HomeMy WebLinkAbout0191 LEWIS POND ROAD - Health 191 LEWIS POND RD. , COTUIT
A = 020 057
I ��
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HE A TH%
OF /
APPLICATION FOR DISPOSAL SYSTE CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (A Abandon ( ) - ❑Complete System ❑Individual Components
Lgca�n _ Owner's Name
/Viap/Parctl## Address
r�yT-J ZvB 4-
Lot# L leph #
Install s Name _ LDeJner'si ,s Name
�� �a vpsS cf XCCAyol7 o v7�?� g CGt
ddress Address
P�( P A' Fu[�® `h �z-ems,i
t o SY D— 3`3 Telephone# Telephone#
Type of Building: /� / t ' � Lot Size 3 2-3oSq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required) 0 gpd Calculated design flow ��, gpd Design flo provided�K3 gpd
-Plan: Date "? Number of sheets Revision Date __eMp
TitleyZ� S csir �
Description of Soil(s)_ e
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not Jplace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �- Zy ` -• Date
Inspections C.Y
I
i
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE N�
/�,,..9BOARD OF HEALTH
OF
�_ •r;:
APPLICATION FOR DISPOSAL SYST& CONSTRUCTION PERMIT_ '�.�
Application for a Permit to Construct (/) Repair ( )fUpgrade (X) Abandon ( ) - ❑Complete System ❑Individual Components, )
Loan �' Owner's Name
ap/Parc I# Address
�srs 74t1 t 3
Lot# !Telephoned�# !
Qf
f / a v Installer's Name �Designer's Name
t:._�.
r (_ D -FYCc VC4 1 I � 1+ . /—K
! ddress Address
ti SDI o-39 3 3 Telephone# Telephone#
Type of Building: 1. Lot Size X 3 2.3oSq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
!' Other—Type of Building No.of persons 'Showers ( ), Cafeteria ( )
Other fixtures
Design Flow min.required) O d ( Calculated design flow O d Desi n flow rovided � 3 d
g ( q )�gP g gP g P gP
Plan: Date Number of sheets / Revision Date
Title � S BSc,- ---
Description of Soil(s)_ 5,ee
'Soil Evaluator Form No. Name of Soil Evaluator h_ Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERAT/IONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fur .er agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �� ���"'-'I/" .,� Date
Inspections
FORM I - APPLICATION FOR DSCP DER APPROVED FORM 5/96
—
NO 7 � THE COMMONWEALTH OF MASSACHUSETTS - FEE hs�
'�.-
BOARD OF HE�ALITH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed Re aired raded Abandoned
' g Y �' g P Y (� P ( Pg ( ),Abandoned( )
by: CU a�
at / ft4lf 0�
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No.le,&;- ;�o dated Approved Design Flow y 3 (gpd)
Installer
Designer: Inspector at� r 1 0
The issuance of this certificate shall not be construed as a guarantee thatfite system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
---- — ————— � ---- —————— _
No. THE COMMONWEALTH OF MASSACHUSETTS FEE 400
1ir,,µap � BOARD OF H E A LT H
DISPOSAL SYSTEM CONSTRUCTION TERMIT
Permission is hereby ranted to Construe ( Rep it{( 44pgrade ( ' ') Abandon ( ) an individual sewage
/�disposal system at _ f-Cwt S Dh ) U( eDoyu t I as described
in the application for Disposal System Construction Permit No. ��.04 dated
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSS WARREN TM PUBLISHERS- BOSTON
r
May 29 '2017 22:27 HP Fax page 1
�8 — -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
4
Owner - +
Owner's Name
information is Cotuit
required for every MA 02635 5-25-17
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 A. General Information filling out formson the
use only the lab ``�a�P_jvA OF 1.44.S,
�i��
1. Inspector: &.,. •.,i4q
key to move your s� t^
cursor-do not a JAMES •ymr
use the return James D.Sears ?At : .
—key. Name of Inspector — SEARS7 _
:co_
Capewide Enterprises
v�I Company Name ;,r�••• RT�F% . �O
153 Commercial Street h,,q�F ....Ngp�c���o�
Company Address
Mashpee MA 02649
CitylTown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification r
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 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
5-25-17
Spector SSignature 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 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.
tSins.doc-rev.6l16
Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
May 29 ' 2017 22,27 HP Fax page 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information is COtUIt
required for every MA 02635 5-25-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
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 system is a 1500 Gal. Tank D Box and six chambers.
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 ears of i d s available.
table.
❑ Y ❑ N ❑ ND(Explain below):
15ins.ticc•rev.6116 Tice 5 Ofridal Inspection Form SuDaurfsm Sewag
e Disposal System•Pape 2 0177
May 29' 2017 22:27 HP Fax page 3
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owners Name
information is required for every Cotuit MA 02635 5-25-17
page. Citylrown State Zip Code Date of Inspection
B. Certification (cost.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
15.30311)(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
151ns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pogo 3 of 17
r
May 29' 2017 2227 HP Fax page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owners Name
information is
required for every Cotuit MA 02635 5-25-17
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well",
Method used to determine distance:
!*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following forall 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 dWANOM.it less than 6" below invert or available volume is less
than Y2 day flow/-C11 C#14-,C
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
May 29 2017 22:27 HP Fax page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Ass
essments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information is Cotuit
required for every MA 02635 5-25-17
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 16,000 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 I I 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.
15ins.doc•rev.W16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
May 29' 2017 22:27 HP Fax page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information is
required for every Cotuit MA 02635 5-25-17
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
0 ❑ 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 NIA)
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
Z ❑ 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): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins.doc•rev.6/16 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System-Pape 6 of 17
May 29' 2017 22:28 HP Fax page 7
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
r 191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owners Name
information is
required for every Cotuit MA 02635 5-25-17
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. Tank D Box and six chambers.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report,) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2015-67,000Gals
Detail: 2016-148,000Gal's
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
CommerciaUlndustrial 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.doc-rev.5116 Title 5 Official Inspwlion form:Subsurface Sewage Disposal System-Page 7 of 17
May 29 2017 22:28 HP Fax page 8
Commonwealth.of Massachusetts
Title 5 Official Inspection Form
WWag Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�zj 191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
Information is Ct7tUlt
required for every MA 02635 5-25-17
page. City/Town State Zip Code Date of Inspection
I
D. System Information (cont.)
Last date of occupancyluse:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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):
l5ins.doc•rev.6116 Title 6 Officlal Inspection Form;Subsurface Sewage Disposal Systerr Paige a of 17
May 29 2017 22:29 HP Fax page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal S stem Form -Not for Voluntary
Po Y Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information is N Cotuit
required for eve MA 02635 5-25-17
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:
2000 Permit #2000-206.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Bu lid Ing Sewer(locate on site plan):
Depth below grade: 30"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 etc.leakage, :
)
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: t�0"
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 Gal. Precast H-10
Sludge depth: 211
t5lns.doc-rev.6/16 Title 50ffidal Inspe.-Gon Forth:Subsurtace Sewage Disposal System-Page 9 of 17
May 29 2017 22:29 HP Fax page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owners Name
information is Cotuit
required for every MA 02635 5-25-17
page. City/Town Stale Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness V
Distance from top of scum to top of outlet tee or baffle
8e
Distance from bottom of scum to bottom of outlet tee or baffle 17"
How were dimensions determined? Asbuilt- Plan -Tape
Sludge Judge
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 at working level. Tank and covers at 20" below grade. Two inlet tee's w/outlet tee. No sign
of leakage or over loading.
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
15ins.doIc•rev.6116 Tltla 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 10 of 17
May 29 2017 2229 HP Fax page 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information for
is every Cotult
required fareve MA O2635 5-25-17
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 wonting 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
15ins.doc•rev.6118 Title 5 0maw Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
May 29 2017 '22:29 HP Fax page 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
owner Owner's Name
information is every Cotuit
required for eve MA 02635 5-25-17
page. City(Town State Zip Code Date of Inspection
D. System Information (cost.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x1T-28" Below grade. Box is clean and solid w/one line out. No sign of over loading or
solid carry,over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5 ins,doc rev,6/16 Title 5Offidal Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
May 29' 2017 22:30 HP Fax page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information Is COtuit
required for every MA 02635 5-25-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 6
❑ 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.):
Leaching is six infiltrators w/3.5' stone. Check D Box and camera out to chambers. No sign of
over loading or solid carry over. No sign of holding water
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.doc rev.6116 TWO 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
May 29' 2017 22:30 HP Fax page 14
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner owner's Name
information is required for every Cotuit MA 02635 5-25-17
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5lrm.doo•rev.5118 Title 5 OfWal inspection Form:$ubsurtoe Sewage DiVosal System•Page 14 of 17
May 23 2017 22:30 HP Fax page 15
i Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owners Name
information is required for every Cotuit . MA 02635 5-25-17
page. Gty/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
R
IV pP£/z £cl�
1
R
3 � A/
a61
13. 3 34'
P �_ 48
3 8`
t5ins.doc•rev.5/18
Title 50ffiaal InWelion Forth:Subsufece Sewage Disposal System•Page 15 of 17
May 29 2017 22:30 HP Fax page 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information is required for every Cotuit MA 02635 5-25-17
page. Uy/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
IV0
Estimated depth tofh1gh ground water: 12+
teet
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: 3-21-00
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:
T.H, on Design plan 3-21-00 no G.W. at 12'+. Bottom of leaching at around 4' below grade.
Bottom of leaching at around 8'above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins.00c-rev.6116 Till@ 5 official Inspection Form:$ubsurrace Sewage Disposal System•Page 16 of V
May 29 2017 22:31 HP Fax page 17
Commonwealth of Massachusetts
U
Title 5 Official Inspection Fort
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Lewis Pond Road
Property Address
Jeanne Deforest
Owner Owner's Name
information is required for every Cotuit MA 02635 5-25-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, 0, 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
t5lns.tlOC•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION �onG( Rd SEWAGE #
VILLAGE CO'tu ZASSESSOR'S MAP& LOT® L(J
INSTALLER'S NAME&PHONE NO. Carl .Cauossa Sr 933
SEPTIC TANK CAPACITY 1 SDCO =
LEACHING FACILrN: (type) S n F;1}r`a'ror5 (size)
NO.OF BEDROOMS
BUILDER OR OWNER Harr)', I
j PERMTTDATE: 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 leachingifAcility) , Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
y ° ..
8 h gs h `' °
61 81
g 4
pvod s I rnaIF
-j
t...... ., - -
TOWN OF BARNSTABLE
LOCAYION por d RA . SEWAGE #
VViEtNGE Co 12 i ac ASSESSOR'S MAP&LOTD
(Sos
INSTALLER'S NAME&PHONE NO. Carl F Ca�ossa Sr,�xrn,yc.�ir�r.Snc. Stil0-39�3
SEPTIC TANK CAPACITY 1500 or,5
LEACHING FACILITY: (type) J +nF;0'rcx�'tDr5 (size)
NO.OF BEDROOMS
BUILDER OR OWNER HMrn i
PERMTTDATE: 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
Lew i s Poy-% RJ(.
A 6
s Jan t. 9(o
r ,
3 �
TOW/N�OF BARNSTABLE
U ATION L e 4. + 0 SEWAGE #Tn S D e ci,,I
VILLAGE C,0 ASSESSOR'S MAP &LOT ®*20 0--JJ7/
INSTALLER'S NAME&PHONE 11 a.6"SQ9
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type). — 13- e CA i ve (size) 6 .)(6
NO.OF BEDROOMS
BUILDER OR OWNER J A'MeS `)e. ;,m c1%
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ��� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If apy wetlands exist
within 300 fee of leachi facility � � Feet
Furnished by �`�l
w
3,5 a"
yott
C.ESSpeo` CeS3pool
Q _Z%e -Q Sc" ae
LUIC—A TIO►f SEWAGE PERMIT NO.
G e wig
VILLAGE
I N S T A LLER'S NAME b ADDRESS
�
(RUILDER OR OWNER
DATE PERMIT ISSUED /
OAT E C 0 M P L I A N C E ISSUED 3
3. _ _ _ _ '.
�l
�'� ' .J
�� � � � � � ���/� 4
_� � � / f
�� �' 3�! �
\ �y , ��
��� ' �
r
� //+
�' ���
� . �
-.
SYSTEM PROFILE TEST HOLE LOGS
TOP FNDN = 32.88' NOT TO SCALE)
ACCESS COVER TO WITHIN 6" OF FIN. GRADE
ACCESS COVER (WATERTIGHT) TO ENGINEER: M.S. FARM, SEA 2a
/ WITHIN 6" OF FIN. GRADE D. MIORANDI, RS W
25.0 MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 24 0, WITNESS:
3 '21 00 1
RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE., DATE: /
P
ROPOSED FOR FIRST 2' 21 .0' PERC. RATE _ < 5 MIN/INCH F ��
o ysr
21.25 ' oo CLASS SOILS P
SLAB 0 25.56' 0 20.5' 0 2' 0 SIDES
LE 20.68' oo� 20.51'
- ---
UNKNOWN
(NOT FOUND)* �-6" CRUSHED STONE OR MECHANICAL 2'
MIN COMPACTION. (15.221 [21) ft4-
14" �'+ o 4ELEV. 4 LEWS POND RD.2 % SLOPE) MIN 1 18.5' p 21.0' 0' 24.0' Locus
DEPTH OF FLOW = 4 ( I % SLOPE) ( % SLOPE) O/A O/A
* INVERT NOT FOUND. TEE SIZES: " 3/4 ' TO 1 1/2" DOUBLE WASHED STONE SL SL COOL ST.
PROVIDE MIN. 2% SLOPE TO INLET DEPTH = 10
PROPOSED SEPTIC TANK - 1 4 1 g^ 10YR 3/2 14" 10YR 3/2 LOCATION MAP NO SCALE
FROM DWELLING OUTLET DEPTH -
LEACHING B B
FOUNDATION- 11 SEPTIC TANK 20' -' D' BOX 3' FA( ILITY 15.4' LS LS ASSESSORS MAP 20 PARCEL 57
9.5' 36" 10YR 5/8 18.0, 30" 10YR 5/8 ZONING DISTRICT: RF
YARD SETBACKS:
FRONT = 30'
BENCHMARK C C SIDE = 15'
CONCRETE BOUND
OF ELEV = 34.66' BOT. TH 1 ELEV. 9.0' 1, MS MS PLAN REF.REAR -�5424 87
G ELEV. 3. t /
0 2.5Y 7/4 2.5Y 7/4 FLOOD ZONE: C
LEWIS POND
ROAD AP DISTRICT
-L C
I' 68 9,4 UPOI7 ----------------------- -.EDGE OF PAVE --
�3�' 113.9 3'
r
4 `
( 3 Y 3�
>,
WIRE STONE DRI E c` 144 9.0' 132 13.0'
�C� LOTS 2oB & PARCEL 3 NO WATER ENCOUNTERED NOTES:
43>230 SFt
i
NOT ALLOWED APPROXIMATED FROM COTUIT QUAD
P(CKET '• SEPTIC DESIGN: (GARBAGE DISPOSER IS ) 1 . DATUM lS .
FENC ' ' EXISTING
E' - t DESIGN FLOW: 4 BEDROOMS ( 110 GPD) = 4±) GPD 2. MUNICIPAL WATER IS
F S` r VIiLMVI I,� PIPF PITrN T� R i /Q" DER rnnT -US__ A 440.. GPD DE4.I�N FLOW 3 ti F _
a�----- - ET WALL-*- -
�y`'� `-EP TANK. 01 (
40 GPb 2 - 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-
LOT
TIC
LOT 19B/ �'"�-_ GARAGE --_._)T- _.. -.--- 5. PIPE JOINTS TO BE MADE WATERTIGHT.
USE A _ a� GALLON SEPTIC TANK 6, CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
REMOVE ANY LEACHING: ENVIRONMENTAL CODE TITLE V.
_988�-~- _ CONTAMINATED/UNSUITABLE SOILS IF 2(40.5 + 9.83 2 .74 = 149 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
FOUND WITHIN 5' OF PROPOSED SIDES.
�j LEACHING FACILITY. REPLACE WITH _ USED FOR LOT LINE STAKING.
-SZ EXISTING CLEAN MED. SAND 40.5 x 9.83 (.74 = 294
ROCK R HOUSE
2 BOTTOM: 4) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
l �c LL WALKOUT TF = 32,88' 1 �99 443 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
£� SLAB TOTAL: S.F. GPD
EL=25.M p INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
USE (6) HIGH CAPACITY INFILTRATORS WITH 3.5' FROM BOARD OF HEALTH,
�21 5'00 K w DETAIL THIS AREA STONE AT SIDES, 1.5 AT ENDS AND 14" UNDER 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING CESSPOOLS.
�20 PROP Zg NOT SHOWN
1 TH1 ADD'N
PROP, STAKED �TgFENCE (SLAB) RO RET W 2�
(WORK LIMIT LINE) C
o SHED 2� LEGEND TITLE 5 SITE PLAN
GA `. H2 3
100.0 PROPOSED SPOT ELEVATION OF
,1� 1 0' 21 191 LEWIS POND ROAD
�13 100x0 EXISTING SPOT ELEVATION
PROP. STAKED SILT FENCE IN THE TOWN OF:
(WORK LIMIT LINE) 0 O O PROPOSED CONTOUR
(COTUIT) BARNSTABLE
1 pp EXISTING CONTOUR PREPARED FOR: JOHAT FALACCI
0
30 0 30 60 90 Feet
1�
#7 9 ti3 BOARD OF HEALTH
1� > MA SCALE: 1" = 30' DATE: MARCH 28, 2000
APPROVED DATE
` #5.5
1�
L
_ 9off
_$Vw 4 8 fax 908 362-9880I
5•
' ! ����h h'�JJ CAR
NE '#1 down cape engineering, 1nc. ARNE H � H.
4 OJALA r^ OJALA
OFCIVIL ENGINEERS NoIVIL2 ��Fs � s6R4
LAND SURVEYORS o�F9F � a�o s' �qt tag
WETLAND DELINEATED BY HAMLYN CONSULTING, MARCH 2O00 939 main st. yarmouth, ma 02675 J
00-022 ARNE H. OJALA, P.E., P.L.S. DATE