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HomeMy WebLinkAbout0451 MAIN STREET (COTUIT) - Health x 451 Ma",ra Sheet (Cotuit) _ `Cotuit P f A 022 023, i, ;j r y t ; ' Commonwealth of Massachusetts Title 5 Official Inspection Form, a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st } u� Property Address DALEY, KAREN A Owner Owner's N e information is Cotuit �/ Ma 02635 3/1/20 t required for every r page. City/Town State Zip Code Date of Inspection ;a 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 3 filling out forms A. Inspector Information /, /4/ �- 9 on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. . 35 Content Lane rab Company Address Cotuit Ma 02635 City/Town State Zip Code B� 508-364-9587 S113522 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 V 3/2/20 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form �= a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 page. Cityrrown 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: ® 1 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: System contains a 1500 Gallon septic tank as well as two concrete distribution boxes and 3 leach pits. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 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 to Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments M � 451 Main st V� Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 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 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: E 7 . 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 LI Commonwealth of Massachusetts ;i Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st v Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) 1 : 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 invertor available volume is less than Y2 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. ❑ E. 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. 0. 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is Cotuit Ma 02635 3/1/20 required for every 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 all 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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l01 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st v Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 . 3/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Description: P Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit?. ❑ Yes ® No If yes, discharges to: s 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 ears usage App 289 Gpd 9 ( Y 9 (gpd))� Detail: Sump pump?` ❑ Yes,E No Last date of occupancy: ° Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is Cotuit Ma 02635 3/1/20` required for every page. Cityrrown 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: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: p 9 Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is Cotuit Ma 02635 3/1/20 required for every 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: Two pits added in 1995 New Distribution box installed in 2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site.plan): Depth below grade: eet Material of construction: ® cast iron Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage,.etc.): System is vented through plumbing 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 ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st V Property Address DALEY, KAREN A Owner Owner's Name information is Cotuit Ma 02635 3/1/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: 4 ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: " 1500 Sludge depth- 3 • ' Distance from top of sludge to bottom of outlet tee'or baffle 24" 3„ 'Scum thickness , Distance from top of scum to top of outlet tee or baffle 4„ • " Distance from bottom of scum to bottom of outlet tee or baffle 3011 How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's in place at time of inspection t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts -,, Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name , information is Cotuit Ma• 02635 3/1/20 required for every page. Cityrrown 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: I I Capacity: gallons I Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,�.p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments V � 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 page. cityrrown 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 Level and at normal level with no signs of back up 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 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: Z leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries " , number: El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system T e/name of technology: 9Y: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �_ �I�,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st t' Property Address DALEY, KAREN A Owner Owner's Name information is Cotuit Ma 02635 3/1/20 required for every page. Cityrrown 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.): 3 Leaching pits functioning as designed 12. 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 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 14 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 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 �r p Title 5 Official Inspection Form �= II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 451 Main st u Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 page. City/Town '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 3/2/2020 Assessing As-Built Cards TOWN OF BARNSTABLE JA /TION7 hlaen Str ee SEWAGE N GE C. ofu/7� ASSESSOR'S MAP&LOT29 "062J INSTALLER'S NAME&PHONE NO. ki l a a.e& ,fie L G z t* (� � SEFnC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS R OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by pw16.rd , oyraAL M om-MTpMVV,,,AaYA g . s Ls Y8T6M II'dZFCiiO(YTOa�f r ranMVW0WUT"(..-, HtNp�aa.e--J�� �1®�70��SWi�Q�yOMLIYRW �larm..�M1 io�l+Hremx.�srr�..neRr.rrs.n�ba• 1q �1 . a https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=022023&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form �' to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 451 Main st vt/ Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 page. Cityfrown 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: 10+ 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) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps indicate nge At 13+ ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 451 Main st Property Address DALEY, KAREN A Owner Owner's Name information is required for every Cotuit Ma 02635 3/1/20 page. City/Town 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 No. / c2v� Fee CJ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for 30ispo8al ,6pstem Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System jj�Individual Components Location Address or Lot No.Y5-1 of a,y S T. co{ .r Owner's Name, _Address,and Tel.No. �-'1 Assessor's Map/Parcel ®2Z, 23 l *..A) Installer's Name,Address,and Tel.No. LJ Z I T-77 Designer's Name,Address,and Tel.No. l S3 Ce ,-w-t i Type of Building: Dwelling No.of Bedrooms Lot Size 3t1 �"� 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 �5 V Type of S.A.S. Description,of Soil Nature of Repairs or Alterations(Answer when applicable) Re p l wz-,Z IP--i3�?C� �oJGt PeM-44,CA„ �ga _ � 0U� Date last inspected: AA SQ C� 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 Health. p Sign Date p 2.^^ 1 Application Approved by Date V Application Disapproved by Date for the following reasons Permit No. J3 ' " Date Issued �. - No. IJ/ ' Fee f 11 y `J THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN"OF BARNSTABLE, MASSACHUSETTS _ citation for s osal*pstein Construttion Permit Application for a Permit to Construct( ) Repair()k Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.145-1 eh a,y 5 f; C o-k.�r" Owner's Name,Address,and Tel.No. Assessor's Map/Parcel U 2.2 Installer's Name,Address,and Tel.No. Cl Designer's Name,Address,and Tel.No. C A �° c-P?.w;J-a r �ce 7 r i t.K �i T t Type of Building Dwelling No.of Bedrooms Lot Size 3 i( sq.ft. Garbage Grinder r 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 `�C�� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)(^�e p A� .. ►'3 c K �, �/ !j✓�y,�G,r�, P .y i Date last inspected: 201 Agreement: i The undersigne4 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 .41 Compliance has been issued by his Board of Health. �" Sign d Date Application Approved by 4 Date 1 Application'Disapproved by Date . for the following reasons Permit No. Date Issued O ! THE COMMONWEALTH OF MASSACHUSETTS {J ✓ BARNSTABLE,MASSACHUSETTS --`j CPrtlfltate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(yL) Upgraded( ) Abandoned'( )by C_-"C wl[ aat has�4� I e,T, p{�,, T has been constructed ,in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No�/ / q dated , - . Installer l.ilp.d RAJ-,SL .P�'� Designer bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as design d. Date _ _ t.3���1 J S Inspector . . � 1 �? ---- ------------------- - ------------------ - - - - - -- --- - - - -- -- - - - ----- - l No. 0 f aS Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS bis oral 6pstrm Construction ermit - Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon System located at ah -5 T . C_-Q-K;,-E 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. i Provided:,Construction must be co m leted itJhin three years of the date of this permit. Date ZD I Approved by .. �MN •,� . �'L._- �. ^�,y�,:,k4�2 Ste' , m Er o IC I L S E C Postage $ ru Certified Fee SdSO C3 Postmark Q Retum.Receipt.Fee t. Here C3 (Endorsement Required) G C3 0 ^�ot u7 Restricted Delivery Fee O 3 (Endorsement Required) rl / Cp a O Total Postage&Fees $ !p 6 tSIV C\ M Karen A. Daley & Ruth E. Ennis, TRS % Summerland Realty Trust PO Box 101 rnti lit NAA m��ti Certified Mail Provides: a A mailing receipt ' o A unique identifier for your mailpiece - o A record of delivery kept by the Postal Service for-two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. e NO INSURANCE'COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt maybe requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for.' a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,Please present the arti- cle at the post office for postmarking. If a postmark on the,Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 COMPLETE THIS SECTION,ON DELIVERY • Complete items 1,2,and 3.Also complete A. Si na item 4 if Restricted Delivery is desired. .�. Agent ■ Print your name and address on the reverse X_ ❑❑Addressee so that we can return the card to you. B. Re iv d by P' tV e) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. o D. Is delivery address i Aa fro item Yes 1. Article Addressed to: If YES,enter deiiv dress below: � o U-.0 s`TRSKaren A aaley,&.RuthEEn 3. Service Type % SummerJand';Rea#yzTrust ❑Certified Mail ❑Express Mail ,PO BOX 101 ❑Registered ❑Return Receipt for Merchandise Cotuit, MA 02635 ❑Insured Mail ❑C.O.D. J4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ` (transfer from service fabeo =; ,7 Q 12 ;10�10 0 0 0 0{ 2850 9361 PS Form 3811,February 2004: Domestic Return Receipt 102595-02-M-1540 f UNITED STATES POSTAL SERVICE I First-Class Mail Postage&Fees Paid I LISPS Q Permit No.G-10 i I • Sender: Please print your name, address, drfd.ZIP+4 in;his b e' Town ofBamstable Public"FIealth Divisi �? 200i fdift Street Hyannis, MA 02601 'A !i'�!�!i!i]11�rii�� ��n� �iill�.► 'i . rit r ii .li lip ,1 ili! ! ! i e I Town of Barnstable Barnstable Regulatory Services Department MWw"dCac j •AMSTABM MASS Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2850 9361 June 25, 2013 Karen A. Daley & Ruth E. Ennis, TRS % Summerland Realty Trust PO Box 101 Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 451 Main Street, Cotuit, MA was last inspected on . 5/08/2013, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. You are ordered to repair or replace the septic system components within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. i PER ORDER THE BOARD OF HEALTH T mas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\451 Main St Cotuit Jun 2013.doc I Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=I I I I �:% Logged In As: Parcel Detail Tuesday,June 25 2013 Parcel Lookup Parcel Info Parcel ID 022-023 Developer Lot __�._.__��_____. Location 451 MAIN STREET(COTUIT) I Pri Frontage 1130 Sec Sec Road Frontage village`COTUIT I Fire District I COTUIT Town sewer exists at this address jNo � I Road Index 0951I Ts- *-r Asbuilt Septic Scan: p Interactive 022023 1 Mapl t ? _,w Owner Info _ Owner DALEY, ItAREN A& ENNIS, RUTH E TRS I Co-Owner SUMMERLAND REALTY TRUST Streetl PO BOX 101 Street2 City CO�TUIT."" ._.__� y , State�MA� zip 02635 County Land Info Acres 0.76 use iSingle Fa MDL-01 I zoning RF Nghbd 0109 Topography Above Street Road ,Paved Utilities Public Water,Gas,Septic ( Location Construction Info Building 1 of 1 Year 1895Ext Built Struct 1 p Wall Roof Gable/Hi all Clapboard MT ao j+ Living 2265 Roof Asph,FGIS/Crop I AclCentral Area Cover Type EIL Style Conventional Int rPlastered Bed 5 Bedrooms Wall Rooms Floor I p Room 1, Model Residential Car et s5 Full+ 1 H Grade Custom Type Hot Air Rooms 112 Rooms w i l I I a Heat Found-r� # stories 11 3/4 Stories #Gas _ iBnck Walls Fuel ation r Gross 3429 _j _ Area Permit History �. http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=1111 6/25/2013 r- � � D ., . i" - 1 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o"t 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 C' /Town State Zip Code page. �Y p 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. ImWhen filling out forms A. General Information on the computer, (� `���`� 1 OF rMq use only the tab 1. Inspector: ��•o`ya�cg SS9�' key to move your ;o�:: .•yG cursor-.donot JamesD.Sears _'�; JAMES .% use the return Name of Inspector =c�; :r„ key. Ca ewideEnter rises,LLC p P Company Name ii� 153 C m r i �� 5 I N Sp �� Company Address Mashpee MA 02649 City/Town State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection,The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the L:ocalApproving Authority 6-7-13 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board. of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the.approving authority. ****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. t5irr.•3113 Title 5 Offiaal Inspection Y Sewage Disposal System-Page 1�of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 451 Main Street Property Address Karen Daley Owner Owner's Name information is Cotuit MA 02635 5-8-13 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D.or€/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, NO)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 ❑ NO(explain below): t5ins•31 3 Title 5 Official Inspection Form:Subsurf m Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is Cdtuit MA 02635 5-8-13 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ® broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below)- ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): Need to replace line tank to old D Box. Need to replace line tank to new D Box. Need to replace older D Box. ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `t 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 page. Cityr 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 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 magol is less than 6"below invert or available volume is less than '/day flow Al t5ins•3113 Title 5 Official inspection Forth: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 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 page. Cityrrown 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. Cl ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 ��� �� /3�'-� �� � (/�- Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 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 ❑ Z 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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 6 Official Inspection Form:SL b wftca Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments ° 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 page. Citfrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 gal. tank two d box's three pit's. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system?(Include laundry ry system in spection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-68,000Gals g ( y g (gp ))' 2012-91,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is cotuit MA 02635 5-8-13 required for 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping; Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 1/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEPapproval. ❑ Other(describe): t5ins•3113 Title 5 Olfidal Inspection Form:Subsurfaoe Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley f Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Tank-older box and older pit na/Newer D Box and two pits, 1995 permit 95-635 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811 feet Material of construction: ❑cast iron ®40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing is PVC and orange burge. Line tank to older D Box orange burge, need to replace line. PVC line out of tank to newer D Box, not pitched right. Need to replace line. Septic Tank(locate on site plan): 811 Depth below grade: feet Material of construction: Z concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast Sludge depth: 2" t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 14 L __ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Dale Owner owner's Name information is Cotuit MA 02635 required for every page. Cityrrown 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 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape-Past-ReportSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and covers at 8"below grade. Inlet tee two outlet, one w/tee. No sign of leakage or overloading. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is Cotuit MA 02635 5-8-13 required for every _ page. Citylrown 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-3/13 We 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is Cotuit MA 02635 required for every page. Cityrrown 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Two D Box's older Box 16"V-14" below grade w/one line out wall's gone, Need to replace .box. Newer D Box 16"x16"-16"below grade, clean and solid like new. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cotuit MA 02635 5-8-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three 1000 Gal. Precast pits. Pit 1 &2 newer pits, installed 1995. 30"below grade w/covers at 10"clean and dry wall's like new, not been in use due to bad line,to newer D Box. Older pit&cover at 31'clean and dry. No sign of overloading. 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owners Name information is Cotuit MA 02635 required for every page. Citylrown 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): i Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every COtuit MA 02635 5-8-13 page. Cityrrown 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—RoAlT A�-fig FA � aa=sa , 13_3 - 9, 3 o x a � ®O � t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is required for every Cptuit MA 02635 5-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar Shallow wells 20'+ Estimated depth to�gh ground water: 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: El Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W. off past report 8-20-05. 20'+ bottom of pits 9' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 451 Main Street Property Address Karen Daley Owner Owner's Name information is Cotuit MA 02635 5-8-13 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness.Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 or 17 COMMONWEALTH OF MASSACHUSETTS , b EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION AP M P , PARCEL C>12) LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: L f J NAP Date of Inspection:d no 1 ®'0 Name of Inspector: (please print � 1QW Company Nam Mailing Address: .0 Telephone Number: 7I CERTIFICATION.STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on'site sewage disposal systems. I.am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes. Needs Further Evaluation by the Local Approving Authority Is Inspector's Signature: 7,/ Date: — The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer; if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at:.the.time'of inspection an'd 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 Inspection Form 6/15/20.00 page I • B Page 2 of l 1 j OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A . • _s {?F'', CERTIFICATION (continued) Property Address: /� v Owner-- . Date of Inspection: 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,c,-_iteria deseribed-in-3.10 CMR 15.303 or in 3:10 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or.repair;.as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N;ND)in the for the following statements.If"not determined".please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or:tank failure.is imminent:System will pass inspection if the existing tank is replaced with:a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is'leveled or replaced ND explain: The system required pumping.more thanA 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 r Page 3 of 11 OFFICIAL INSPECTION FORM-.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: l/l Q Date "� .. . of lns ection P r/.0 a4z 1,t -i 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•.willrpass-unless;;Board;;ofY:ealth:adetermines:in accordance rr:ith.31'0 CN1W15:303(l (b)th'atAhe system is not functioning in a manner which will protect public health,safety,and the environment: Cesspool or privy is within 50 feet of a surface water. _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)..determines that the system is functioning in a manner that protects the public health;.safety and.environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply: — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic.tank and.SAS and the SAS is within 50 feet of a private water supply well .The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a. private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified.laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.. 3. Other: 3 i Page 4 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .i Owner: 7`/(-.P C.:4 (�../' Date of°Inspection:: _ ��►060 125 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nqi Backup of sewage into facility onsystem 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 �., P 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 r available q P P o 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 ,J P P w 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 cesspaptorprivy is within a Zone 1 of a:public well. _ y/Any portion of a cesspool or privy is within 50 feet of a.private water supply well. l/ Any portion of a cesspool or privy is less than :TOO feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)iThe 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.fa6lity with a design flow of 10;000 gpd to 15,000 gPd You must indicate either"yes"or"no"to each of the following: (The.following criteria apply to large systems in addition to the criteria above) yes no _ — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II of a public water supply well P PP Y If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"-in Section DI-above the large system has failed. The owner or operator of any large system considered a signifcant 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 t Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1,4 Owner: �L Date of Inspection: a,-yo, cl_ }2 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 __Z-.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 backup? Was the site inspected for signs of break out? Were all system components,excluding the SAS;locaied 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? c/'_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil.Absorption System (SAS)on the site has been determined.based on: Yes no _ Existing information.For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page6of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Y 5 Owner: Date of.Inspection:z 9e.�t!f.U. j LOW CONDITIONS RESIDENTIAL' Number of bedrooms(design): . Number of bedrooms(actual): . DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: - Does residence 1ave a garbage grinder(yes or no):_ - Is laundry on a separate sewage system(yes or"no):_ f if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: CO,MMERCIALANDU Type.of establishment: �RIAL w / Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no)_:,� Industrial waste holding tank present(yes or not/A0` Non-sanitary waste discharged to the Title 5 system(yes or no):z&— Water meter readin57 gs, if availa le: Last date of occupancy/use: 00 Ayelxy-- otaceI ,R.-449&Alc .� OTHER(describe): . � t✓� ���j�l,,,J�p . GENERAL INF,ORMATION Pumping Records Source of information:A0 D-4QAfl< Was system pumped as part of the inspecti (yes or no): If yes,volume pumped: gallons--How was quan tty 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 copyof the DEP approval Other(describe): A proximate age of a I corn nent ,date'nstall (if kn wn)an source of information: Were sewage odors detected when arriving at the site(yes or o): 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: RECEWED Owner Zee Y Date of Inspection: -- ° o -MAR 1 7 2003' TOWN OF BARNS BUILDING SEWER(locate on site plan) HEALT ABLE H p T . EFT. Depth below grader cl--� Materials of construction:_cast iron _40 PVC other(explain): Distance from private.water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: r� Material of construction: i---c-oncrete 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) /I Dimensions: Sludge depth: f ° Distance from top of sludge to bottom of outlet tee.or baffler . Scum thickness: Distance from top-of scum to top of outlet tee or baffle: H �, Distance from bottom of scum to bottom of outlet tee of b�af'fl"e� _ How were dimensions determined: YOAI ��e� � �1 �1>ry;• Comments.(on pumping.recommendations, in et and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert evidence of leakage,etc) /= ,_ _ Ems" /W IYA GREASE T�JRAP, (locate on-site,plan) Depth below grade:_ Material,of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum.thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:. Comments(on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, liquid levels j as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 w Owner Date of Inspection: . D j TIGHT or HOLDING TANK! (tank must be pumped at time of inspection)(locate on.siteplan) Depth below grade: Material of construction* 'concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓(if present must be opened)(locate on site plan)`\`J � J Depth of liquid level above outlet invert:G o t c Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover;any evidence of eakage into or out of box, etc.) PUMP CHAMBE (locate on,site plan) Pumps in workinb,order(yes or no): Alarms in working order(:yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 f , Page 7 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.-INFORMATION(continued) Property Address: Owner. Date of Inspection: ��� � 03 BUILDING SEWER(locate on site plane Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: . Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade:. 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: Sludge depth: Distance from top of sludge to bottom of outlet,tee.or baffle:. 24 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:JQ Gz � Comments.(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels faft related to outlet invert,evidence of leakage,etc.): p _ ,00 GREASE.TRAIW, -(locate:on siterplari) Depth below grade: Material.of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum.thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet,invert,evidence of leakage,etc.): Y Page 8 of 71 a OFFICIAL.INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM`INFORMATION(continued) Property Address: YS7 T OwnerP Date of Inspection: )o Q TIGHT or HOLDING TANK: A�&(tank must be pumped at time of inspection)(locate on.site plan), Depth below grade: Material of construction:- concrete —:metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm.present(yes or no): Alarm level: Alarm.in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): f . . DISTRIBUTION BOX: V (if present must be opened)(locate on site plan)\ aA—& Depth of liquid level above outlet invert: 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 or no): Alarms in working order(.yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 1.1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner• j,4J, Date of Inspection:,�i,n,� ay / OF,�',WO SOIL.ABSORPTION SYSTEM (SAS):y(locate on site plan,excavation not required) If SAS not located explain why:, Type Zleaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: _innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc14&� /00 0 &Vn,AeAr-A j oid a&,y co ): n CESSPOOLS (eesspool must be pumped as part of inspection)(locate on site plan) �/B�, r��/� Number and configuration: Depth'—top of liquid to inlet invert: w Depth of solids layer: Depth of scum layer: Dimensions of cesspool:. Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of pond ing;7condition of vegetation;"eic:):x 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: dolh'LlLbd Owner: v Date of Inspection: ' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100'feet.Locate where public water supply enters the building. f . 10 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION(continued) Property Address: Owner: 7k r Date.of Inspection: rj(j 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan.reviewed:. Observed site(abutting,property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you'established the high ground water elevation: ,. U . rim 4/,s; , 11 Permit Number: Date: Completed by: 9 ' HIGH GROUND-WATER LEVEL COMPUTATION J� Site Location:_ 7 P�/q�17 �5 , C� �` Lot No. Owner: T�f� ��'�L>//� 1�'j� Address: Contractor:. 61& 9/151, Address: S G 57`f Notes: STEP 1 Measure depth to water table tonearest 1/10'ft. .....:.....................:..............................................:.... .Date month/day/year STEP 2 Using Water-Level Range Zone _ and Index Well'Map locate site and determine: OAppropriate index well.......................... �� �� UB Water-level range zone .................... G STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to 2 . water level Q1�3 $; z -for index well .......::..................: month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP.3)., and water-level zone (STEP 2B) determine water-level adjustment........................:....:.............................:................................ STEP 5 .. Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water �7�7 levelat site (STEP 1) ....................................:......•.................................................................... Figure 13.--Reproducible computation form. 15 f e Ll a }} l gate Pq TA >+ 3 F � } (j � � 4 r �4 __ _ . 3 i _5 r I r P�i!I��; ixil WOO- Oil an 44 1 1 P. } � 17 ! fir �� � aai IWx1 .,,TOWN OF BARNSTABLE SEWAGE # VU.LAGE �G® G11 ASSESSOR'S MAP& LOTOZ 2 `",/,1 INSTALLER'S-NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �°'��®O1lP � Is NO.OF BEDROOMS BUILDER OR OWNER PERMIT.DATE: COMPLIANCE DATE: Separation'Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lead faci ' Feet Furnished by %" � � =, �� i �� �� f� �' .,r �,.... �. a_� .��, rr v i w TOWN OF BARNSTABLE LOCATION ' / �LIGi h .Sf r e t SEWAGE # Y-M!,AGEi}tofu/ It I ASSESSOR'S MAP & LOTOaa " �3 INSTALLER'S NAME&PHONE NO. k l e A a e 1. lie L L o t t ( SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS Ji OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ?' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propetay Addrms:r- fol t Owner.�j 1 Date oflnspaetlon. R fbl0� . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal sysmm incbwmg ties to n Ines[two pwin tefa'ence 1,,d w.i,or t b=hmmi®.Loam all wells within 100 feet.Locate whoa public wmer supply eW=the building. a5 �1a 3 Uo C-4 T ION _ SEWAGE PERMIT NO. VILLAGE (oTUii INSTA LLER'S NAME A ADDRESS ! BUILDER OR OWN ® ,• I' I DA T E PERMIT I S S U E D /,�7,z DATE COMPLIANCE ISSUED ` -� m � r- ::k - j Ti�� o _ ' G �� _ \� � .. -.. _ _ �7 _� �` _ !• i ^y �i �J'r w. i � „� ,� ..., ASSESSORS MAP NO. d 4 Z • PARCEL N0: No................` _'� F r� - ps..�/.-...��'..!...1..�'`�.... THE COMMONWEALTH1 OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Eli-nVinial Mirlw Tomitrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ............................ ••-------------------------•------•---•---......------••---•...--------._...........------ Location-Ad ess .. Lot No. ...__�.,�.�,..�-�------Coo-�- -����----------------- W �� ncr t;nx .; /' Ad ress Installer ` Address U Type of Building Size Lot............................ Sq. feet �-, Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder (X/6) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow................................./...... ...gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid capacity l ---------gallons Length---------------- Width---------------- Diameter.---.----------- Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----------_------ ------- ............................................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water...................... f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 P4 ---••----•-•-----------------•--•---•-----------••-------------•------•-----•••-•-•----......------.......................................................... Description of Soil............................................................................... ------------------------------------------------------------------------------------•-•. x U •-•••-••-•--•---•--------•-----•----•-•...•---•••-----•--•-----•--•-•---------------------•••-•-----•-----•------------••••------•----------------••••--•----•---------••--••-•-----.. ................... ...... W ••••-------•------------------------------------------ x ,� •---- U Natuurpe�o'f Re pa�itrs orl. lterations— nsNv when applicable,__ ._ `_ ______._j_.___ tJ-l._.� _ _ ...__c 1_ .....--- ....---PZi.rs �..... Agreement: The undersigned agrees to install the aforedescribed Indivi ual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place thi system in operation until a Certificate of Compliance has been issued byubeboard healZ�A lV Zl�`j Signed .... - - - ------ - --------_....- -- --------... -._. . ............ '�Z Dace Application.Approved B _._. .( .... G�%/i / ^.............. - C� .�:.--- -- Dne Application Disapproved for the following reasons: ........................ . Dare Permit No. ........ .... ..��.. .... Issued ... ......... Dace No............ ....... V//` FEB..,- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratintt for Dili-paiial llirkti Cnnmitrtir#inn runtit Application is hereby made for a Permit to Construct ( ) or Repair ( t) an Individual Sewage Disposal System at: �/. I G s� c � 1^ .------. . .5 � � Locaattion. Address or Lot No. W Owner �/`/`✓J J . l _-- ---••t•-•----------- r a 1-�r�---t ; -',7C _ ' . --= =------------ d ess--- 1 Installer Address UType of Building `� Size Lot............................Sq. feet .—I Dwelling—No. of Bedrooms.__,__ ---.f------------------------------------Expansion Attic ( ) Garbage Grinder (X/t)' aOther—Type of Building __________________________•- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow..------------------------------------------gallons. W Septic Tank—Liquid capacityl�.�0..galIons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area.........._.........sq. ft. Seepage Pit No.................... Diameter----------- -------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------- --------------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 ..........................................................'............................................................................................... Descriptionof Soil = -----------•`•.................•-----•-------------------------------------------------------------------------•--------------. x F l`" UW --- -------------------------------•--------•---••-•--------------------------------------------------------- ' .................... '==-------------•--................................. Nature of Repairs or Alterations—Answer when applicable..... -(� �..__._.�..__. J .1._._�� �.- (.Q�'1C- S ( � . ._._ r .._.__._._p_ ... . .... ....... ....q... �_r ...._..__i_._._..___.__... �... Agreement: / S Gr/ DI` Ste`©yip rGsX�;' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b_y_t eebboard of health: — ........... Signed ---- e ` T/.....� J ._........ Dare ` Application,Approved B .....--- ... .....?~ = hr ........................................ ..... ........ .v_r- c . Dare Application Disapproved for the following reasonf- --------------------------------------------------------------........................................................... ------ .......................................... `�... .. -------------------- - Permit No. ------ ..... Issued .................!!7!Pn...'-"...5 Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#tfictt#e of Compliance THIS IS TO CERTIFY`That the Individual Sewage Dispos 1 System constructed ( ) or Repaired ( C� y - ..�.. ........... ............. ....... Installer ........................................................... has been installed in accordance with the provisions of TITLW__1 e State Environmental Come as described in the application for Disposal Works Construction Permit No. .._.,` dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , DATE._�/'._��.. '.......�c"�.....�` '.. .._.._._.... Inspector THE COMMONWEALTH OF MASSACHUSETTS — — BOARD OF HEALTH TOWN OF BARNSTABLE _ No. ...........:......... FEE. ' Biapnsat orkii Tonatrurtin rrrntit Permission is hereby granted-------41'`�' `.'1 1�t `v ��� J `............... to Construct ( ) or Repair (V) an Individual Sewage Disposal System atNo.............---•--•••..=� `---� •f`'1.G..-- --- -----------------� a -----.--------------------------------------------......---------------...--•--........... Street �— as shown on the application for Disposal Works Construction Permit N�.����Dated._=��..���- �9�.--• • Board of Health DATE. -•---------•-----------•---------- �' (�(/ FORM 38908 HOBBS 6 WARREN,INC.,PUBLISHERS 1