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HomeMy WebLinkAbout0220 LEWIS POND ROAD - Health 220 Lewis Pond Road Cotuit P A = 020 133 0�� s�.n TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 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 leaching facility) Feet Furnished by Qpck aF Nv6�S'Q, .07 PVC S��SbavA� "wA7er �® Pi 4 -pwk P,f �yg� L May 01 2016 15:10 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Lo as Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �°~ -C - 220 Lewis Pond Road .. Property Address David &Jill Gaieski Owner Owners Name information is required for every Cotuit MA 02635 4-27-16 page. City/Town State Zip Code Date of Inspection Irc 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 out forms l A. General Information S on the computer. OF Fpa.,•......... use only the tab 1. Inspector: key to move your p?: '•.SG cursor-do not James D.Sears = JAMES m use the return Name of Inspector key. Capewide Enterprises, LLCa= Company Name ��j�'; Cj K;. F 153 Commercial Street Company Address Mashpee MA 02649 City/Town r State Zip Code 508A77-8877 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 a DEP approved system inspector pursuant to Section 16.340 of Title 6 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ 'Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-27-16 Inspector's Signature Dale The system'inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *""*This report only describes conditions at the time of inspection and under the conditions of use at that time.This1nspection does not address how the system will perform in the future under the same or different conditions of use. ' l5ins•3113 ` Title 5 Ofriclal Inspection Form.Subsurfsoe Sewage Disposal System-Page 1 of 17 I . /o qq May 01 2016 15:10 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is COtUit MA 02635. 4-27-16 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described 10 CMR 15.303 or in 310 CMR 15.304 ex ist. An failure criteria not evaluated are in 3 Y indicated below.. Comments: The system is a 1000 Gal Tank and 1000 Gal.Pit. µ 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 o'r 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-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 May 01 2016 15:11 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l , 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is It tU required for every CO MA 02635 4-27=16 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced_ ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑-Y ❑ N ❑ ND(Explain below): { - ❑ distribution box is leveled or replaced ❑ Y. ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with,approval of the Board of Health): ❑ broken pipe(s)are replaced ❑�Y • ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 May 01 2016 15:11 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yt 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is Cotuit MA 02635 4-27-16 required for every page. CitylTown 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ` Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes` No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ❑ ® due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded fV� ❑ or clogged SAS or cesspool El ® Liquid depth in MEOWis less than 6" below invert or available volume is less than 1/day flow. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i , r May 01 2016 15:11 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is Gotuit MA 02635 4-27-10 required for every page. City/town State Zip Code Date of Inspection B. Certification.(cont.) Yes No El ® 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. ❑ ® 9 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 C 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•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 May 01 2016 15:11 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form ' . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is Cotuit MA 02635 4-27-16 required for every page. CityfTown 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? ® 0 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. j Determined in the,field (if any of the failure criteria related to Part C is at.issue 0. ® approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 15ins•3113 Title 5 Official Inspection_Form:Subsurface Sewage Disposal System•Page 6 o117 May 01 2016 15:12 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts . Title 5 Official Inspection Form x a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is Cotuit MA 02635 4-27-16 required for every page. City/Town Slate Zip Code Date of inspection D. System Information Description: The system is a 1000 Gal. Tank and 1000 Gal. pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ _Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No 2014-22,000Gals Water meter readings, if available (last 2 years usage(gpd)): 2015-30,000Gal's Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sci t., 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•X13 - Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 7 of 17 May 01 2016 15:12 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, °f 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is required for every Cotuit MA 02635 4-27-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information r Pumping Records: Source of information: 09 Was system pumped as part of the inspection? El.,Yes ® No If yes,volume pumped: gallons How was quantity pumped determined?` . i Reason for pumping:: Type of System: ® Septic tank, , soil absorption system ❑' Single cesspool ❑ Overflow cesspool ❑ Privy s ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) t ❑ 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•3113 Title 5 Oificia Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 May 01 2016 15:12 Jim The Inspector Man 5085349919 - page 26 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r`a 220 Lewis Pond Road Property Address David & Jill Gaieski . Owner Owner's Name information is required for every Cotuit MA 02635 4-27-16 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? '❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan):. 811 Depth below grade: feet Material of construction: v. ® 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: 1000 Gal. Precast H-10 3 Sludge depth: 15ins•3113 Title 5 Official hspedion Form:Subsurface Sewage Disposal System•Page 9 of 17 May 01 2016 15:12 Jim The Inspector. Man 5085349919 page 27 Commonwealth of Massachusetts wet Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 220 Lewis Pond Road Property Address David & Jill Gaieski Owner Owner's Name information is Cotuit MA 02635 4-27-16 required for every page, Cityfrown 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 27' Scum thickness Distance from top of scum to top of outlet tee or baffle 4 12 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-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 cover's at 18" below grade. Inlet tee, outlet baffle. No sign of leak age or over loading. Note: Maint pump afther inspection. Grease Trap(locate on site plan): Depth below grade: feet - Material of construction- ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Scum.thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping; Date 4 15ins-3!13- Title 5 Official Inspection Form:subsurrace Sewage Disposal System-Page 10 of 17 May 01 2016 15:12 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 220 Lewis Pond Road lug - Property Address David &Jill Gaieski Owner Owner's Name Information is required for every Cotult MA 02635 4-27-16. page. City(rown _ 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): r Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level:. Y. _ 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•3113 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 11 of 17 it •. t May 01 2016 15:12 Jim The Inspector Man 5085349919 page 29 s Commonwealth of Massachusettsµ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is required for every Cotuiit MA 02635 4-27-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): . Depth of liquid level above outlet invert No Box Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): ' Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): E _ *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required)-.. If SAS,not located, explain why: , t5ins 3/13 - Till-5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 May 01 2016 15:12 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title. 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 220 Lewis Pond Road Property Address David &Jill Gaieski _ Owner Owner's Name information is required for every Cotuit MA 02635 4-27-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: „ 4. ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool - number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is a 1000 Ga. Precast Pit. Pit and cover at 2' below grade. 6"water w/stain line at 1'. No sign of over loading or solid carry over. No high stain line. 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 15ins•3/13. Tille5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 17 May 01 2016 15:13 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments UV 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name ` information is required for every Cotuit . MA 02635 4-27-16 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.): 4. C. t5ins•3113, Title 5Official Insp ection Form:Subsurface Sewage Disposal System•Page 14 of 17 May 01 2016 15:13 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is required for every Cotuit MA 02635 4-27-16 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 • �'gAR aILI �-� 73 0 3 tSr s•3113 * Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 May 01 2016 15:13 Jim The Inspector Man 5085349919,, page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form ., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Lewis Pond Road Property Address David & Jill Gaieski Owner Owner's Name information is required for every Cotuit MA 02635 4-27-16 page. Cltyrrown State Zip Code Date of Inspection D. System Information, (contj Site Exam: ❑ Check Slope • r ❑ Surface water' ❑ Check cellar.- ❑ Shallow wells NO depth to hi h round water: 4 Estimated de p .9 feet ' • Please indicate all methods used to determine the high groundwater elevation:' ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date t ❑ 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: ; On file at B.O.K. "- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5 ns 3113 r Title 5 Official Irspection Form:Subsvlace Sewage Disposal System-Page 18 of 17. May 01 2016 15:13 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Lewis Pond Road Property Address David &Jill Gaieski Owner Owner's Name information is Cotuit MA 02635 4-27-16 required for every page. City(Town State Zip Code Date of Inspection E. Report Completeness Checklist Z 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 t a t5ins•3.113 Title 5 OFfiolal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 SEWAGE INSPECTIONS LOCATION220 Lew.iA Pond Road DATE 6125103 VILLAGE Cotuit, 17azz. 02635 ASSESSOR'S MAP & LOT 020- 133 -INSPECTOR to,3eph P. 17 as�omge2 12. SEPTIC TANK CAPACITY 1000 f Box LEACHING FACILITY: (type) 1- 1000 Leaching Pi, (size) 1500 ga. eonz NO. OF BEDROOMS 3 3 BUILDER OR OWNER Cato e veaee/zca OWNER MAILING ADDRESS 6 Rn Co.tuit, (jazz. 02635 l' y J ' /•A� �a�I _0�1 � ' / � �� �` ®, ✓ .� / t �`/ � J f ��g--- DATE :6/25/03_---- PROPERTY ADDRESS:220 Lew.iz Pond Road ----------------------- _ Cott ttl7a�!----------- A 02635 ------------------ On the above date, I inspected the septic system at the above address, Tnis system consists of the following: w 7. 1- 1000 ga.22on 3ept.ic tank. 2. No d.iztaigut.ion Sox. 3. 1- 1000 ga-2.2on /22ecaat .Peaching 12it, Based on my inspection, I certify the following conditions: 4. 7hi.6 "iz a tit Pe 1"ive ze/11_:ic zyht�;m. ( 78 Code J 5. The ze/2t.ic zyztem "iz .in 12aopelz woak.ing oadea at the /22e.6ent time. 6. Oa.ate waten .i-6 60' ge2ow the .inveat 12il2e ,ol the 2eaeh.ing 12.it. SIGNATUR Name : _ J__ P__Macomber_Jr Corhpany :, gatph _per_ M-oggmt P,r d_ S,o'n, Inc . ACards S :__a(2x'_ErL - - -Q-e-nseLYLLLe._ :1a__QZ_632-0066 ofBA�ris1ABIE ' Pr)one : 508- 775_ ) 338 ________ TOWHEA�TH DEPT. THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY IOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.0 Box 66 Centerville, MA 02632.0066 775.3338 775.64'12 k . -\ COMMONWEALTH OF MASSACHUSETTS = 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: 220 Lew.iz P on.6 Road COi-u,Lt, Na 3.6 Owner's Name: Ca/LO.e Ve29ua g Owner's Address: /3 n x 16 8 0 ('nflii i , Pln.t.1_ 02675 Date of Inspection: _612 5/0 3 Name of Inspector: (please print)ao,se/2h /P. Macomlen ;a. Company Name: I. 10. acom e2 9 Son inc. Mailing Address: /3o x 66 a 02632 TelephoneNumber:m 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 trairting 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: _;Z Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F 'Is Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 F- ****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. :R Title 5 Inspection Form 6/15/2000 page 1 P Pg Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:220 Lewie Pond Raod o ui , ae4. Owner: Cato P Velt9u zg Date of Inspection: 6125103 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D , �1 A. �Passes t I have not found any information which indicates that any of the failure cr terJl'a described in 310 CMR r / 15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are,indictite' low. J Comments: _7he .set .ec zy�5 em c� .en Raofe2 woe .eny at the /22ezent t2me. t B. System Conditionally Passes: •Vb 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. ,VO 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: /V_ Ebservation 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: -Vc)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:220 Lewis Pond Road o u.c , a.6.6. Owner: Cazoi Ve29usQ Date of Inspection: 6/25/0 3 C. Further Evaluation is Required by the Board of Health: 4JO Conditions exist which require father 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: 46 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. A?Q The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. v The system has a septic tank and SAS and the SAS is less than 100 feet b4h5O 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 L Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 220 Lewlz Pond /2o¢d Owner: ('<i/n.P V a l�tl Date of Inspection: 6/)5/o 3 D. System Failure Criteria applicable to all systems: You must indicate',yes"or"no"to each of the following for all inspections: Yes No 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 (JOdg�State liquid level thew �distribudor�box Bove outlet invert due ton overloaded or clogged SAS or cesspool _ squid depth in-cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number J of times pumped 7) . !/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 _ _vwater supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ y portion of a cesspool or privy is within 50 feet of a private water supply well. �y 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 the system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary.to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page S of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 220 Lewin Pond Road Crl2oQ .o.ta4t, Nazz. Owner: ' Date of inspection: 6/25M Check if the following have been done. You must indicate'yes"or"no"as to each of the following: Yes No/ 11 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,eV*cluding the SAS, located on site ? ,V _ 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 Yes,no Existing information.For example, a plan at the Board of Health. . Determined in the field(if any of the failure criteria related to Part C is at issue approximation is unacceptable) (310 CMR 15.302(3)(b)J pp oxtmatton of distance 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 220 Lew.i.6 Pond Road Cotu.i.t, l�a.s•s. Owner: Caso-g Ve29u2U Date of Inspection: 8125103 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 edrooms): Il xv Number of current residents: Does residence have a garbage grinder(yes or no):410 Is laundry on a separate sewage system es or no):A.6 (if yes separate inspection required) Laundry system inspected es or no): L Seasonal use: (yes or no): r Water meter readings, if available(last 2 years usage(gpd))2001=4 0, 000 ga P.Ron s=709. 5 9 9PD Sump pump(Yes or no): A/o _ . ga 22 o n,6 112. 3 3 qP D Last date of occupancy: COMMERCIAL/WDUSTR.IAL - Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no)420 Non-sanitary waste discharged to the Title 5 system (yes or no):,{,X ) Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 917101 Tank f'la.in.t. J. %. Raeom9e)t & Son Inc. Was system pumped as pan of the inspection(yes or no): If yes, volume pumped: © gallons-- How was quantity pumped determined? �Ji¢ Reason for pumping: Ti�c OF SYSTEM ptic tank, di3e'ibutiorrbo"oil absorption system lbSingle cesspool' 44 Overflow cesspool ,Q Privy /)D 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 VA Attach a copy of the DEP approval Lb Other(describe)- Approx rym' a age gf all 6mponents,date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 J Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE DISPOSAL SEWAGE G O AL SYSTEM INSPECTION FARM PART C SYSTEM INFORMATION(continued) Property Add ress:220 Lewin Pond Raod o t u.c t, Nazz., Owner: Ca2oi e/z u2g Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: � Materials of constructionW,4 cast iron ✓40 PVCA/Bother(explain): .eA,4 Distance from private water supply well or suction line: 0 Comments(on condition of joints,venting,evidence of leakage,etc.): 2n1n i A nano nn Li gh.t- No evidence o, ieake g The z y stem .ie vented � the /took vent. SEPTIC TANK:Zlocate on site plan) /A�11 �l Depth below grade: Material of construction: /concrete.(1b meta l fiberglass &olyethylene AJD other(explain) 4) If tank is metal list age: B Is age confirmed by a Certificate of Compliance(yes or no);,/ (aaach a copy of certificate) p, - n Dimensions: / 6 �.tIQ Sludge depth: Distance from top of Judge to bottom of outlet tee or baffle: Scum thickness: -r— Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_1aalt-R, 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.): 12un? And fho AP,Di,r frank o>>ony 2-?1i061 A IRQBi P nillf Oaf fag 4 , _ in npnro 7h9 fnQ& ;A e �.dy 49uAd QR-d 3�Z-A�d4 f29 �b E�B�e� o/ 2eakage.'Liqu-id ievei at the outiet .invent iz 51" GREASE TRAP7 locate on site plan) Depth below grade: Material of construction:.e)*oncrete�metaW,4fiiberglass4�4olyethylenot/,,O_other (explain):_ 461 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 141W Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Xl),# Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): a ag nAv Enna JA nnf �n_e6Pnt ' r 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOW ATION(continued) Property Address: 220 Lew.iz Pond /toad Owner: Ca/LO.Q vgaguay Date of Inspection: 6125103 TIGHT or HOLDING TAN144�(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: IJA Material of construction: concrete 4�A metal,40 fiberglass�polyethylene4/,$other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm present(yes or no): Alarm level:— �O Alarm in working order(yes or no): Date of last pumping: 1W Comments(condition of alarm and float switches,etc.): 7.iUht oa hoid.ing .tanka aae no /2/Lezint. DISTRIBUTION BOUT (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1,,14 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.): _[2��fniD�itinn pnx '.� o �se�sen.z` PUMP CHAMBE};'r1 t (locate on site plan) Pumps in working order(yes or no):A# Alarms in working order(yes or no): 2 Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): rhnm0on i,5 nnf 1217yApnf - 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 220 Lew.ie Pond Road Cotu.iit, Ma.s.6. Owner:Caitoi Ve zAu2g Date of Inspection: 5 03 SOIL ABSORPTION SYSTEM (SAS):Zlocate on site plan,excavation not required) 1- 1000 .ga.P2on //tecazt -eeach.cng p-it. If SAS not located explain why: l or-a.tvd: Le age 10 Type ✓ leaching pits, number: / Alb leaching chambers, number: 0 leaching galleries,number: leaching trenches,number, length: O leaching fields,number,dimensions: D overflow cesspool, number: / 70 innovative/alternative system Type/name of technology:/4/e ` �� 4y° Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy aand to dine nand. No aignz o. hydaauiic -Pa.iivae oa ponding. .60.e.ez ate d2y. Vege ai-ion- .cz no2ma . Glazte watea 60' geiow .the .inv�e��n""t'' /2.i/2e. CESSPOOLSt.e (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: --N 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,): Co.A A pnnPA vino nnf 4,79APnf_ PRIVYt"locate on site plan) Materials of construction: Dimensions: /f Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): fin i m4 i t nnf�nnoAonf 9 f 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: 220 Lewia Pon.6 J2ogd Cotui . N a._s4. Owocr: Ca/ o V Prim g Date of lospeetioo: r /.�5L3 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 publie.tiwater supply enters the building. f t 10P Y r / f 10 i . Page 1 1 of l l + OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 220 Lew.iz Pond Road (-37=t, 71azz. Owoer:Cano.2 Veagajg Date of lospectioo: 6125103 SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: 14a.,6 Obtained from system design plans on record- If checked,date of design plan reviewed: 6125 0 3 rn NO Observed site(abutting property/observation hole within 150 feet of SAS) IL"Checked with local Board of Healh-explain: V i p .,,N 4,6 �3 /i p Ipnrz. 1 Checked with local excavators, installers-(attach documentation) �6Accessed USGS database-explain:.h f f n . //f awn O r/a a At a UP— rna, U13. You must describe how you established the high ground water elevation: ll.aed: Gah1tetu & Nii e2 Oodee. 12116194 Ozound wate2 e2evat.iona move .sea 2evei. 11zde: dSaS QkApauezi.inn lVnpp /7rifrz 7,/no 9992 11eed: USA% ZapAni/.r/ 0 /ql/ QOnfin 92 nnn l 1pPrlfa r .5�1992 At2121LCLP nr,ngeb Leaching f Pit / :ect Groundwatcr�> reef Below Bottom of Pit High g Groundwater Adjustment 1.8 ft per Fnmpter Method Therefore, the vertical separation distance between the boa Qm Of the leaching pit and the adjusted groundwater table is 1 feet. 11 ..I.nl1 r—n TIr.Tr�{nT�J.If•nor/�-nrt+n�rr1rn11+a+�rliw*ar'nn'1 rnrwlu 1tr-wa'�n I�'I TOWN OF BOARD OF HEALTH ,SUI;SURFACF 9FWAGF DISPOSAL SYSTF,M IN9PFCTION FORM - PART D •- CERTIFICATION •••T^1�T••.'::a—T.I.t.�.STTaIH}III•.,.'n1.TR.fTaf 7AT7'T'a'—t'1�'1 Vtll77fR}r•'r'�����7 '�, -TYPE OR PRINT CLEARl,1'- PROPERTY INSPECTED STREET ADDRESS 220 Lewin (Doric/ Road Cotu it ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME CaAo.2 Vez9a2g PART D - CERTIFICATION NAME OF INSPECTORJoseph P.Macomber Jr.F COMPANY NAME J P Macomber & S o R Ind711 COMPANY ADDRESS Box 66 Centerville Mass. 02632 Street Town or City State ClP COMPANY TELEPHONE ( 508 ) 775 3338 FAX= ( 508 ) 790 -1 578 CCRTIFICATION STATEMENT " I certify that I have personally inspected the sewage disposal system at this address and that 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 . Check one: System PASSED41 ,The inspection I+hich I have conducted has not found any. informati'on which indicates that the system fails :to adequately. protect public fieRlLh or the, environment as defined in 310 CMR I5`. 303 , Any failure criteria not evaluated are as stated 'in the FAILURE CRITERIA section of this form. System FAILEll# " The inspection whicli I have con Vcted � has found -that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , . and as specifically noted on ,PART C - FAILURE CRITERIA of this inspection form , Inspector Signature F-Date ne copy of- this certification must be provided to the OWNER the BUYER ( where applicable ) and the BOARD OF HEALTii. * If the inspection FAILED, the owner or``opera•tor shall u d he ' ste within one year of the date of the inspection , unless allowed ortrequiredm o the rwipe as `provided in 3.10 CMR 16 , 306 . partd . doc i DATE: 6/4/99 PROPERTY ADDRESS: ----------------------- 220 Lewis Pond Road ------------------------ Cotuit, Ma. ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank 2. 1 -1000 gallon leaching pit Based on my Inspection, I certify the following conditions: 3 . This is a title Five Septic. System. ( 78 Code ) 4. The_ septic_ system is__in ._proper working--order at the-pres-ent 'time . 5. Tank cover is 6" below grade . 090 l 3� 6. Leaching pit cover is 30" below grade . 7 . Waste water is 66" below the invert pipe to the leaching pit . SIGNATURE:1 Name:_,�LL Macomber Jr�______ Company: Jose_ph_P. Macomber_& Son , Inc . Address:- Box-66--- --------------- Centerville , Ma. 02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY \��11 -9 f-- 1, JOSEPH P. MACOMBER & SON, INC. RECEIVED Tan ks-Cess ools-Cesspool Pumped & Installed J U N 1 6 1999 Town Sewer Connections towNOFanptrsrgg� P.O. Box 66 Centerville, MA 02632-0066 y�p� 775-3338 775-6412 S 'b I ti I�i { r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COX Secretes ARGEO PAUL CELLUCCI DAVID B. STRI.•H Governor Co-r_ss:cc, I pi LI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 220 Lewis Pond Road Name of owns. James George Cotuit Ad&o"of owner:_ Box f 3 oats of lrupecuw' Cotuit Name of Inspector:(AWPA Joseph P, Macomber Jr. I am a DEP approved sysm te Inspector purwant to Saction 15.340 0l TIM. 5 (310 C M R 1 5.000) ConVany Name: Joseph P. Macomber & Son,-- on, Inc. W-Ing Address: Box 66, Cen - _ yi 1 1 P'_ Ma _ 02632-0066 Te+aphaew Numbw:qQ$-775—'3'11R CERTIFICATION STATEMENT I csrtity that I have personally Inspected the sewage disposal system at We address and that the Information reported below is true, eccurats and complete as of the time of inspection. The Inspection was performed based on my training and experience in the propet function end maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails J� Inspector's Sigrunure: ( ( Date: The System Inspecto hall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the inspector end the system owner shall submit the report to the appropriate regional office of the Department ohfnvironmemal Protection. The original should be sent io trR system owner and copies sent to the buyer,If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Paeelof11 f..? Printed on Recytted Pipet SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAd&—: 220 Lewis Pond Road, Cotuit Owner: James George Date of Inspection: 6/4/9 9 INSPECTION SUMMARY: Check A, B, C, Or D: A. SYSTEM PASSES: -t 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate ye`,no,or not determined(Y,N.or NO). Describe basis of determination In all instances. If "not determined explain why not. L(/ The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was installed within twenty(20) years prior to the date of the Inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box Is levelled or replaced - The system required pumplrtg-more than-four-dmes v yeardue to broken or obstructed pipe(sl. The system wilt-ran-- inspection if(with approval of the Board of Health): - broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWACE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION (continued) PropxtyAddr.aa: 220 Lewis Pond Road, Cotuit Owner. JAMES George l C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: AConditions exist which require further evaluation byths Board of Health In order to determine If the system is felling to protect O)a public health, safety and the environment. 1) SYSTEU WU1 PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WfTH 310 CI.IR 16.303 (1)(b) THAT THE SYS 'IS�NOT FUNCTIONING W A MANNER WH1C1i,WUlpRO.TFCT THE PUBUC H&kLTRAND SAFM ANo THE D[� OK.6LF . ' i Cesspool or privy Is within 60 feet0f surface water Cesspool or privy Is within 60 fast of a bordering vegetated wetland or a sett marsh. 2) SYSTEU WILL FAIL UNLESS THE BOARD OF HEALTH WID PUBUC WATER SUPPLIER, IF ANY)DETERJtLNES THAT THE SYSM FUNCTIONWG W A FANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE 1?/VIRONwENT: The system has a aspdc tank and soll absorption system(SAS) and the SAS Is wlWn 100 fast of a sumacs water supply tributary to a surface water supply. AIV The system has a septic tank and soli absorption system and the SAS Is wlthln a Zone I of a public water supply wail. 4 The system has a septic tank and loll absorption system and the SAS Is within 60 lest of a private water supply weu. The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 60 Isst or more Irom e private water supply wall,unless a well water analysis for coUform bacteria and volatile organic compo-unds indicates Vw wall Is ties horn pollution from that facility and the piss ncs of ammonia nitrogen and Nuats nluogen is equal to or lesi than 6 ppm. Method used to dstsrmine distance _ (approx)madon not valid).- 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Proparty Address: 220 Lewis Pond Road, Cotuit Owner: James George Data of Irtapeadon: 6/4/9 9 0. SYSTEM FAILS: You must Indicate either"Yes' or 'No' to each of the following: _ I have determined that one or more of the following failure conditions exist as described In 310 CMR 1 5.303. The basis for this determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No •71r�/ Backup of sewage Into iacilitywr•*Vtem componenCdua¢o an overloaded orctogged'SASor•cesspool. Discharge or ponding of affluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in a di;y�ution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth In Is ssllless than 6' below Invert or available volume Is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe($). Number of times pumped !/ Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a 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 I of a public well. -tom/ Any portion of a cesspool or privy Is within 60 feet of a private water supply well, than 100 feet but greater than 50 feet from a private water supply well with no Any portion of a cesspool or privy Is less acceptable water quality analysis. If the wall has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organ)(,-compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes N the system is within 400 feet of a surface drinking water supply the system•IrwitWn 200 feet oi•e-t«buta(y-to a eurfaoo drinkkag ware+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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforpation. revised 9/2/98 Page 4of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropoMAddr"s: 220 Lewis Pond. Road, Cotuit Owrw: James George Date of Inspection.- 6/4/9 9 Check if the following have been done: You must Indicate either'Yes' or 'No' as to each of the following: Yes N Pumping information was provided by the owner, occupant, or Board of Health. None of the ayr<tem-compowants.k ;baan puaspod4orat•Jeasttwowes"ar&tha•rystem hasboeaascei iagw..sa!flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this — � Inspection. As built plans have been obtained and examined. Note If they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was Inspected for signs of breakout. _ ) All system components,eeicluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected for condition of baffle: or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C Is at issue, approximation of distance is unacceptable) 115.302(3)(b)) The facility owner.(and.occupants,lf difteraat if na"wxl of).w aia,prauided.with infor asioaan Tha props aintaa�f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropenyAddr"s: 220 Lewis Pond Road, Cotuit owner; James George Date of Inspection: 6/4/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow:,&& g.p•ddbedroo . Number of bedrooms(desi ): Number of bedrooms(actual):1 Total DESIGN flow Number of current residents Garbage grinder(yea or no): Laundry(separate system) �s or® If yes, separaielrtspectlon,required �a_ 19 Laundry system inspected` or no) •�'�` Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): �Last date of occupancy: COM M ERCIAL ANDUSTRIAL: Type of establishment: Design flow:_ 11A avd ( Based Qn 16.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no).,w Non-sanitary waste discharged to the Title b sys�em: (yes or no)&6I - Water meter readings,If avails le: Last date of occupancy: OTHER:(Describe) 1'9 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of Informatio , System pumped as part of inspection:(yes or no)jo if yes, volume pumped: 0 gallons Reason for pumping: A /' TYPE OF YSTEM Septic tank/d4irUw49*4,cWso(I absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous Inspection records,if any) I/A Technology at Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval .Other APPROXIMATE AGE of all components, date InstWediif known)-and source o 4oformation: ,c� Sewage odors detected whemarriving at the site:(yes or no)� f revised 9/2/98 Page 6ofll r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrDnuod) NopoayA""a: 220 Lewis Pond Road, Cotuit Owner: James George. Data of Inspection: 6/4/9 9 BUILDING SEWER: (Locate on sit@ plan) Depth below grade: Material of construction: cast lron ' 40 PVC_other(explain) Distance from ivate water supply well or suction line Diameter Comments:(condition of Joints,venting, evidence of issa)tage,•etc.) Joints age . s CTAxx:_ a nouse vent . (locate on site plan) Depth below grado:-L Material of construction:ZnSrate Mnat&W Fib@rglass�Polyethylene.�other(explain) It tank is (nota),Ilst ago Is.ags.confwmad by C"ficato of Compliance (yes/No) Dimensions• s�ykiyG Sludge depth:'Distance from from top of udge to bottom of outlet too ortrat'161 Scum thlcknoss � op Distance from t of scum to top of outlet too or batfle� '" Distance from bottom of scum to bottom of outlet too orb Hie:� How dimensions were dotermined: Comments: (recommendation for pumping,,condidon of Inlet and outlet tees or•batfles, depth of liquid level In relation to outlet invert, structuraf4ntegrr evidence of leakage, etc.) rump tank every 2-3 ypnra Tnl gt & eUt 1e•t—comes— ar.e in pla.ce . Licluid e tank ence Of ea age . GREASE TRAP: (locate on site plan) Depth below grade: 'V� Material of cons uuctionrj!!i concrata&MelaL�i Flberglass�✓!0 PolyethylenoA)Ather(explain) It 1.9 Dimensions: Scum thickness: Distance from top of scum to top of outlet tea or baffle:_22 D(stanco from bottom of scum to bottom of outlet toe or baffle:_ Date of last pumping: .V-4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural intogn evidence of leakage, etc.) Grease revised 9/2/98 Page 7orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrdnued) NopenyAdd<eu: 220 Lewis Pond Road, Cotuit Owner: James George Data of Inspection: 6/4/9 9 TIGHT OR HOLDING TANK:AhL(Tank mL6t be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade:, Material of construction• ' concreteA)AmetaW Fibergla334AP01yethylone4l other(explain) AM Dimensions: Capacity: gallons Design flow: IJA gallons/day Alarm present ��d Alarm level: Alarm In working order:YoXA No O Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks are notpl:eseat DISTRIBUTION BOX:,AjtiPi (locate on site plan) Depth of liquid level above outlet Invert: W/� Comments: (note-if level and distribution is equal, evidenoo of solids carryover, evidence of leakage Into or out of box, etc.) — - — Distribution box is not =rPePnt PUMP CHAMBER:4)AVe- (locate on site plan) e' 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.) Pump chamber is not nrPSPnt I revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corrtinued) PropertyAddreu: 220 Lewis Pond Road, Cotuit owner: James George Data of Inspection: 6/4/9 9 ,, SOIL ABSORPTION SYSTEM(SAS)L�0ao-v &0KjV '_ (locate on site plan,It possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:/ leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) 1.0camy sand to fine r CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: AIX Depth of solids layer: AW Depth of scum layer: Dimension's of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of Inspection) (spool G arP not prPgPnt Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of.vagetation, etc.) Cesspools are not present PRIVY:'_f,�(J'r° (locate on site plan) ,p . Materjals of construction: ��/ Dimensions: ry� pepth of solids:_14H Comments: (note condition of soil, signs of hydraulic failure,fevel of ponding, condition of vegetation;etc.) Privy is not prPsent revised 9/2/98 . Page 9of11 SUBSURFACE SEWAGE OLSPOSAL SYSTEM WSPECnON FORM PART C i� SYSTem LNFORuA710N (cortdn.iad) 220. Lewis Pond Road, Cotuit orr*r: James George 6/4/99 SKETCH OF SEWAGE DLSPOSAL SYSTEU: Include des to stleast two permanent reference landmarks or benchmarks locate all wells wlWn 100' (locate where public water supply comes Into house) Centerville Osterville Marstons Mills Water Company 428-6691 9=> r Ack of Wyk _ a o 5z ' n c -#z - - I ( revised 9/2/98 Pete 10octt f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropenyAddra": 220 Lewis Pond Road, Cotuit Owner: James George Date of Inspection: 6/4/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater-6 Feet Please Indicate all the methods used to determine High Groundwater Elevation: �Obtained from Design Plans on record OJ Observed.Site(Abutting property, bservation hole, basement sump etc.) determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/l( jgq revised 9/2/98 Page 11of11 r I TOWN OF B RN2TARI R IlOARD OF HEALTH UQ 11 SSURFACR SEKACE DISPOSAL SYSTEM IN9i'FCTION FORM - PART D •- CEI1'r1 F1 CATION •1�'7•t1�T••. ::.—T.tIR1T.Ty..r.1.•.1..Tr,T1TIrn/1T'TT.rl7"11/tRT R'Rl.f�`T'ATti7lAV�>•'1tT{ Rnl/1TRfTTSTT�TTn�i��•.��T•r•-fir - -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 220 Lewis Pond Road, Cotuit ASSESSORS MAP , BLOCK AND PARCEL OWNER' s NAME James George 111� PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & Son', Inc . COMPANY ADDRESSBox 66 Centerville Ma . 02632-0066 street Town or City Stat. 1 P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Informat ion reported is true accurate , complete as of the time of -inspection . The inspection wase forand recommendations regarding u performed and any g g upgrade ,' maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : v Systeci PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healtlj or the environment as defined in 310 CMR 15t303 . Any failLire criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAIL D* The inspection which I have con'hcted has found that the system fails to protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE C1ITERIA of ' this inspection form . Inspector Signature J;; d-) Date - L One copy of this certification must be provided to the OWNER, the BUYER ( Where applicable ) and the DOARD OF .Ii8AL17I; If the inspection FAILED, th'e owner or"`" pastor shall upgrade within o'ne year of the date of the inspection , unless allowedortrequiredm otherwise as provided in 3•10 CMR 16 . 306 . partd . doc