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HomeMy WebLinkAbout0700 MAIN STREET (COTUIT) - Health 700 Main Street COtu it A= 036 - 049 f r, I = May 08 2019 22:17 HP Fax page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 700 Main Street Property Address James Sullivan Owner Owner's Nam$ N Information is every COtUit required for eve MA 02635 5-6.1',9 page: CityfTfwm State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. ,t�ulttttiugpp��i Important When A. Inspector Information �' ,q , �� ., . filling out forms I#'38� ��y>, ' sO��. on the computer, O`Z:' % use only the tab James D.Sears JAMES m key to move your Name of Inspector Jq:J; SEARS cursor-do notCA 7 use the return Capewide Enterprises - key. Company Name K�j''�RT1 -O 153 Cmmercial Street °''y�F s fV� 9E�� dflre II Company Address OFFr Mashpee MA 02649 City/Town State Zip Code ^�^ 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: 1 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 5-6-19 %pectoes 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. 15insp.doc•rev.7/26/2018 Title 5 Cflfcial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1e r May 08 2019 22:58 HP Fax page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form - j� Subsurface Sewage Disposal System Form - Not P Y for VoluntaryAssessments :N 700 Main Street Property Address James Sullivan Owner Owners Name information is required for every Cotu It MA 02635 5-6-19 page. City(Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is two block c.pools. 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.dx•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•page 2 d 18 I May 08 2019 22:58 HP Fax page 21. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owner's Name information is required for every Cotu it MA 02635 5-6-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 '❑ NO (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: t5lnsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16 May 08 2019 22:58 HP Fax page 22 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Sullivan L Owner Owner's Name information is required for every Cotuit MA 02635 5-6-19 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, x ' ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance; **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into,facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc-rev.7/2612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 18 May 08 2019 22:59 HP Fax page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form I& Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 5-6-19 page. City/Town State zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cant.) Yes No �� ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/Z day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000,gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No " ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 15inso.doc rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 al 18 May 08 2019 22:59 HP Fax page 24 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 5-6.19 - page, City/Town State Zlp Code Date of Inspection C. Inspection Summary (cost.) 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 GA 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 ❑ 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 agiMilaft manholes uncovered, opened, and the interior dMONktift inspected for the condition of the 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)] r 15Wsp.dac•rev.VW2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 May 08 2019 22:59 HP Fax page -25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subs urface Sewage Disposal System Form Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owner's Name Information Is required for every COtUIt MA 02635 5-6-19 page. city/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: The system is two block cesspool's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2017-35,000Gals Detail 2018-1,000 Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date 15insp.doo-rev.7PM12018 Title 5 OMldal Inspection Form:Subsurface Sewage Disposal System-Page of 18 May 08 2019 22:59 HP Fax page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 700 Main Street Property Address James Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 5-6-19 page. City/Town 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: Source of information: NA Was system pumped as part of the inspection? ❑ Yes 9 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: �., t5insp.doc•rev.MUMS Tine 5 Offidal Inspectlon Form:Subsurface Sewage Disposal System•Page 8 of 10 May 08 2019 23:00 HP Fax page 27 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owners Name information is required for every Cotuit MA 02635 5-6-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system n1Af a ® gialls 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 VA 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5, Building Sewer (locate on site plan): -Depth below grade: 2' feet Material of construction: . i ❑ 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 SCH 40. tNnsp.doc•rev.MM2018 Title 5 Official In5pedon Form:Subsurface Sewage Disposal System•Page 9 of 18 May 08 2019 23:00 HP Fax page 28 f s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 5 700 Main Street Property Address , James Sullivan Owner Owner's Name Information is required for every Cotuit MA 02635 5-6-1 9 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth, Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): t&nsp.doc-rev.7/26/2018 Tft 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 x IMay 08 2019 23:00 HP Fax page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owner's Name information Is required for every Cotuit MA 02635 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 7. Grease Trap (locate on site plan): , Depth below grade: feet Material of construction: - ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 16 May 08 2019 23:00 HP Fax page' 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 700 Main Street Property Address James Sullivan Owner Owner's Name Information is required for every Cotuit MA 02635 5-6-19 page. Cityf town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No- Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc:): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): r 15insp.doc•rev.7/2612016 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 1a I May 08 2019 23:00 HP Fax page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 700 Main Street Property Address James Sullivan owner Owners Name information is Cotuit MA 02635 ,, 5-6-19 required for every page. CitylTown 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,): i If pumps or alarms are not in working order,system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: - t5insp.dcc-rev.7W2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 o118 May 08 2019 23:00 HP Fax page 32 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments .S 700 Main Street Property Address - James Sullivan Owner Owner's Name information is required for every Cotuit MA 02635' 5-6-19 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,): Leaching is a 9'deep block c pool. Cover at 16"below grade, Pool Is clean and dry w/no high stain line. No sign of past over loading or solid cant'over. 12. (cesspool Cesspools p ( pool must be pumped as part of inspection) (locate on site plan)_ ^410 1 Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Dry Depth of scum layer Dimensions of cesspool 7" Deep x 6'wide Materials of construction _ Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc,): Main pool 7'deep block w/cover at 11" below grade two inlet's. PVC w/tee's, One outlet line w/tee. Pool is dry. f t5insp.doc•rev.7/26/2010 Title 5 official tnspectlon Form!Subsurfece Sewage Disposal System•Pape 14 of 18 May 08 2019 23:01 HP Fax page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �L 700 Main Street Property Address James Sullivan Owner Owner's Name information is equired for every COtUIt MA 02635 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 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.): ' I 15insp.doc•rev.7126l2018 Title 5 Ofridel Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 May 08 2019 23:01 HP Fax page 34 Commonwealth of Massachusetts Title 5 official Inspection Form ki�. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owners Name information is required for every Cotuit MA 02635 5-6-19 page. Clty/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 0 drawing attached separately REA CLAS5121, Li JP � 8 - 884 1 • I51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 16 of 18 May 08 2019 23:01 HP Fax page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments !7 700 Main Street Property Address James Sullivan Owner Owner's Name information is required for every Cotu it MA 02635 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar " ❑ Shallow wells Estimated depth to high ground water: 45'; 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: pate ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: U.S.G.S.Well SDW 253 48'ADJ 3'. You must describe how you established the high ground water elevation: , U,S.G.S. Well SOW 253 at 48'w/3'ADJ Bottom of pool 10' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7126=8 Title 5 Ct6clal Inspection Form:Subsurface Sewage Disposal Srslem•Pege 17 of 18 May 08 2019 23:01 HP Fax page 36 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 700 Main Street Property Address James Sullivan Owner Owner's Name information is Cotult MA 02635 5-6-19 required for every 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 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tighl)Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation cf estimated depth to high groundwater included �SAS a.FL� ��ADF saw as3 _ No t5insp.doc•rev.7/25/20IS Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 18 of 18 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes I PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for bisposal *pstrm ConstTULtion 3pPrmit Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ?e 1c) ktA(u Ss 4.a-t3-t- Owner's Name,Address,and Tel.No. Map/Parcel ® 41Y� K1LJ A-Lk� Assessor's Ma P 8(G O ob -ML Installer's Name,Address,and Tel.No. j5M`471-V'J'77 Designer's Name,Address,and Tel.No. E u-mv,4 -0 (- tza Q!Zfa4awK=W Type of Building: p / -, Dwelling No.of Bedrooms !� Lot Size 0-9. ( sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Y gpd Design flow provided_IVgpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date yX5 -� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. c� d `-�`� �-- Date Issued °L 3 .--, No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS *� il 2pplitation for Disposal *pstem (Construction Permit , . Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 d o u4A1 U SX Go'Tu r-r Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 03(p p Ltq 140 7V C' Installer's Name,Address,and Tel.No. 15Og`4Z1-1ir4 77 Designer's Name,Address,and Tel.No. G'JE0'�1AQ of sEl r &D7 Type of Building: j Dwelling No.of Bedrooms / A Lot Size aZ9, — sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Ii Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) kGPLAGG Q r AkX0 NOVA i t) «-, x, 1 Q tr Tr -ZZ> oUcSy.LC)C Date last inspected: �y 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 t ompliance has been issued by this Board of Health. •: Signed - Date s�� ' 71 Application Approved by i Date i !3. Application Di-sapproved'by !"" s i `d -' Date for the,following reasons Permit No. U — I �- _ Date Issued ('' j TIC E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by C AO&Ujt 7)C.. CI J-cEttp QISe5 at "7 O n gIb ¢ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - 05 dated Installer (t me-ZO S13 ct-< -- Designer W .� #bedrooms Approved design flow � r� �f t � gpd �ak�f�^ The issuance of thism"it shall nno)t,be construed as a guarantee that the system will functtio as desiigg(d,, Gf J ; 1 J;� �;1� 1 Y� ✓ Date '� d P Inspector -/ - --------------------------------- -.------------------------------------- -------------------------/--------------- No. P 1 �� Fee I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS imisposal *pstent ConstrUttion Permit Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon( ) System located at �U V MAt 4) 5 T Z U l 7 i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply'with Title 5 and the following local provisions or special conditions. Provided:Construction uA be millet d within three years of the date of this permiL--T:Z L Date `( ' Approved by V gay 08 14 07:26p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street k�ww Property Address James Killalea Owner Owner's Name information is Cotuit MA 02635 5-7-14 required for every C /Town page. �Y State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection form_s may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information 0filling out forms _ \ ���{OF on the computer, I ,,. use only the tab 1. Inspector. s`F1 `off ' �ct key to move your ;�: JAMES •u'' cursor-do not James D.Seafs =�: — m+r use the return Name of Inspector =v' """�" y E key. CapewideEnterprises,LLC �ko'IT I ; z Company Name '�G � 153 Commercial Street ip,��s I N Sp Company Address Mashpee MA 02649 City/Town State Zip Code 50BA77-8877 S1623 Telephone Number License Number B. Certification I certify that 1 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 Local Approving Authority 5-7-14 ector'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. v t5ins•3113 Title 5 ORcial Inspedion urrace Sewage Disposal System• age 1 of 17 May 08 14 07:27p p.2 t , Commonwealth of Massachusetts Title 5 official Inspection Form co Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street Property Address James IGflalea Owner Owner's Name infomiation is required for every Cotuit MA 02635 5-7-14 page. City[Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: The system is two block C. pools B) System Conditionally Passes: ❑ One or more system components as described in the°Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old` or the septic tank(whether metal or not) is structurally unsound, exhibits substantial sinfiltration 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): 45ins•3/13 Title 5 Ofikia•Inspection Farm:Subsurface Sewage Disposal System•Page 2 of 17 ' .. . May 08 14 07:27p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form T Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 700 Main Street Property Address James Killalea Owner Owners Name information is required for every Cotuit MA 02636 5-7-14 page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) ❑ 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is-leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO(Explain below): ❑ obstruction is removed` ❑ .Y ❑ N ❑ NO(Explain below): f 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 prnry' is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15hs•3113 rite 5 Official Inspection Famr.Subsurface Sewage Disposal System•Page 3 of 17 f May 08 14 07:27p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 700 Main Street Property Address James Killalea Owner Owner's Name information is required for every Cotuit MA 02635 page. City/Town State Zip Code Date of Inspection B. Certification (cant.) 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. . i 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 El ® 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 �A ❑ ❑ 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'b_eloW invert or available volume is less than'%`day flow l5ina•3113 TRIe 5 Official Inspection Form:Subst0ace Sewage Disposal System-Page 4 or 17 i May 08 14 07:28p i p.5 i Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �P 700 Main Street Property Address James Killalea Owner owner's Name information is required for every Cotuit MA 02635 577-14 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. ❑ ® 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 chainof custody must be attached to this form.] El 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems. To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to'15,000 gpd.. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-.I,WPA) 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 31'0 CMR 15:304. The system owner should contact the appropriate regional office of the Department. bins•3113 Title 5 Official lnspacton Fom:Subsurface Sewage pisposa System-Page 5 of 17 May 08 14 07:28p p,6 Commonwealth of Massachusetts Title 5 Official Inspection Form -I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address , James Killalea Owner Owners Name information is Cotuit MA 02635 5-7-14 required for every page. CityFrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health C] ® Were anyof 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? AAA ❑ ❑ Were as built plans of the system obtained and examined?(If they were not available note as NJA) N ❑ 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,,'gM manholes uncovered, opened, and the interior alE+talMl inspected for the condition of the Vollhomw 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 CUIR 15.302(5)] D. System Information` Residential Flow Conditions: Number of bedrooms(design'): NA Number of bedrooms(actual): 4 440 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 151ns•3r13 Title 5 Officlat Inspection Form:SubSurtaoa Sewage Disposal System•Paga 0 or 117 May 08 14 Q7:28p p.7 Commonwealth of Massachusetts Title 5 OfficialA Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street Property Address James Killalea Owner Owner's Name information is required for every Cotuit _MA 02635 5-7-14 __...__. page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is two block cesspool's. Number of current residents:' 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No . ' 000GaIs , Water meter readings, if available(last 2 years usage (gpd)): 201 2012-72 2-72 00Ga1's Detail: is Sump pump? ❑ Yes 0 No Last date of occupancy: Present Date CommerciallIndustrial Flow Conditions: Type of Establishment: r Design flaw(based on 310 C,MR 15.203): Gallons per day(gpd) Basis of design flow(seats/personslsci t,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tankrpresent? ❑ Yes ❑ No Non-sanitary waste discharged to the Tide 5 system? El Yes ❑ NoY Water meter readings,d available: t5ins-3113 - Tille 5 official inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 . t 6 May 08 14 07:29p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street ` Property Address James Killalea Owner _ Owner's Name information is required for every Cotult MA 02635 5-7-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): ,i General Information Pumping Records: Source of information: NA Was system pumped as parf'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 i ® cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternaave 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): 15hns•3/13 Title 5 Offmal Inspection Form:Subsurface Svyage Disposal System•Page 8 of 17 May 08 14 07:29p p.g Commonwealth of Massachusetts Title 5 OfficiaV Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 700 Main Street Property Address James Killalea Owner Owner's Name information is required for every Cotuit MA 02635 5-7-14 . Cityrrown page. Slate Zip Code Date of Inspection D. System Information (cunt.) Y. Approximate age of all components,date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2- Depth below grade: teat 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.): Peeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•,3113 ; Tale 5 Official Inspection Form Subsurface Sewage Disposal System Page 9 of 17 A May 08 14 07:29p p.10 Commonwealth of Massachusetts Title 5 Official 'Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street Property Address James Kiilalea Owner Owner's Name information is Cotuit MA 02635 5-7-14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (corn.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Grease Trap (locate on site plan): • Depth below grade: feet Material of construction: 0 concrete 0 metal ❑fiberglass ❑polyethylene ❑ other(explain): r Dimensions: Scum thickness - Distance from top of scum to top of outlet tee or baffle -- P Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins 3113 _ Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 May 08 14 07:30p p.11 Commonwealth of Massachusetts Title 5 Official-Inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 700 Main Street Property Address James Killalea Owner Owner's Name information is Cotuit MA 02635 5-7-14 required for every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet-invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: „ ' Date Comments(condition of alarm and float switches, etc.): Attach co of,current pumping contract(required). Is copy,attached? ❑ Yes ❑ No copy P P 9 15in3-3/13 Tills 5 official Inspedion Form subsurface Serfage Disposal System•Page 11 of 17 May 08 14 07:30p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Killalea Owner Ownees Name information is Cotuit MA 02635 5-7-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: F _ r 15ins•3113 Title 5 Official Inspecllon Fomr Subsurface Sewage Disposer System-Page 12 of 17: May 08 14 07:30p p.13 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 Main Street Property Address James Killalea Owner Owner's Dame information is Cotuit MA 02635 5-7-14 required for every page Cityffown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: El leaching galleries number. ❑ leaching trenches i, number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/altemative system Type/name of technology_ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 9'deep block cpool. Cover at 16" below grade. 20"water in pool inlet line 4' above water, wall's clean No sign of over loading or solid carry over. No high stain line. 1 . xv19�N Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 14" 41' . Depth of solids layer Depth of scum layer -- Dimensions of cesspool 7" Deep x 6'wide Materials of construction Block Indication of groundwater inflow ❑ Yes ® No L51-is-2413 � Tile 5 Ofridal Inspection Farr[Subsurface Sewage Disposal System-Page 13 of 17 May 08 14 07:31 p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 700 Main Street Property Address James Killalea Owner Owner's Name information is Cotuit MA 02635 5-7-14 required for every page. Cityrrown State ZJp Code Date of Inspection D. System Information (cons.) - Comments(note condition of:�soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool T deep block w/cover at 11" below grade two inlet's: PVC w/tee's. One outlet line w/tee. z t 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.): t5ins%3J13 Tice 5 Official Inspection Form Subsurface Sevrage Disposal System•Page 14 of 17 May 08 14 07:31 p p.15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street Property Address James Killalea Owner Owner's Name - — ---- — - - required on is Cotuit MA 02635 5-7-14 required for every - page. Ci;y(Town State Zip Code' Date of Inspection D. System Information {coat.} 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 F{) Q 1 - pv^..lf• / 8-, - SY GI j O T 15.ns-3113 - Tige 5 Official Inspection Famr Subsurface Sewage Disposal System-Page 15 of 17 May 08 14 07:31 p p.16 Commonwealth of Massachusetts Title 5 Official "Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 Main Street Property Address James Killalea Owner Owner's Name information is Cotuit MA 02635 5-7-14 required for every _ page. Cityrrown State Zip Code Dale of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 45+' 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 t ❑ Observed site(abutting property/observation hole within) 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS!database-explain: USGS Well SDW 253 .48' A.D.13' You must describe how you established the high ground water elevation: U.S.G.S.Well SDW 253 at 48'w/3'A.D.J.. Bottom of pool 10'below grade.- Before filing this Inspection Report, please see Report Completeness Checklist on next page. 154ns•3M3 - Title 5 Official Inspacion Form Subsurface Sewage Disposal System•Page 16 of 17 i May 08 14 07:32p p.17 Commonwealth of Massachusetts Title 5 Official.Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 700 Main Street Property Address James Killalea Owner Ownef's Name information is Cotuit MA 02635 5-7-14 required for every page. City/Town Stale 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 . y t5tns 3113 - Title 5 Official hspecGon Form:Subsurface Sewage Disposal System-Page 17 of 17