: 12/4/01 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? . YHave 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 iof break out? ; _ Were all system components,ekluding the SAS, located on site? a 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: Y;es /no Existing information. For example,,a plan at the Board'of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) a; 5 Page 6 of 1 1 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C w SYSTEM INFORMATION Property Address:7 Lewis Pond Road Cotuit,Mass. Owner: Robert St. Thomas Date of Inspection: 12/47 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:_7 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):dd [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):R Water meter readings, if available(last 2 years usage(gpd)):,04M - C!5Z Sump pump(yes or no):Last date of occupancy: ,i�/ COMM ERCIALq"USTR.AL ` Type of establishment: Design flow(based on 310 CMR 15.203): t14 gpd Basis of design flow(seats/persons/sgft,etc Grease trap present(yes or no): Industrial waste holding tank present(yes or no):,__ /y . Non-sanitary waste discharged to the Title 5 system(yes or no):&0 Water meter readings, if available: Last date of occupancy/use: ,U ; OTHER(describe): G GENERAL INFORMATION Pumping Records Source of information: 1,ble-le, ' Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons-- IjQw 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) �d Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) �Tight tank �Attach a copy of the DEP approval { Other(describe): __ R Ap go,xjmate age o all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued), Property Address: 7 Lewis Pond Road Cotuit,Mass. Owner: Robert St, Thomas Date of Inspection: 1 2/4/01 , BUILDING SEWER(locate on site plan) Depth below grade: ✓l�� Materials of construction: cast iron Z40 PVC,t�othey(explain): Distance from private water supply well or suction line: ID 7` Comments(on condition ofjoints, venting, evidence of leakage, etc.): i Joints appear ti4ht No evidence of leakage.The system is x vented through the house vent. SEPTIC TANK: v(locate on site plan) �9 A Depth below grade: Iy // „ Material of construction: �ConcretexLmetalOG'fiberglasv Oyolyethylene '1Pother(explain) If tank is metal list age: © Is age confirmed by a Certificate of Compliance(yes or no)•r�(anach,a copy of certificate) , 0 w Dimensions: 7 Sludge depth: �� Distance from top 2Lsludge to bottom of outlet tee or baffle:,-,e, .0 Scum thickness:- — Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bottoA of outlet a or baffle: How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): y ,'Pump the septic tAnk PVPry 2-1 vPnr6 Inlet & `outlet tees_ are in place.The tank is structurally sound_ GREASE TRAPr4 locate on site plan) Depth below grade:1621 Material of construction:42// concrete!/9metalJgfiberglass��olyethylene t'>h other (explain): (�i9 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from.bonom of scum to bottom of outlet tee or baffle: Date of last pumping: 16 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Grease trap is not present 7 r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road, Cotuit,Mass. Owner: Robert St, Thomas Date of Inspection: 12/4/01 TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete 4)A metal,tW fiberglass�olyethylene4/ other(explain): Dimensions: , Capacity: gallons Design Flow: gallons/day Alarm present(yes r no):20— Alarm level: Alarm in working order(yes or no): Date of last pumping: _W_ ' Comments(condition of alarm and float switches,etc.): Tight or holding tanks arP not c rpgpnt •: Z(if resent must be o ened locate on site lan)DISTRIBUTION BOXp p )( P Depth of liquid level above outlet invert: Comments(note if box is leveN and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Digtrihution hnx hag nna lateral Tn eVir3ence of se]Jds GarTnu, e ar No evidence of leakage into or nut t of ha hnx PUMP CHAMBER JWe(locate on site plan) Pumps in working order'(yes or no): Alarms in working order(yes or no):iE , Comments(note condition of pump chamber,condition of pumps and'appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL STEM INSPECTION PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road Cotuit,Mass Owner: Robert St. Thomas Date of Inspection: 1 2/4 /01 SOIL ABSORPTION SYSTEM (SAS): Zl ocate on site plan,excavation not required) If SAS not located explain why: Located; y - • T e "" • leaching pits, number: _g t� /,pJI(rJ4� leaching chambers, number: i 0�T/ leachinggalleries,number: 0� - leaching trenches,number, length: 4 leaching fields,number,dimensions: overflow cesspool, number:�o3l / 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.): Loa No signs er- ponaing.bolis are r .Ve CESSPOOLS:N AICcesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: f Depth—top of liquid to inlet invert: A Depth of solids layer: NA Depth of scum layer: NA Dimensions of cesspool: NA Materials of construction: NA ' Indication of groundwater inflow(yes or no):_NA Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc,): PRIVYNQNE(locate on site plan) Materials of construction rTA Dimensions: NA , Depth of solids:NA Conunents(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): „ Priv I ' 9 , x Page 10 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road Co ui , ass. . Owner. Robert St. Thomas Date of Inspection: 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. S 1 23'9 Z4-6 B 2 Zd/ 8N it 301 :z.8-4 x 3 34-0 124-� cn o00 Z 4 47' za'- lb S 73-4 36,-5 A LEW-45 'POND RD. ; . 10 page 11 of 1 1 jE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Lewis Pond Road Cotuit,Mass. Owner: Robert St. Thomas Date of Inspection: 12/4/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date-of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of 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 mnapl Ground water above sea level. USGS: Observation well data.June 1992 USGS; Ranges of ground water level. 92-0001P1ate # 2 Tup of n 'eet Groundwaterwet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter,Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 4 .•nrnrn.-n.r��.Tt� rnrlRf•ns.n.s••nrt+e.rrrtm•.'rr+trTfr�.IRTw'n misty/Alllfn.rn .TT'9'rr 1-.�-... r..•' TOWN OF Barnstable` BOARD OF HEALTH � t•,-. .-r r-SUDSURFACF 9EHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION r� _ I -TYPO OR PRINT CLEARLY- 1 PROPERTY INSPECTED _ STREET ADDRESS 7 Lewis Pond Road Cotuit,Mass." ' ASSESSORS MAP , BLOCK ' ANU PARCEL # 035-036 OWNER' s NAME St. ThomaO Robert PART'D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & 54n Inc . COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Strevt Town or City State LIP COMPANY TELEPHONE (508 ) 775 3338 FAX ( 508- ) .790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage` di'spos67 system at this address and t1lat the information reported is true , accurate , and omplete 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 . ; Chec one : a . V System PASSED + The inspection which I have conducted has not found, any information which indicates that the 'system fails to adequately protect public heall)1 ot• the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated. in the FAILURE CRITERIA section of this form . System FAILEll* r The inspection which I have con 'Voted has found that the system fails to protect the j)ublic health -and. the environment in .accordance with Title 5., 31Qr CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature • Date �o ne copy of this certification must be provided to the OWNER, the BUYER ( Where applicable ) and the I30ARD OF HEALTH. * If the inspection FAILED , the owner or operator shall upgrade ' the system within one year of tl)e date of the inspection , unless allowed or required otherwise as provided in 3,10 CHR ' 15 . 305 . ' partd .doc T WN OF BARNSTABLE ,-TOCA71ON G' SEWAGE # VILLAGE �l�`� G/� �` ASSESSOR'S MAP &c LOT _ INSTALLER'S NAME&c PHONE NO. SEPTIC TANK CAPACITY 16�6 2" 1,4A LEACHING FACILITY: (type) (size) NO.OF BEDROOMS f BUILDER OR OWNER • PERMITDATE: COMPLIANCE DATE: T 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 Le hing Facility(If y w tlands exist within 300 fee f �' acility) Feet Furnished b 7 q, Zq OWN OFF BARNSTABL.E c/ LOCATION ' tS 0"� ``�. SEWAGE # 3�0 VILLAGE COrQ t ASSESSOR'S MAP & LOT 03 SZ 0's(0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �<N LEACHING FACILITY: (type) C In tll b�Aj (size) NO.OF BEDROOMS BUILDER OR OWNER G• doPkl�S °PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by v ❑ 3 Q Q � a3q ay -• ' a i 3 3vY ayeL A FronT [-13 Y13 t. y y� aq /cwiS Po�� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 3ppfication for Diopogal *pgtem Construction 3dermit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7/.15NI S P014v )2J Owner's Name,Address and Tel.No. e0_1 Robert' 64% -r*/WAS Assessor's Map/Parcel P0,00jc /. 4S'_ 0 0 3 6" 10"7? co 01 r 014 aZ&35_ stag-477-ZYA6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. d l owed CF�/l5rr/✓ Oiy 56. 0462*0 All Tog Type of Building: Dwelling No.of Bedrooms 4- Lot Size sq.ft. Garbage Grinder( f� Other Type of Building 61 iF-SI P N7f L No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 440 gallons per day. Calculated daily flow gallons. r ''Plan Date Number of sheets Revision Date . •' �� Title Size of Septic Tank /_'®0 ORAL Type of S.A.S. .�/#/��'A���i Description of Soil aaSr y&4 &e S;cw Nature of Repairs or Alterations(Answer when applicable) �L'Zy feiO6 i - ® SWS 691.1- leb 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 E vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss y is Boar Health. Signed Date /, /I Application Approved by Date •" Application Disapproved for the following reasons Permit No. Y e vk7 Date Issued / i f Nb. � Y. ✓AGFee H +�% G.J' �— �� T THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ' {` TippYtcation for Di.5pont *pgtem Con5truction.,Vermit Application for a Permit to Construct( v Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 L15W IS j 44,D lJ Owner's Name,Address and Tel.No. { coTv�T Rcker4 St 7-*AfAs Assessor's Map/Parcel P0,00 4 03 -- 0.3 4� ;W coral r Ag oz-&W ' SOS-477-2-888 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Crowell Coai�cJor► `..,: Ro. sox 309IM o -3R,9*134- h Type of Building: P Dwelling No.of Bedrooms 47 Lot Size sq.ft. { �. Garbage Grinder(/ Q Other Type of Building ESIDENN4 No. of Persons j i 4 yp g�, Showers( ) Cafeteria( ) Other Fixtures 4 - ..� Design Flow 440 gallons per day. Calculated daily flow gall ns. Plan Date Number of sheets' Revision Date Title Size of Septic Tank 1S-00 6AL Type of S.A.S. S RI-eAI,1QZr1NA►M6f.V4S 't Description of Soil Nature of-Repairs or Alterations(Answer when applicable) Affen e 6)P' "sws CD&AQSED Date last inspected: - `ly / Agreement: ..' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system Jin accordance with the provisions of Title 5 of the E vironmental Code and not to place the system in operation dntil a Certifi- cate of Compliance has been iss y is,Boar Health. Signed Date i Application Approved by Date / 9 Application Disapproved for the following reasons Permit No. '' Date Issued ^ / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE , that the On-site Sew a Dis offal S stem Coeructed( )Repaired ( )Upgraded( ) Abandoned( )by � / % at �"1�G� ha been constructed in accordance with the provisions of Title 5 and the Or Di posal System Construction Permit No. dated Installer /�I ¢c ,� . 1_ Designer The issuance of this permit shall doct be c strued as a guarantee that the system wrll function as designed} Date Inspector !t 1, J Y f ,/Y'_ �./ V Y ... No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS xi.gpogal *p5tem Construction 3permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon System located at 7 W1 s I7/�Li G�r� liP 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this At. Date: �"" l�"Or e" . Approved byC.....- J rf I '� l of 3 o �S_ammaDc r-o-W �MA SYSTEM DRSICrN: - FLOOD ZONE 'C" Design Flow:. 4 Bedroom @;1109od/room' ' 440 a�. Septic. Tan 440 x 20.0 '/m = 880 Sal. Use,. 1500Saa 7aAk 9 Leos h Faci l i+y 4408a1/0.74 = 5"9S Fta WWW Sidedall : ,(2X2%37.25�+ (2x2x10.83xxx '�. _ 192.32 FfiZ W W W moon Bof tom : (10.83�x.37zS) 40.3.41 Ftz 192.3z FEZ . 403.41 Ff Z err S95'.73 Ft� >M595 Ft2 S9S.73 FFt z I CnC4 Effec+ive Depth 2. f. _ Effective k/idfh` : io.8:3 � , � i USE 5 Ali 'l Sn��4r L, arS . _ -CaPac�y � •v _ WA 4'o� jB/ �t/�1S/IED S40A4 i @ S iks anal 3'of D`bL. 1 4SNID. _ 1 sroNE @ AMP G i 1 i {p3 t k i i a' 20F ;:. carol IR �11 SOIL TEST 'LO Gr ELEV. CoLoQ LOAM eLACk 12„ LOA14Y/S�AND 1g... SILVER e / W W W .. _. {BOA.12SGC xxx W W W o .. Y 0 th 4n .• a n o S MEDI UM .., ... REDISN- BEDWJ✓ a a SAND aaa �,.. 'i H N N F t e ii MEDIUM:_ SAND coxv l SWAt .. f 'SAND f . i TEST HOLE PERFORMED THURSDAY JUNE /o 9 1999 $Y: Nicholas A. Tanner E Crowell Cons+ruc+ion E So. Oenni S MA Witnessed By: P Robet4 S+. Thomas Proper4y Owner k t • i 1 MAS MEA19. 0 00 00 aaa. ev a er co . ;IIJ j O 4 4 W S 4® 22'50" E . 110.01 1 f ' l 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L Nicholas s A. Tanner hereby certify that the application for disposal works construction permit signed by me dated 10 dUNE 1999 , concerning the property located at 7 LEWIS POND R® COTUIT MA meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business / uses associated with the dwelling. Y The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system V/ There are no private wells within 150 feet of the proposed septic system w There is no increase in flow and/or change in use proposed There are no variances requested or needed... The bottom of the proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be-located less than fourteen(14)feet above the maximtun adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation 7.j!r +the MAX. High G.W. Adjustment. 2 = AOL 9•s DIFFERENCE BETWEEN A and B /7.2 SIGNED :J DATE: v [Sketch proposed plan of system on back]. q:health folder:cert TOWN OF BARNSTABLE LOCATION -? LEWfS PoND QoAD SEWAGE # 99-34+ VILLAGE_ 6TWT ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. RAiZLY SH 3 9 3-8334 SEPTIC TANK CAPACITY 15M GAL- LEACHING FACILITY: (type) /�C6f/ r�M�xa'fY /.df=/�lPl (size) NO. OF BEDROOMS BUILDER OR OWNER J&Let4 CIO MAS , PERMITDATE: !o "17— l999 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility. (If any wells exist on site or within 200 feet of leaching facility) Feet • Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by QIYOd. » „ S-9 E A-4L S Qb p z .Z S 9£X if PI?Y TOWN OF BARNSTABLE L-OCA N I LEWfS POND 914D SEWAGE # 99-34+ VILLAGE emir ASSESSOR'S MAP & LO +L INSTALLER'S NAME&PHONE NO. K1;N BL LeW SM 3 98-8334 SEPTIC TANK CAPACITY 13W CfAl- LEACHING FACILITY: (type) J-IiAq CAMAQrY ;AJA"Zf (size) NO. OF BEDROOMS BUILDER OR OWNER TOOMAS 'PERMITDATE: r17- 1999 COMPLIANCE DATE: Avw Separation Distancel-Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by $ 1t x 36' ,. ZS-4 nol 3 2 2a-8 3 34-8N Z4�6, C1) 00 0 41 47-0 zg'- lb ZLJ s 5— 73-4 36 5" A Tt LEW1 S POND RD.