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HomeMy WebLinkAbout0904 MAIN STREET (COTUIT) - Health �904 Main StPEET i . Cotuit A = 035 091 x May 10 15 04:06p p.18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information is required for every Cotuit MA 02635 5-6-15 Page Cityrrown State Zip Code Date of Inspection Inspection results Must be submitted on this form.inspection forms may not be altered in any, way. Please see completeness checklist at the end of the form. Important:When A. Genera! Information Iling out forms n the computer, D. .`��� ��Yl OF P�gS o use only the tab 1. Inspector: ,,`71_�` ' sy�y key to move your S- a o: •• G - cursor-do not James D.Sears J = ; JAMES m use the return Name of Inspector key. Capewide Enterprises,LLC • o� l0 o-* ICE Company Name �'i���T( '••..TIFF Ggo``�� 153 Commercial Street Company Address Mashpee _ MA _ 02649 City(Town State Zip Code 508-477-8877 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 Local Approving Authority t 5-6-15 spector's Signature Date a 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 j 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 wilf perform in the future under the same or different conditions of use. 15ins•3M 3 Title 5 OV621 Inspection Fam:Subsurface Sewage Disposal System•Page 1 of V t , May 10 15 04:06p p.19 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not fior Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owners Name information is Cotuit MA 02635 5-6-15 required for every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,0 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 a 1500 Gal. Tank D Box and two chambers. Note: All units are H-20. I i l 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 j 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): l I ' i t5ins.3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Gage 2 of 17 May 10 15 04:07p p.20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owners Name informationis required for every Cotuit MA 02635 5-6-15 —_ page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) ❑ 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 pipes) 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): 0 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): i i I i 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 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: i j] 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 Wns-3113 Mile 5 Official Inspection Form-Subsurface Sewage Disposal System-Page 3 of 17 i a May 10 15 04:07p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit MA 02635 5-6-15 page. Cityfrown 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 t . supply. l ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water ' supply well. Q The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 fleet 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 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 i Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in swommad is less than 6" below invert or available volume is less than%day flow f-�i��ifi•�� t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17 May 10,15 04:07p p.22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit MA 02635 5-6-15 ; page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Itoa`ologge,Required pumping more than 4 bones in the last year NOT due obstructed pipe(s). Number of times pumped: ov ❑ ® Any portion of the SAS,cesspool or privy is below high ground water ele {atlon t� ❑ Any portion of cesspool or privy is within 100 feet of a surface wafer supp y or tributary to a surface water supply. la ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well ' r ` E] ® 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.analys s. his system passes if the well water analysis, performed at a;DEP certifted laboratory,for fecal coliform bacteria indicates absent an "I a presence of ammonia nitrogen and nitrate nitrogen is equal to or less.than S.,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. I . ❑ ® The system fails. I have determined that one or more of the abbye failure crifieria exist as described in 310 GMR 15.303, therefore the system fal(s. The system owner should contact the Board of Health to determine wt at wilEbe necessary to correct the failure. 4 i E) Large Systems: To be considered a large system the system must serve a facility`withila design flow of 10,006 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. s 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 Il 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. 1, (3 t5ins-3lt3 TrBe 5 Official Inspection Fomc Subsurface Sewage Qisposd si ��Page 5 of 17 May 10 15 04:09p p.23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every cotuit MA 02635 5-6-15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks?' ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? 0 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable))310 CMR 15.302(5)) D. System information Residential Flow Conditions: . Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 } a` 15ins•3113 Title 5 Official Inspection Force Subsurface Sewage Disposal Syslem•Page 6of 17 May 10 15 04:09p p,24 Commonwealth of Massachusetts Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information is Cotuit AAA 02635 5-6-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and two chambers. Note: All units are H-20. 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 ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2013-89,OOOGal 2014-79,00OGa Detail: Sump pump? ❑ Yes 21 No Last date of occupancy: PresentDate Commercialllndustrial 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 Tide 5 system? ❑ Yes. ❑ No Water meter readings, if available: t5ins-3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 u',17 4` May 10 15 04:09p p.25 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information is Comt AAA 02635 5-6-15 required for every page. Cityrrown 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: 2010-2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ' ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ElOther(describe): 15ins•3113 Tille 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17 May 10 15 04:10p p.26 Commonwealth of Massachusetts Title 5 Official Inspection Form Ai5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit MA 02635 5-6-15 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information-'s'.; 2001 Permit #282 Were sewage odors detected when arriving at the site? Q Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 18"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: 1500 Gal.Precast H-20 Sludge depth: 1 . bins-3113 Title 5 Official Inspection Form:Sutsurrace sewage Olsposal System•Page 9 of 17 May 10 15 04:10p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit VA 02635 5-6-15 page. Citylrown 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. NA Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc_): Tank at working level.Tank at 18" below grade w/inlet cover steel at grade in stone drive_ In and outlet tee's. No sign of leakage or over loading_Tank is H-20.0 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: flare t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Dlspml System•Page 10 of 17 May 10 15 04:10p p.28 Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit MA 02635 5-6-15 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.): II 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tins-.3113 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposed System•Page 1 t of 17 May 10 15 04:11 p p.29 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information is required for every Cotuit MA 02635 5-6-15 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.): D Box is 16"x16'-34" below grade wlsteel cover at grade in stone drive. Box is clean and solid wltwo lines out. No sign of over loading or solid carry over D Box is H-20. 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: f5ins-3r�3 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page.12 or 17 May 10 15 04:11 p p.30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Flame information is required for every Cotuit MA 02635 5-6-15 page, Citylrown State Zip Code Date of Inspection D. System Information (cost.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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 two 500 Gal.dry well's wM!stone(12.Wx29').Chamber's are 40" below grade wlone cover steel at grade in stone drive. Chambers are clean,wall's like new.Chambers are H-20- 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•3113 Title 5 Ofiidal Inspection Farm:Subsurboe Sewage Disposal System•Page 13 of 17 a May 10 15 04:11 p p.31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit MA 02635 5-6-15 page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1*. May 10 15 04:12p p,32 Commonwealth of Massachusetts _ v Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ljv 904 Main Street Property Address Patricia Browne Owner Owner's Name information is required for every Cotuit MA 02635 5-6-15 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 s 4z3G� 3=3 � 13 V.:3 , t5ins•3r13 Title 5 Olflclal Inspection Form:Subsurface sewage Disposai System•Rage 15 or 17 May 1.0 15 04:12p p.33 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 904 Main Street Property Address Patricia Browne Owner Owner's Name informrequire for Cotuif MA 02635 5-6-15 required for every Ci !To page. h wn State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ND 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: 10-16-2000Date ❑ 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: T.H. on Design plan 10-16-00 No G.W. at 10'+. Bottom of chamber's at U below grade. Bottom of chamber's at 4'+above T.H. Depth. Qefore filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 otrrcial Inspection Form:Subsurface Serwage Disposal System•Page 16 of IT r May 10 15 04:12p p.34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 904 Main Street Property Address Patricia Browne Owner Owner's Name information required for every Cotuit AAA 02635 5-6-15 page. CityrT'own 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 fife I c1 5 ns-3113 Title 5 Offidal Inspection Form:Subsurface Sewage Oisposal System-Page 17 or 17 /Of'319 F �.�13/J_01,5 � ►Er Town of Barnstable Office: 508-862-4644 �.. Regulatory Services Department Fax: 508-790-6304 K. ,, � Aa Public Health Division 'M:A09: Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt !Septic Inspection Payment received: $25.00 (Check) on 5/13/2015 Permit number: 10859 Check number: 32434 Check amount: $25.00 Name on check: Capewide Enterprises, LLC i0wner: EDWARD M &PATRICIA H BROWNE Address: 904 MAIN STREET(COTUIT), Cotuit Commonwealth of Massachusetts W Title 5 Official Inspection Form m _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 904 Main St. Property Address p Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out W forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name 1110�1 P.O.Box 763 Company Address Centerville Ma. 02632 remm City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furt er Evaluation by the Local Approving Authority vneffl7-z-�j 7/8/2010 Ins ec or s ignature 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 i the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sew Disposal System•Pag of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? If the were not ® ❑ P Y ( Y available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2008:67,000 g ( y g (gp ))' 2009:67,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7/8/2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts U9. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed in 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented threw the house vents. Septic Tank (locate on site plan): Depth below grade: 2.5' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon H2O 411 Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" � Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or.baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 904 Main St. M Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank T (tank m m i Tight or Holding a (ta 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition.of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 904 Main St. M Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Chambers were dry at time of inspection.Stain line observed 20" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is Cotuit Ma. 02635 7/8/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to - at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately �' fl A V t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 904 Main St. Property Address Deborah Schilling Owner Owner's Name information is required for Cotuit Ma. 02635 7/8/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file a t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f' ; ` TOWN OF F BARNSTABLE COCA 1ON SEWAGE # V-??LAGE R r tiC i-T" -y ASSESSOR' S MAP & LOT JNSTALLER'S NAME&PHONE N0- 2 et --y ►"'i f ��" -7 7 Y SEPTIC TANK CAPACITY /:S-etD ZA-(— r LEACHING FACILITY: (type)-7rcZ (Z_I -- Gtt-46 3 size) L-Y— -��X NO. OF BEDROOMS t BU L:II.DE OR OWNER h- ;t(� o0� �t.cS(4yia,— PERMITDATE: ���N(01 COMPLIANCE DATE: 2 2 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 +� Li 13 z7 TOWN OF BARNSTABLE LOCATION /�7 �� ST SEWAGE # VILLAGE' ('-D7U 1 T. ASSESSOR'S MAP &LOT !.- INSTALLER'S NAME&PHONE NO. +� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) r "• (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 leaching facility) Feet Furnished by � - ,--• 7 O� 3 r, N � ' � � 11111 © f t i �, 15 H��I W1 ,�` .s 4 A �-' t No. ytic/`I Z Fee ��r� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓/� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppfica[tion for rkoponl *pgtem Comaruction Verna Application for a Permit to Construct( )Repair( )Upgrade(X)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 9,04 �q t n Skfe�,� C-a+jA r+ Owner' Name,Address and Tel.No. D e A M4 t �A C h of lti 0. RV ?, �� X 0, �Assessor's Map/Parcel 035 /0 9 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. EJ 66Ce, F654,�Q tv'(k 3 OC_ J0 1 e (10 RpiA NG (PA bQn.8W MA 3M IG 08 _883-b(.00 Type of uilding: Dwelling No.of Bedrooms 3 — Lot Size OVA(0 sq. ft. Garbage Grinder( ) Other Type of Building OW-e I i lnct No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 353 gallons per day. Calculated daily flow gallons. Plan Date AaeI 1 13,100 1 Number of sheets I Revision Date Title P` a�d ��i le 5ys1�rn LcuA Pow. Size of Septic Tank i5o Type of S.A.S. Z—%00 90,110n .PN W-e l(S Description of Soil A rox i mQ 6 tiq 3 (t o- A Q io Y—Ci!' d 11A Y" eou Iaor'Zon Natur of Repairs or Alterations(Answer when applicablapplicable)lAn fXlSk I M room 8 Ni-2 i 11 ng 1-8 iC1,6 Lc To 4'-trrof-td onc) t±w 6Ac46 A nc� 67n� t�r 1,e_ 6 !i:&e. �,1 L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Board of ealth. Signed Date IJJ27,101 Application Approved by Date / !7 Application Disapproved for the following reason Permit No. 20 �" �� —— Date Issued * "g'• ^' .,;;;7.. Fee \ � a t/THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes q 6 CPUBUC`HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mig'ogar *pgtem Construction Permit fi Application for a Permii to Construct( )Repair( )Upgrade(X)Abandon( ) O Complete System O Individual Components y Location Address or Lot No. q Q4 fth i n 5}f2G'1' C o+tA Owner' Name, 1 ddress and Tel.No. p fl MC%G A(- C�'f n_ {�0- 041- g�!j/ 10 U26Assessor's Map/Parcel 035/0Q-11 4 yR Yvttk , mac_ ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. EA IC)a � go(A SondwlC MA Jx4� 50$ -�33-bt-3q Type ofBuilding: n Dwelling No.of Bedrooms 3 : Lot SizeY °I�(0 1 sq:ft. Garbage Grinder( ) F Other Type of Building OW No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�J 3 gallons per day. Calculated daily flow 35 3 gallons. Plan Date 4 Number of sheets I Revision Date Title fee le_ 516(.orn l i fad. Size of Septic Tank 154o (rallJrz.``'a Type of S.A.S. 2"5ao 9m IIJn UN W-f 1 IS Description of Soil A rox m l e ( 3 �' A -i+ Q 11`1 2��'e. J r-C(� (r e ca 1.In fl'f Natur of Repairs or AlterationsCswer when applicable) X f i r raa rn c�W-@ 1 Q!� 1 a 1r . l c St, n L,M 15 Fa-pe. r-tm,,-(-tJ on, c44 la u d ry I- % n, nx x v rnr,� MITI S sea�1c. 5ta5IeYYI 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 Certifi- cate'of Compliance has been issued b this Board of Health. _ Signed ` _- Date 14).27101 Application Approved by ! Date 7� Application Disapproved for the following reasons i / Permit No. Date Issued .S- /y O I ————————————---,,,THE COMMONWEALTH OF MASSACHUSETTS BARNS TABLE, MASSACHUSETTS - 1 Certificate of (Compliance loe THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(W-)Repaired ( ) Upgraded( ) Abandoned( )by at 90 el 0+1&4;1 r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ?-VV dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst�will nction as de signet Date ,?--cu1 Inspector, � . No. 2 FZ 0 — Fee 0,THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Migpogal *_jigtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at � Q.t%�-t and as described in the above Application for Disposal System Construction Permit. The`applicant recognizes;his/ger duty to comply with Title 5 and the following local provisions or special conditions. 4, Provided: Construction must be completed within three years of the date of this perrwt. Date: I a I; ? /2 v„ 1 Approved by— t s Cotuit Fire Department pT U Fire, Rescue & Emergency Services l�' '• cam 64 High St. - P.O. Box 1632 1926 Cotuit, MA 02635 y REc�G" Paul A. Frazier Phone (508) 428-2210 Chief of Department FAX (508) 428-0202 TO: Tom McKean, Director of Public Health I own Of 0C11 I RACLURV, OUdl U ui r 1tVd Ll l P.O. Box 534 Hyannis, MA. 02601 FROM: Chief Frazier, Cotuit Fire Department SUBJECT: Tank Removals, et al DATE: December 6, 2000 The following tanks have been removed/abandoned since my letter dated June 5, 2000. If,you should have any questions or require additional information, please feel free to call. Thank you. NAME ADDRESS DATE NOTES McEnroe 70 Vineyard Rd. 07/17/00 500 gal. tank removed, Cotuit, MA 02635 No contamination or odor present . Connolly 23 Point Isabella 08/05/00 2000 gal. tank removed, 75, Od Cotuit, MA 02635 no contamination or odor present. Oyster Real Estate 904 Main St. 10/23/00 275 gal. tank removed, Oq Cotuit, MA 02635 no contamination or odor d � present. r COMMONWEALTH OF MASSACHUSETTS _ — EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292=5500, TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A I, . CERTIFICATION Property Address: q0j Name of Owner.{ rz ClZr P META ' P�IFErf E­4. Cam' 1 r M Addres3 of Owner: SAME ✓' �. Date of Irupaction: 5 Ir3 1"tc( Nome of Inspector: (Please Print) -rERFtY i�Ftc-rFr e_ I am a DEP/approved system kvspec.-tor pursuant to Section 15.340 of Title 5 (310 CMR 15.D00) Comp any Nurs l_te: rZ Ec.l' S fl FN v r Ro-1 L l C ° ' M w Mailing Addross: P.C. J�:rx 1`i��-��'l^r.,.;r'rS-4-KI C.1_bc1 TeSephone Numbw: C 5 ) 790- &(0 z CERTIFICAMN STATEMENT ro 199.9 t I certify that I have personally inspected the sewage disposal system at this address and that the informa 'o eport true, accur'a e and complete as of the time of inspection. The inspection was performed based on my training and expen the p� motion and"-�li maintenance of on-site sewage disposal systems. The system: A V Passes 1 Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails " kLspector-s Signalime: ° Ct t1-- Date: �i/(4: Ct The System Inspector shall s`7btcopy of this inspection reportr to the Approving'Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority: 1 NOTES AND COMMENTS a @i� 1,1E' 1 G� irri�c f)�i�/.• • � 4' a - t - � � .. _ revised 9/2/98 Page lerll SUBSURFACE SEWAGE..(DISPOSAL SYSTEM INSPECTION FOIIM Y PART A CERTIFICATION (continued). °roportyAddress: �jG4 M��; SM-t'C:T, ��'h-�;'i P Owner: t1ErL4�Ertc q P}r�Elq P1�e� rr�l Date of Inspection: ! (13 I<.ty INSPECTION SUMMARY: Check A; B, C, or D: A. SYSTEM PASSES: V I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below COMMENTS: S �iSCE1� �ywJc� '`. I�� iiJ c. �c1 �,v' i✓ n. Co.��' ' B. SYSTEM CONDMONALLY PASSES: w'►T One or more system components as described in the "Conditional Pass sect:o%,need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health roll+pass. Indicate yes,no, or not determined (Y, N, or NO). Describe basis of determination in all Instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the.system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system w711 pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken,pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping,more than four times a year due to broken or obstructed pipes) The system will pass inspection if(with approval of the Board of Health): broken pipes) are replaced'*' obstruction is removed a' F revised 9/2/9.8 Page 2or,1, �' k SUBSURFXCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addcesa: '9G4 M�4iJ 5tYLCF r, (o}u`iT Ownef: 2bc-a:r k Ph�E1h at, Data of Impaction: Y C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N ' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. Y 1 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WTTH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is e llhin 50 feot,)I It bordering vegetated wetland or a salt marsh. A r' t 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. 1 — The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from:that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than,5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/.2/98 Page 3 of I I 1 SUBSUItfACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATIONµ(continued) Property Address: 9 oq VAO ,13 Owner: HL<rzbrr`c l��t etrj: P� Ney.' Date of ku paction: I c,1 131`t'1 i ��I ' D. SYSTEM FAILS: I You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 1 5.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to•an overloaded or clogged-SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters duo to an overloaded or clogged SAS or cesspool. "{ _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 time^ in the-last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool'or privy is within 100 feet of a surface water supply or tributary to"a surface water supply. Any portion of a cesspool or privy is within a Zone I,of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen, E. LARGE SYSTEM FAILS: I You must indicate either "Yes" or "No" to each of the following: ' The following criteria apply to large systems in addition to the criteria above:' The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 Jaet of is tllbui•Sry to a.surface drinking wator supply the system Is locoted in a nhluIldri sensitive are;,(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a'public water supply well) ;The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the lo cal regional office of the Department for further information: a r ,' revised 9/2/98 Page 4or1l "" SUBSURFACE.SFWAGri DISPOSAL. SYSTFM INSIIFCTION FORM - ' PART B CHECKLIST PropeftyAddress: 5G6, M4-'Ir4 S+X4ZCTI C�}gait ' Owner: FiFrz�e 2T rG P, c IFt. P��L„1. Date of Irupection: tCheck if the following have been done: You must indicate either,"Yes" or "No. as to each of the following: <: Yes No Pumping informotiarr. v.ns proulded by the owner, occupant, or Board of"Health. None of the system compcl!oniG have been purnl:rpd for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this ' inspection. _ As built plans have been obtained and,examined. Note if they are not available with.N/A.` : ✓/ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow, ; The site was inspected for signs of breakout. ' _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened,'and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sliidge, depth of scum. I n The size and location of the Soil Absorption System on the site has been determined based on: (] _ Existing information. Forexamplo, Plan at B.O.H.. 1 _ Determined in the field (if any of tha failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)1 The facility owner (and occupants, if different from owner) were provided with,in formation on the proper maintenance of SubSurface Disposal Systems. , revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYST M INSPECTION FORM ' PART C SYSTEM INFORMATION I'ropertyAddress: Owner: 11ErL��vLT pnh�Elq i.jrz Date of Inspocbon: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design):_ Number of bedrooms (actual): Total DESIGN flow i Number of current residents:_ Garbage grinder(yes or no):_ - t Laundry(separate system) (yes or no): ; If yes,;separate inspection required ° Laundry system inspected (yes or no) Seasonal use(yes or no):_ Water meter readings, if available (last two year's usage(gpd) Sump Pump(yes or no): Q I; Last data of occupancy: COMMERCIALANDUSTRIAL: _ Type of establishment: p �( Design flow: .3, 11.C2 qpd ((rBased on 15.203) ^ Basis of design flow IJU6 SN• Yy. �.f'la c= 5�� .r !' L'o G iA �ti N 7+� u' ' 2�` .I zed) ; U a1 A �i Grease trap present: (yes or no)�D9 �' Industrial Waste Holding Tank.present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) iJ 0 Water meter readings, if available: 199$ 4,11 t1 Last date of occupancy: Cu2ftt]J'l1� 0C«,- i t 1.-� f OTHER: (Describe) w' Last date of occupancy: ' GENERAL INFORMATION ,, J PUMPING RECORDS and source cf.information: (\rcN+: Ani Q, A-bo �w.. P]0 14- G>Z System pumped as part of inspection: (yes or no) S ' If yes, volume pumped: I0,0 " gallons } Reason for pumping: CtSS L., 1 rr �: c jr k r�L 6.Ir itm Q E A j. SYSTEM OF SYSTE P J P F Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool - Privy Shared system (yes or no) (if vet Jttach previoul. inspection records,if any) I/A Technology otc, Attach copy of j1p to dntb 6perotion and maintenance contract Tight Tank __Copy of DEP Apia(.)V,l I Other APPROXIMATE AGE of all components, date installed(if-known) and source of information: Z9 Sewage odors detected when arriving at the site: (yes or no) w) revised 91/2/98 Page 6orII w``"' SUBSUI.FgCE SEWAGE DISPOSAL SYSIEM INSPECTION ITOIIM PART C SYSTEM INFORMATION (continued) Property Address: �jc¢ MA:-4 Si-rt-rtT,.,Ca��T Owner: Pnt�E�� P�tEC�+E�j Date of Inspection: BUILDING SEINER: (Locate on site plan) I Depth below grade: Z Material of construction: cast iron 40 PVC -"other (explain) Distance from private wet r suppl ell or suction line "(A, ' Diameter 4„ Comments: (condition of joints, venting, evidence of leakage, etc.) LANl1�)r 'Cu f. FiiC�Pvi ,�-i:7C Lo:. {"I..cl iiJ C.2!r •( SOtSt la�C�P"� ucn (�.tnG SEPTIC TANK - (locate on site plan) Depth below grade:_ Material of construction:_concrete metal_Fiberglass _Polyethylene_other(oxplain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance (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 dimensions were determined: ` Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: rJl n ' (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 tea of baffle: f 1 Date of last pumping: Comments: (recommendation for,pumping, condition of inlet outlet tees orbaffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ��t'.II I ' revised 9/2/98 Page 7ofII I SUBSURFACE St_WAGC' OJSI'O5AL_;YST[M IN!',VEC110N f0111A e. d PART C r SYSTEM INFORMATION (c(xrU(wed) Property Address: 904 lAp;- '&+V -T'r, Owner: N62btlu-'C A, P M,c 111 P hE-CI-Z�.-j ' Date of Inspection: fi 13 l`19 SOIL ABSORPTION SYSTEM(SAS): N' 11I,I (locate on site plan, if possible; excavation not'f'e'�( rbd, location may be approximated by non-intrusive methods) If not located, explain: Type `z leaching pits, number:_ 1 leeching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ ' Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,Level of ponding, damp soil, condition of vegetation, etc.) - ! CESSPOOLS: ' (locate on site plan) t Number and configuration: Depth-top of liquid to inlet invert: I,� _ ' Depth of solids layer: Depth of scum layer: fJp01' + Dimensions of cesspool: (01yC Materials of construction: no jj c%FL€'thE b(pC-V- ' Indication of groundwater: f.1Cn1E inflow (cesspool must be pumped as part of inspection) ' Comments: '�— "•. (note condition of soil, signs of hydraulic failure, IeVal of'ponding, condition of vegetation, etc.) 6u T't-+ .-T LLSS n-GI' ) iS c(-ero-K i l,� Not '�ceT•,cNt ��I +. oT��'t'+•w;SF -G���',o C� i„h} It IN i-• -4 - :uN_ � \ +r�1 AFSom'.,c -1-I�E :'�'fw r-. .h{ .vs 'ten'f. Z' fib:.ly F I�:a Yiui-L+. VC--L}-a {.{•ar! G.J -n" S-(t tt A7P"}Ctr l_ rw Wit. ItU {J4j y1Q—,j-V R.$5 �v�+d }o 6c �uti.:,.� 1N Iv1l� w��DG U1• I PRIVY- N } ffr (locate on site plan) Materials of construction: Dimensions: Depth of solids: ' T Comments: (note condition of soil, signs of hydraulic failure,level cf ponding,'condition of vegetation, etc.) y revised 9%2/98 Page 9of11 SURSURFACF SEWAC F: DISPOSAL SYS 1 FM N;14-C ION FORM, ' PART C SY',TEM WFORMATION (c(nlLrxied) t , ropertyAddrrss: yea iA4'% t str2�cT y �o i'; T Owner: trrbct I� tFt� nkEFr��f Data of k1spection: f3 I t1 �r1`j TIGHT OR HOLDING TANK: N 1r (Tank must be'pumped prior to, or at time of, inspection) ' (locate on site plan) a 4 Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day " Alarm present Alarm level: Alarm in working order: Yes_ 'No Data of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ' DISTRIBUTION BOX: lj/4 (locate on site plan) Depth of liquid level above outlet invert: ' ,omments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: r✓I�. ' (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) ' Comments: ' (note condition of pump chamber, condition of pumps and appurtenances, etc.) ' ;revised 9/2/98 Page 8nfl1 , ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corttinued) I'roperty Address: '{ 4 P-A q i A S tLcti•T, Owner: Date of Inspection: E; I�S I`i`r SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks . locate all wells within 100' (Locate where public water supply comes into house) F P� S EZ �E n t t-�e lne,� 5 k.�1-z=l•. �15 • � ..a 9t,. ' � » , ♦ , . ` '. `JCL .» '.. E .. ' t'ev1.d 9 2 98 . r rs• 10 orri Rk SUBSU.RI ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` ' PART C SYSTEM INFORMATIO?J (corrorwed) Property Address: 9r,4 �AO}'IN SiaEz 't r Co �t'� t Owner: i}Ei2��rn t �hrn(tA I�hEEvt� j Date of Inspection: NRCS Report name ' Soil Type_ C-A2�l�R Typical depth to groundwater USGS Date wobsite visited No-N'..�`i;`,+c� ��5�<1 111'C;.�, '4 1qS `}. {�r..q ti-,1 q T Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope F)4T- Surface water trJNE Check Cellars . Shallow wells .-otj i Estimated Depth to Groundwater 'L2 Feet �i-. TI1kl-' > n �E " Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump,etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers ' ✓Used USGS Data Describe how you established the High Groundwater Elevation (Must be completed) 1u,..,,J 4z-'-Js+y,�It.' C�1S .�.;� N <Lt: its. t�rwu�J'n'+Z'K �`v Y:e 't c;L V a r .t•.'� L. `f-V, --' w t �1 S �� T�n 'A C4,a �e 4 lie TJA,� i�Si�y:� l s *PPr�r', 1� ibeIl�te ( TM 'C-N-r".�,,.1 r SF A'S a:u,4 , �,n.�.fin .)�i.-•_N<l w,}�va, t 5 �P f �: :-r r�i'< <� t`� ' Tvtr CaiS�>u ' re i s e d 9/2/98 Page tI or II