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HomeMy WebLinkAbout0046 MAIN STREET (COTUIT) - Health (2) l - 45 MAIN STREET, COTUIT A= 023 005 i y No. Z00 q 3 l0 1 Fee a��.. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L� PUBLIC HEALTH DIVISION - TO BLE, MASSACHUSETTS Yes Rpplitation for tlo6 tPIYC�(�OttB Utt1on Permit Application for a Permit to Construct( ) Rep r( ) pgrade( ) Abandon ❑C plete System ❑Individual Components Location Address or Lot No. Vnoq�L< (pj�„� Owner's Name, ress,and Tel.No..��q),,, Assessor's Map/Parcel 02,3 O(5 44tm " Installer's Name,Address,and Tel.Noic �, �L o'.ei Designer's Name,Address,and Tel.No. � ' ✓c ? / Type of Building: Dwelling No.of Bedrooms Lot Size i0 t sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank j ©OO Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 15,ndt Ce-% a L o L � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea Signed Date 1 J2-,n=9 Application Approved by L S Date Application Disapproved by Date for the following reasons Permit No. 0_6 O ri— 3ro Date Issued 1 i l 2 zoofl 6 .. No. zoU'l Fee 0 j*- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN-OF-1EARN IT BLE, MASSACHUSETTS 2ppYication for aY- psfein ions uttion Vermit Application for a Permit e pp to Construct( ) Repair( ) JJpgrade( ) Abandon ❑Co plete System El Individual Components Location Address or Lallo. (4 r►'l✓a`n S czyJ& Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q Q 14C. Installer's Name,Address,and Tel.No-e .1 �yl��r�,s�J Designer's Name,Address,and Tel.No. f ✓a pcu, l Type of Building: ~ Dwelling No.of Bedrooms / Lot Size "( � - sq.ft. Garbage Grinder( ) Other Type of Building 6, jllj C i 6m . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank G)oc, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ;)k)janQ a1a �, \ st��l. C.,--5S On i,. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Signed r Date Application Approved by G 4e•S Date /Z ZG Application Disapproved by Date for the following reasons Permit No. Z G D 1- &,`7 Date Issued tii 0 2 Z UO fl THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance ' -' THIS S TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned )by�,,A^tZt�,.J�(� ��.-�/ip✓�j�S !b,�„� , at �Vh(¢,fn S t. Ce�-�-t��� has been constructed in accordance � with the pr//ovisions of Title 5 and the for Disposal System Construction Permit No. tl�°I-3�� dated � i'I��G� Installer oet)eS Designer /v 01 1 #bedrooms Approved design flow /`/ gpd The issuance of this pe it shall not be construed as a guarantee that the system;il�nctio n as designed. Date �I��� I) � Inspector � /c ,� �i11.✓- _� {No. 2-00 l " 3� I Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposai *pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(�) System located at " c., VVIA-m rj-r—e-el and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date �/ �/ 2�,,) Approved by lam. S 7/7/2021 ShowAsbuilt(1700x2800) LOCATION 5EWAGE PERMIT NO. W VILLAGE (' ';7- 1 N S T A L L R'S NAME t ADDRESS I U I L D I R OR OWNER 1-�.ctiN � �ca i f /'tGvrJir/L DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i i i N 3 6 https://itsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuiIt?mp=023005&sq=1 1l1 r Commonwealth of Massachusetts W - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: o only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name � P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 511(310 CMR 15.000). The system: .a Z Passes ❑ Conditionally Passes ❑ Fails a 4?") r DNeeds Fu her E nation by the Local Approving Authority 2/08/2010 Inspector's E�ig-nat~ Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ®, I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water_ ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each.of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well: ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate "yes" or"no"as to each of the following: Y 9 Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists od a 1000 gallon tank,D-Box and leaching pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2008:42,000 g ( y g (gpd))' 2009:31,000 Detail: 2008:115gpd 2009:85gpd Sump pump? ❑ Yes ® No Last date of occupancy: 2/08/2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ` Grease trap present? ❑ Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form 141 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 3" Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top p of scum to to of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note.if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® 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.): Sandy dry soil.No signs of hydraulic failure.Water level was 5' below invert at time of inspection.Stain line observed 4' below invert. Cesspools (cesspool must be pumped as'part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Map Page 1 of 2 .Town of Barnstable Geographic Information System Parcel Viewer Custom..Map Abutters Map Size ■J® Zoom Out j�1 j j j fl j j jIn A K ' `•� -'fib+�^ .�F�e -t"�• - .. ,- �I ,,� " r I i 1 q �ON- K�Y a f � pp91 fi I. 2 eet Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER (`nnvrinhf 9MF_9l11 f1 Tr... of Q-f.hic PAA All rinhfe rnecnu .. I I w.... .� i I / / n • TT\ /�.1 n A!�r n 7 1 .1 M//1 A A A L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 35' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 C ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Main St. Property Address Stephen Hoffman Owner Owner's Name information is required for Cotuit Ma. 02635 2/08/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed. ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFIGE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL_ SYSTEM FORM PART A CERTIFICATION Property Address: 46 Main Street. Cotuit, MA 02635 Owner's Name: Steve Hoffman Owner 's s Address : Date of Inspection: September 1 2009 - Name of Inspector: (Please Print) Jaynes M. Ford Company Name: . .. James M. Ford ' Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 8624400 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 tiine of the inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system. ✓ passes(main system) a,wu Conditionally Passes 5 ds Further Evaluation by the Local Approvirig ',uthority -- T 4DV s(kitchen system)Inspector's Signature: Date: Se ternb 9 20097The system inspector shall sub i -inspection report to the Approving Authority(13 and7ofe'dhH or rn 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 ' Kitchen system fails ****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. Title 5 Ins ection Form 6/15/200 p 0 page • i P � L� Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: 46 Main Sheet Cotuit, MA Owner: Steve HofTnan Date of Inspection:. September 1..2009 Inspection Summary: Check A,B,C,D oiE/,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: Main system passes B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement.or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years.old* or,the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years'old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection_if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed - distributi,on'box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Main Street Cotuit, MA Owner: Steve Hoffman Date of Inspection: September 1, 2009 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of.Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the.. system is not functioning in a manner which will.protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines-that the system is functioning in a manner that protects the public health,safety and environments The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within'a Zone 1 of a public water supply. The system has a septic tank,and SAS and the SAS is within 50 feet of a private water supply well. The'system has a septic tank`and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile.organic compounds indicates that the well.is free from pollution from that facility and the presence of anunonia 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 f Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued),. Property Address: 46 Main Street Cotuit MA Owner: Steve Hofrnan Date of Inspection: September 1. 2009 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: ✓ Any portion of a cesspool.or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is.within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at.a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the:analysis must be attached to this form.] Yes " (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. The kitchen needs to be re-piped to main system E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The.following criteria apply to large.systems in addition to the criteria above). Yes No the system is within 400 feet of a surface drinking water supply the system is within 20.0 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 5 of 11 OFFICIAL INSPECTION`FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46Main Street Cotuit MA Owner: Steve Hoffinan Date of Inspection: September 12009 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping infonnation was provided by the owner,occupant,.or Board of Health Were any of the system components pumped out in the previous two weeks ? ✓ — Has the system received normal flows in the previous two week period? ✓ Have large volumes:of water been introduced to the system recently or as part of this inspection? Were as built plans of the system.obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back-up? ✓ — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ Existing infonnation. For example,a plan at the Board of Health. ✓ _ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 Main Street Cotuit MA Owner: Steve Hoffman Date of Inspection: _ September 1 2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for.example: 110 gpd x#of bedrooms) 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)); Unavailable Sump Pump(yes or no): No Last date of occupancy: Currenth COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,ew,): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/user OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval . Other(describe) Approximate age of all components, date installed(if known)and source of information: Installed on unknown date Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFF ICIAL INSPECTION FORM='NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(continued) Property Address: 46 Main Street Cotuit. MA Owner: Steve Hoffman! Date of Inspection: September 1, 2009 BUILDING SEWER(locate on site plan) Depth below grade.- Materials of construction: -_cast iron _40 PVC .other(explain):. Distance from private water supply well or,suction line: Coimments(on condition.of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 36" Material of construction: concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: . 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: S" Distance from top of scum to top of outlet tee-or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions detennined: Measuring stick Connnents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.). _Tees were present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakage Note. kitchen system was full up to the cover, it needs to b piped over to the main system i GREASE TRAP:. None (locate on site plan) depth below grader 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:.. I Comments(on pumping recommendations; inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 46 Main Street' Cotuit. MA Owner: Steve Ho m an ff Date of Inspection: September 1 2009 TIGHT or HOLDING TANK None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: ._concrete _metal _fiberglass. _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: . gallons/day. Alann present(yes or no): Alarm level: Alarm in working-order(yes or no): Date of last pumping: Comments(condition of alarn and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was normal PUMP CHAMBER: None (locate on,site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,'condition of pumps and appurtenances,etc.): t 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Main Sweet Cotuit, MA Owner: Steve HoEman Date of Inspection: September 1. 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 6'x 6'F1000 Qal) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields;number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Cormnents(note condition of soil,signs of hydraulic failure;level of ponding, damp soil,condition of vegetation, etc.): _The pit had 4'ofwater on the bottom The scum line was 4'6"up from the bottom There was no sign offailui e A camera was used for the inspection. CESSPOOLS: None (cesspool must be-pumped as part of inspection)(locate on site plan) i i Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: j Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no) Conunents (note condition of soil,signs of hydraulic failure,level of ponding; condition of vegetation,etc.): i PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids:. Conunents (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation;,eItc.): ` I I ` i j 9 I Page 1.0 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued): Property Address: 46.Main Street Cotuit, M4 Owner: Steve HoLinan - Date of Inspection: September 1. 2009, 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 1.00 feet. Locate where public water supply enters the building.. ITIU N i r3 air o 0 3 as a3 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Main Street Cotuit MA . Owner: Steve Hoffinan Date of Inspection: September f 2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design'plans on record If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:..topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topo¢raphic and water contours trans the mans were showingapproximately 50'+/ to ground water at thts site. This report has been prepared only for the septic system and components described herein. This main septic systenrhas been inspected and passed as of the date,of inspection: This report is not a warranty or guarantee that the,system will. function properly in the future. There have been no warranties or guarantees,either expressed, written or iritplied, relating to the septic systenz, the inspection, this report and/or any components of the.septic system which have not been located and inspected. ' 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVII20NMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 WILLIAM F. WELD TRUD,,Y- et Governor 3 a ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i�n H ner` PART A 3_j2Vi 31V8Vg 40 NM01 CERTIFICATION '" 866 Property Address: 46 Main Street, Cotuit, MA Address of Owner: , /�(� y^, •d�����la,t Date of Inspection: October 3, 1998 (If different) `S Name of Inspector: lames M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) �+ Company Name. James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map:23 Telephone Number: (508) 862-9400 Parcel:5 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 inspection. The inspection was performed based on my training and experience In he proper function and maintenance of on-site sewage disposal systems. The system: cb RECEIVED i ✓ Passes Conditionally r,Passes � OCT 9 1998 —a Needs Further Evaluation By the Local Approving Authority TOWN OF BARNSTABLE Fails c9 HEATLH DEPT. ti Inspector's Signature: NL Date: October 4, 1998 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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 yes, no,or not determined.(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why. 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page I of 10 DEP on the World Wide Web Attp./fwww.magnet.state rna us/dep 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 B] SYSTEM CONDITIONALLY PASSES (continued) 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). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 04/25/9 e 2 of 10 ( P SUBSURFACE SEWAGE, DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. 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 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes"or "No" as 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 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 H of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. - program eq g P (revised 04/25/97) Page 3 of 10 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner, occupant, and Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note 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, excluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manhol6s were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ✓ _ Existing information. Ex. Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J. (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroory for S.A.S. Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two(2) year usage(gpd): 1997-31,000 gals; 1996-50,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present(yes or no): Industrial Waste Holding Tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pied in 1996- per owner. System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) UA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed(if known)and source of information: 1985-per owner. Sewage odors detected when arriving at the site(yes or no): No (revised 04/25/97) Page 5 of 10 I:. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: Yes (locate on site plan) Depth below grade: 36" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8' X 4'6" X S' (1000 gal.) Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined: Measuring stick Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Both of the baffles were present. There were no signs of leakage. The liquid level was even with the outlet invert. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/9) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day - Alarm level: Alarm in working order_Yes; _No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yes (locate on site plan) Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The D-box was level and there were no signs of solids or leakage. PUMP CHAMBER: None (locate on site plan) Pumps in working order(Yes or No): Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) } (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Main Street, Cotuit, MA 'Owner: Scott Fenner Date of Inspection: October 3, 1998 SOU,ABSORPTION SYSTEM (SAS): Yes (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: I 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, condition of vegetation, etc.) Grass covered the system. There were no suns of failure. The bottom to grade was I1'. CESSPOOLS: None (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: . Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 ofjo r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100' (Locate where public water supply comes into house). �ecJ� i T MAIn A� � � r O O O /� 13 14 -r„k I Nle_T as IS TArk oullfT � 8 �s D. ` 0') a3 (revised 04/25/97) Page 9 of 10 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Main Street, Cotuit, MA Owner: Scott Fenner Date of Inspection: October 3, 1998 Depth to Groundwater: 32 feet . Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers ✓ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) Using the Barnstable topographic and water table contours maps, the maps were showing 32'to water at this site. This report has been prepared and the system inspected and passed as of October 3, 1998. This report is not a warranty or guarantee that the system.will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. (revised 04/25/97) '.Page 10 of 10 it