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Home My WebLink About0120 MAIN STREET (COTUIT) - Health 120 MAIN STREET _ - --_'- - -- - ` Cotuit A= 023-010 i 1{ 1 i� I i 1ME TQ� Town of Barnstable Barnstable u * ��"Re Regulatory Services Department >AvsreASM 1 1 9 1639. ,.� Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0060 February 22, 2018 COBB, EILEEN D & HARPER, DIANE E TRS 64 RUSSELLS PATH BREWSTER, MA 02631 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 120 Main Street, Cotuit, MA was inspected on 01/26/2018 by Shawn Mcelroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action: PER ORDER OF,THE OARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\120 Main Street Cotuit.doc i ; Town of Barnstable ILI Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA•02601 Office: 508-8624644 Richard Scab,Dirccmr FAX' 508-790-6304 Thomas A McKean CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ An`Z'marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground . o Pumping more than 4 times during the last year not due to clogged or obstructed pipe. o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis."('This system passes if the water analysis indicates the well is free from pollution): TWO (2)YEAR DEADLINE CRITERIA q Single'Cesspool- ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) /Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code v §,360-9.1) - ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:ISEPTIC0EADLINES TO REPAIR FAILED SYSTEMS.doo a.3 _o(a Commonwealth of Massachusetts Title 5 Official Inspection Form 11.1 Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments , 120 Main St I dl Property Address Diane Harper t � Owner Owner's Na a !2 information is > required for every Cotuit ," MA 02635 1-26-18 , 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. A. General Information 51W LOOP J.; Inspector: ,: . . . Shawn Mcelroy " Name of Inspector Upper Cape Septic Services ; Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this'address and that the information reported below is true, accurate and complete as of the,time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes , .y r; ❑ Conditionally;Passes :; ® Fails, ❑ Needs Further Evalu the Local Approving Authority ,r,• . 1--26-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paagge 1 of 11177 : , Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 120 Main St Property Address Diane Harper - Owner Owner's Name information is Cotuit MA 02635 1-26218 required for 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: r B) System Conditionally Passes: f' ❑ 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 y ❑ ND (Explain below): t t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 l Commonwealth of Massachusetts a=1 Title 5 Official ,Inspection -Form ' W! Subsurface Sewage Disposal.System Form Not for Voluntary Assessments ` 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) I - - _ t; . . ❑ Pump Chamber pumps/alarms not operational. System will pass with.Board of Health approval if pumps/alarms are repaired.' B) System Conditionally Passes (cont.): P , ;. fi ' ❑ Observation of sewage•backbp 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): ❑ i broken pipe(s) are replaced ❑'Y ❑ N ❑ ND (Explain below): r El obstruction is removed ❑ Y ❑ N" El ND (Explainbelow): ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection -Form W , CAI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method.used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes".or"No"to each of the following 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 Y/2 day flow ` t5ins,doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • - 120 Main St ` t J'' Property Address Diane Harper Owner Owner's Name information is required for every Cotuit • _ - MA 02635 1-26-18 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. 4 ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑l ® 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.]• Ej The system is a cesspool serving a facility with a design flow of 2000gpd- ® ° • 1 0,000gpo: ,F The system fails. I have determined that one or more of the above failure {i 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 s •+ necessary,to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow.of 10,000 gpd to,16,000 gpd., T 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 E] !he 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . �R+ (z Title 5 Official Inspection Form' .. 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main St Property Address Diane Harper Owner Owner's Name information is recuired for every Cotuit MA 02635 1-26-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ ' Were all system components, excluding the SAS, located on site? ® ❑. Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: _ ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): ' 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurfa:e Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts r a= Title 5 Official Inspection Form . 1 ' '�-I Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments Al, 120 Main St r t J"" Property Address Diane Harper Owner Owner's Name information is Cotuit MA 02635 1-26-18 required for every - page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection_. Yes ® No information in this report.) Laundry`system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): . . , 2 Detail: Sump pump? ❑ Yes ® No -Last date of occupancy: 2017Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): R Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): r Grease trap present? , El Yes ❑ No Industrial waste holding tank present? ` El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 , Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J§ 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) X Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--within last few years 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 t ® 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form .I Subsurface Sewage Disposal System Form Not for Voluntary Assessments �•�•,�! 120 Main St r Property Address Diane Harper Owner Owner's Name information is required for every Cotuit - MA 02635 1-26-18 page. City/Town ' . State Zip Code Date of Inspection D. System Information (cont.) 'sr r Approximate age of all components, date installed (if known) and source:of information: 1970's E Were sewage odors detected when arriving at the site? 3 ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: * �r. • �� , ® cast iron `` El40 PVC`' " ® other'(explain)'' Orangeburg Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: r,, , See Cesspools Pg 13 feet Material of construction: F;r - • {t ❑ 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: Sludge depth: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection Form x' � I Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 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 Scum thickness w Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Traplocate on site plan): ( p ) 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 0. f Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 120 Main St rt l J' Property Address .y Diane Harper • Owner Owner's Name ' information is required for every Cotuit f r 't MA 02635 1-26-18 page. City/Town y 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: uon per d • ga s e aY 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.): _A *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts lal Title 5 Official Inspection Form' CAI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 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 N/A 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.): * 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts • '.:- a Title 5 Official . Inspection Form, �1 �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c� 120 Main St Property Address Diane Harper Owner Owner's Name information is Cotuit r" MA 02635 1-26-18 required for every page. City/Town ' _ State Zip Code Date of Inspection D. System Information (cont.) 41 9 Type: ❑ leaching pits ' ^ number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields (number, dimensions:- ® overflow cesspool ; number: 2 ❑ 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.): Both cesspools show signs of failure with stain lines above inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 3-Inline Depth —top of liquid to inlet invert 60" Depth of solids layer 12" Depth of scum layer 1" Dimensions of cesspool 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ..I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 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.): All three cesspools show signs of failure with stain lines above inlet inverts. 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.): L ''1 r t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official � Inspection Form ' •�A Subsurface Sewage Disposal System Form, Not for Voluntary Assessments a 120 Main St t J Property Address Diane Harper Owner Owner's Name - information is Cotuit MA 02635 1-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r , Af f ,l. f ..a •... { � - t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts =1 Title 5 Official Inspection Form f .q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26-18 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: 20' 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: ® Checked with local excavators, installers- (attach documentation) SG eed® database Acc s U S s e e - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 � Commonwealth of Massachusetts .a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main St Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 1-26.18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LOCA IRO . go : tea S}� SIrWAGir# A'SSfiSSOR'S MAI'&LQT JNSTp,�,LETt'S NAiI PIHONE TRIO Sfil�'I'iC AN. CAPACITY Ccs 3 �, 6 LI ACI itNa PA.0 Ti'Y t 1 SS cam/ (size) »..".: r NO '()p,EDROOiS 3 aR c� R i FEIxpt�TT1~ `C�I�r..�Nt ��....,...... ..�._..., � ....... SepAratcon�9�stutar i3eta►eeta tie `' Maxiittum Acijusted:Graundwatet'lble to the i�attnm of X.eachm�i�ne1hty kPilvke Vbta " �l�utt3 Y.Cas�6ti�g 1'�tcaitry �m►Y'�c%t9s exist uPPly we k�a�fl an s9te ac within::�Qp feat oi'leac4utt�f�Giltt}�) . Ed.L'"crf tiUt9aad said lLeAc1u Paciilty�Yf;acay a�ciiands exist fee rJDt�attl�{Q(}fc:et:p ieacisicag f� ,��►} .. - � � "..�---�--�----�- J�UTiii3h4y. wd � r U P i � 3��a- � �.F O � G i C3 .. • i- C3 C3 .- c 0 F F C I A L A, -- -. c:0 Certified Mail FeeEr Er $ Extra Services&Fees(check box,add fee as appropriate) "' Y ❑Return Receipt(hardcopy) $ f\ C3 ❑Return Receipt(electronic) $ 2 PostmAark O ❑Certified Mall Restricted Delivery $ Q- N e O ❑AdultSidnatureRequired $ �L, ICI f i-..❑Adult Signature Restricted Delivery$ �i OPost--_- - - �-�- - - - - - -— - - -- - m $ ' Total COBB, EILEEN D & HARPER, DIANE E TRS jLn seat'; 64 RUSSELLS PATH r o St�eei BREWSTER, MA 02631 :rr r rr ,rr•r. Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the- ■A record of delivery(including the recipients retail associate. { signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specked period. delivery to the addressee specified by name,or to the addressee's authorized agent. :a Important Reminders: Adult signature service,which requires the ■You may purchase Certified Mail service with r' Y P signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age, international mail. and provides delivery to the addressee specified, ■Insurance coverage is notavallable for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). `; of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on i ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion. of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply t_ You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Li Receipt attach PS Form 3811 to your mailpiece;. IMPORTAUr Save this receipt for your records. PS Form 3800r April 2o15(Reverse)PSN 7530-02-000.8047 REM= • • • • ® Complete items 1,2,and 3. s' k „ature .. t ❑A t ■ Print your name and address on the reverse . p gessee so that we can return the card to you. ® Attach this card to the back of the mailpiece, Received by(Printeddame) C. Date of Delivery or on the front if space permits. Ct/ tGt'Y, !Y 1.1""-�-"� """'" ✓ery address differe t from item 1? ❑Yes enter delivery address below: ❑No I COBB, EILEEN D & HARPER, DIAI'TE E TRS j64 RUSSELLS PATH I BREWSTER, MA 02631 { II II I I If IIIII I II BI II III I vloo Type ❑Priority Mail Expre ss®I ❑Adult Signature ❑Registered MailTm dultSiRestricted Delivery ❑Registered Mail Restrict ed—III� i�ilIDIIli II �❑. ai Maul® Delivery 9590 9402 1933 6123 1784 39 rCertifed Mail Restricted Delivery NOReturn for ❑Collect on Delivery 2. Article Number GT ansfer from_secvice lahen ❑CollectonDelivery Restricted Delivery ❑Signature ConfirmationT lil ❑Signature Confirmation 7 015 ,17 3!0 .0 0;01 =4 9 8 6%, ;O 0 6 0 FI Restricted Delivery Restricted Delivery I PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt I _ .I USPS First-Class Mail Postage&Fees Paid USPS• Permit No.G-10 9590 9402 1933^6123 1784 39 United States •Sender: Please print your name,address,and ZIP+4®in this box* Postal Service Town of Barnstable j I Oa Health Division I 200 Main Street I Hyannis,MA 02601 � h I I il.ililtilllIli,ilhlilic lie Ili iil't"lIltiil-i=ibliil. PliIiiiii 6 Commonwealth of Massachusetts Title 5 Official Inspection Form 7a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main StreetR Property Address Diane Harper Owner Owner's Name information is ` required for every Cotuit (� MA 02635 10/31/2018 ' page. City/Town State Zip Codie� 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. filling out forms A. Inspector Information S/ filling out forms ¢� %3� on the computer, use only the tab Richard M. Capen key to move your Name of Inspector cursor-do not Capewide Enterprises use the return Company Name key. 153 Commercial Street „� Company Address Mashpee MA 02649 City/Town State Zip Code »n 508477-8877 S113385 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1 /�_ 2-0 Inspector's Sllnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (/ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within Y p P Y � ) 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.. � 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® 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. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f c � Commonwealth of Massachusetts i - Title 5 Official Inspection Form 7� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for an inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 2017 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M � 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 2016= 16,000 ,2017 6,000 Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Past report stated Owner---within the last few years Was system pumped as part of the inspection? ❑ Yes ® No r If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 r cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1970's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® cast iron ®40 PVC Orangeburg ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c / 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: El concrete D metal El fiberglasspolyethyleney other(explain) 9 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �x Title 5 Official Inspection Form (� a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2 ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2 overflow cesspool in good shape both were dry at time of inspection 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 3 Depth—top of liquid to inlet invert 0 Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool 6x8,6x4,6x9 Materials of construction cesspool.block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The main cesspool was nearly empty, 6 to 8 inches of water on bottom. All three pools had covers to grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f� 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of p design Ian reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 120 Main Street Property Address Diane Harper Owner Owner's Name information is required for every Cotuit MA 02635 10/31/2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18