HomeMy WebLinkAbout0941 MAIN STREET (COTUIT) - Health 941 Main Street (Cotuit)
cotuit P
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TOWN OFBARNSTABLE
- r3CATIONCi.<n 43 SEWAGE # 3/!
LAGSE ASSESSOR'S MAP & LOT3 1, 1 ao
INSTALLER'S NAME&PHONE NO.�
SEPTIC TANK CAPACITY /5-00 6 10-14gel,
LEACHING FACILITY: (type) /21 1 To'e_b+a-e-S (size) f o? d .e 4-
NO. OF BEDROOMS 5' D
BUILDER OR OWNER E�CQ-ti �1 SCUCIVe/1
PERMITDATE: COMPLIANCE DATE: 7//" G
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 fTrrPfleaching f cility) Feet
Furnished by
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TOWN OF BARNSTABLE
LOCATION 9,w SEWAGE #
`aILLAvE 1, ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER -
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist-
within 300 feet of leaching facility) Feet .
Furnished by
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eft �
No. / �, n
Fee
i THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer: V
.PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MAS;SACHUSETTS Yes
`ZippYicotion for &.5pont i§p5tem Cori.5tructiou Permit
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 476 l Ale?`%tl .Jro Q Owner's Name,Address,and Tel.
lNo.,S�B�Y�lik�
Assessor's Map/Parcel ` �ael�®�_ 1W �
Installer's Name,Address,and Tel.No.Agk0Vk1,4iU G esigner's Name,Address and Tel.No. d ( wT
.0" rO 49
Type of Building: A
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building 1 SC�r No.of Persons Showers( ) Cafeteria( )
Other Fixtures ut ,e I +
Design Flow(min.requi ed) gpd Design flow provided /16 C,+ AAD I-e 4 gpd
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 this Board of Health.
Si Date 8 /7 0 �e
Application Approved b Date _
Application:Disapproved by: :Date
for the following reasons
Permit No. OC'D& — 3 I! Date Issued 7 M
. No.I r9�z � / Fee
1 �
jo
THE COMMONWEALTH OF MASSACHCrSE'FTS Entered in computer: 1r M
11
PUBLIC HEALT"IVISION - TOWN OF BARNS BLE,1 MAS ACHUSETTS Yes
F ».-
"Rpplicalion for �Di5po5al! tem Cow5truction Permit
Application for a Permit to Construct Repair`( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
r Location Address or Lot No. �* G Owner's Name,Address,and Tel.No.
Assessor
4 -
's Map/Parcel
Installer's Name,Address,and Tel.No. Awzaem/6i?Z1k#Awesigner's Name,Address'and Tel.No. � (T
Type of Building:
Dwelling . No.of Bedrooms.`r L�Otµ Sizei'1)T7 sq. ft. Garbage.Grinder ( )
Other Type of Building 1>o No.of Persons Showers;( ) Cafeteria( )
Other Fixtures
Design Flow(mini qui ed) gpd Design flow provided X(5 C P8•AD l(O gpd
Plan Date 57001 0 - Number of sheets Revision Date
Title
Size of Septic Tank�'. / -Z_52 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) `
Date last inspected:
� 4
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 arid not to place the system in operation until a Certificate of
Compliance has been issued b.y this Board of Health. F
Si 8 Date
8 i7 o �.
Application Approved b}� � Date
�g
Application Disapproved by: Date
for the following reasons
Permit No. C a 3) n Date Issued 7 1 ?
———————————————————————————————————----------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Con tructed ( Repaired ( ) Upgraded ( )
Abandoned( )by ,C,r./?- )
at `i(/�S't' (� has been constructed in accordance f
with the provisions of Title 5 and the for Disposal System Construction Permit No. ��0 3 /� dated �1,1?A .
Installer JASo J SC�U�*- Designer �POU ""'� r��
#bedrooms�7 Appro" ved daig /�� ' gpd
The issuance of this ermit hall not be construed a a guarantee that the system t on as designed.
Date .er P Inspectoor�
——— ————No. �� (DI •—' �1 1 C� Fee
l THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
=i5pool i§pgtemY Con6truction Permit
Permission is hereby granted to Construct (lam Repair ) Upgrade ( ) Abandon ( )
System located at '7 � �" 1 "
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construct711
n mu t be completed within three years of the date 4 f t`hi pex�ri+.
Date '�7c (P Approved bye
MAR-21-2007 WED 12:59 PM BSC GROUP YARMOUTH FAX NO. 6087788968 P. 01
MAR-a-2007 01:23 MR9* M:5W77BG%6 P.2
i
TT4n ®f Barnstable
ulatory Seryiees
a r®aye & T'h4aias F.Geiler,Director
F Pu lie Health Division
The bias McKean,Director
200 Nis n'Street,Uye axis,MA 02601
Office: 508-862,4644 � Fu: SOR_ M6304
Installer&..D i ner Certification]dorm.
Date: ID6 Sewage Permit# .206 f-3 Assessor's MaplParsel ! 1/ too
Designer: . 9S C. c Installer: IQ.
Address: In4l, �t_ Address:
Ind 402V A JZ Lf
On `7 was issued a perknit to install a
ate insta lT#
Septic system at -- , basest on a design drawn by
addres
- d ited
(designer)
4— I certify that the septic system ra kToncekl above was installed substantially according to
the design, which may include m nor approved changes such as lateral relocation of the
distribution box and/or septic tai k. Stripout (if required) was inspected and the soils
were found satisfactory.
T certify that the septic system rs ferenaed above was installed with major changes (i.e.
greater than 10` lateral relocation of the SAS or any vertical relocation of auy comport mt
of the septic system)but in accordince with State&.Local Regulations. Plan revision or
certified as-built by designer to follow, Stripout(if require inspected and the soils
were found satisfaetsuy, mk op
MARK Q,
Des
CIVIL
S attire ca No.45987
-
esigrier'sSignature) ' esiguer a Stamp ere)
SE RETIMN '1C ARN9TAM PUBLIC IMALTH IDYV' =N. CE_RT_?`C TE
OF COM[PLIAN WILL NOT SSUED Bt] THSS F 1) AN.
CAIt(?ARE I�CEIVE D B BABNSTA PU'�GIC HIEAILTH'.DIVISION.
,
THANK X
QASepti6DoASw CoraScation Poem Rev 034)9-06.
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of*�
Town of Barnstable
Board of Health
° A 200 Main Street,Hyannis MA 02601
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Paul Canniff,D.M.D.
A
May 30, 2006
Mr. Mark Dibb, P.E.
BSC Group
657 Main Street, Unit 6A
West Yarmouth, MA
Dear Mr. Dibb,
You are granted permission, on behalf of your clients, Scott and Alice Scudder,
to construct an onsite sewage disposal system designed for six bedrooms at 941
Main Street, Cotuit, Massachusetts.
Sincer y yours,
Wa e M' er, M.D.
Chairma
BOARD OF HEALTH
TOWN OF BARNSTABLE
Q:DibbScudder6Bedrooms2006
s
i
�p tME lti DATE:
BARNSfABLE = Town of Barnstable REC.BY
9 MASS.
1639. A.,. Board of Health
ArFO MA'I
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,M.S.P.H.
Wayne A.Miller,M.D.
Application to Construct or Expand to Six (6) or More Bedrooms::
LOCATION
Property Address: 941 Main Street Cotuit MA __5
Assessor's Map and Parcel Number: 3 5/11 & 100 Size of Lot: 78 , 743 s. f.
Wetlands Within 300 Ft. Yes Business Name: Residence
No X Subdivision Name: N/A
APPLICANT'S NAME: BSC Group, Inc Phone 508-778-8919
Did the owner of the property authorize you to represent him or her? Yes X No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: Scott & Alice Scudder Name: Mark Dibb — BSC Group, Inc.
Address: 14 Rosewood Drive Address: 657 Main Street Unit 6
Pittsford, NY 14534 West Yarmouth, MA 02673
Phone: 585-381-8483 Phone: 508-778-8919
�r
Checklist
Please submit copies in 4 separate completed sets.
Four(4)copies of this application form
Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted e.g. house plans)
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Q:\Application Forms\SixBedroomForm.doc
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°`�r°'+w Barnstable :' ,)
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` �, Department of Regulatory Services
Public Health Division
ti9 ��' Date �o_
f' r r �En a 200 Mam Saret,Hyannis MA 02601 .
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J: Date Scheduled f f Y
' _ �. . ' Time /1
{ y, , t '{ Fee Pd.
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. Soil Suitability „ a,x
�5 Assess W
P?rt neti By: 5 o meat for tSewage'Di sal , `
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7 �1� t Witnessed B ,.;
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location Address �.U`- T- N&,GENERAL INFORMA .
9.41 Main Street: TION .:
Owper's Name
of Cotult MA Scott & Alice Scud er
Address 14 . Rosewood UR%ve . .
Assessor's Map/Parcel -0`3 5/O 11 '
Pittsford, NY 14534
NEW CONSTRUCTION g Engineer's Name gSC Qr6,p, I11C..
REPAQt , .
E�g Telephone# 5 0 8 '.17 8 . 919
Land Use .
�h✓7-�' L Slopes(96) ''S 20je, F
. Distances from: "Open'Water Bad /0/i Surface Stones I
r . ---�_R .Possible.Wet Area
v
--_ R . Drinking Water Well 4 R
l Drainage Way /1i4 . .Properly Ltne /U_____o _ft Other.
s tt
SKETCH ,
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(Street name j r s u •k ,dimensions of lot,exact locations of test holes&pe
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' rc tests,locate wetlands in proxtimty to holes)'
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61��...,.:_!,,,I,..�I-..;:�I�.11,+.:�:Il",.,*;�I..1'.q�.�I—'.l,.,,,J,.-�..1,II�I,�..:-,.,,1,...�,�I 1..,0:.��".-.i,.,,�.:I_�,I..,.,,:�.,�—�.1._�.%':b:....,,--�.—..�_.-',�..;:...:I—-:t..,—
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Parent material eolo is G&-Al PrJG, ,* cJ s r ' s(g g ) 4 ,.Depth to Bedrock. VW '
... -4 i.'
Depth to Groundwater ,.
- Standin Water'
B m Hole: Weeping from Pit Face N '
i?stimated Seasonal High Groundwater / �/� , m 3 i
. •.
F .t ...
DRTERMINA"ION FOR SEA ANAL HIGH WATER TABLE ' _'.:
„z INt had urea: OVo w 4rel' '
yt
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.�.�.�,�:'��_.I—...�-...-.,�.,,%-.*,.-,1I...-_.Iq.....-".".,.I...,,.....:.,-.—,.._::.,�...,'..�.-..,�..,.'�..,�..T:�.I�11.,.,.,-.,.1�;._-.:.:-.�...I.A'..-I.I._.�..,:�.,_,,...,'1...Z,.0_—*�,....,..._-A!�--,--+.�,.'-.,...1,-�.6.I I1�.,,.�.
Depth Observed standing in obs hole: ' 7,
Depth to weeping from side of obs hole - " 'io Depth to soil.Mottles.` In
-trader Welt N�, Reading Date: Index Weli level �n araundwater AdJueAmdJntO Co '
.-,...�J,...�,.�_�+..:-...,-,..I-..�,�I:.;.'...
- ,-.c.., � _ AdJ.factor..,.,.,, roundwaterlxvel,,,,., - i,_'
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. PERCOLATION TEST: bate T
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Observation a Q ,
Hole# ' ,#
7�i � i�: Time at 9" _,,,,,, /�,_,
Depth of Per. —=rw
' : a Tima'at 6" ;,
Start Pre-soak Tune® 0-'Aa 0-`0 e„ z '
End Pre-soak `Y F� �,
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Rate MmJlnt h _ 4. _Z k #
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Site Suitability Assessment :Site Passed _ s . ?,
• Site FaileA Additional Testing Needed(YM)_ :,. "
Original Public Health Division .. , r,
Observa'tgOn HOIe Data To Be Completed on Back --- y
h v,•,. c r' , 4'. F
***If percolation testis to be conducted within 100'of wetland,you must first notify the c t �
tt
Barnstable Conservation Division at least one(1) week prior to beglnlning
Q\SEPTIMERCFORM DOC :t' c e
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DEEP-OBSERVATION HOLE LOG Hole# i
Depth from Soil Horizon Soil Texture :Solt Color Soil Other
Surface(in.) (USDA g (Stnteture.Stones;8aulders`
(Munsell) Mottlin
0_a On i e v 1
DEEP OBSERVATION HO E LOG Hole# 2:
Depth from Soil Horizon Soil Texture �V Soil Color, Soil Other
Surface(in.)
USDA) (Munsell) : Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
A/&l/�
'10 15#41vIO Ao yo7
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture. . . Soil Color Soil Other
Surface(in.) (USDA) (Muosell) Mottling . (Structure.Stones,Boulders.
Co sistency.%Givivell
ip
F
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture :: Soil Color Soil Other
Surface(in.).: (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
QMVjlj
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Flood Insurance Rate Mao:
Above 500 year flood boundary No Yes x
i Wthin 500 ear bounds
Y rY ... No_ .X s
e
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material!
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? YES
If not,what is the depth of naturally occurring pervidus material?
Certification
I certify that on �- (date)I have passed the soil eyaluator examination approved by the
Department of Env ronmental Protection and that the above analysis was performed by me consistent with ,
e9 .,..B P , ed in.3 10 CMR:>I5.017,
the r ulred tralntn ,ex erhse and ex erlence descrtb
�Slgnature } Da Dt
te< r
Q:wer"G1PBRCPORM Doc 1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d MAP
PARCEI. L.. �
n C 0W
LOT -
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 941 MAIN ST COTUIT 02635 �5_ �` '
Owner's Name: MRS.SCOTT SCUDDER Ej LOmrY
.
Owner's Address: 14 ROSEWOOD DR PITTSFORD NY 14534
Date of Inspection: 2/20/04
Name of Inspector: (please print) JOHN GRACI,INC. RECEIVED
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536
MAR 0 5 2004
Telephone Number: 508-564-6813 FAX 508-564-7270 n
TOWN OF BARNSTABLE
HEALTH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally ses
_ Needs Furth aluation by the Local Approving Authority
Fails
Inspector's Signature: d Date: 2/20/04
The system inspector shall submit a py of this inspection report to the Approving Authority(B,oard of Health or DEP)within
30 days of completing this inspectio . If the system is a shared system'or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title. 5 Tncnar.tinn Fnrm 6/,1 5/?nnn 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS. SCOTT SCUDDER
Date of Inspection: 2/20/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed.
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of,
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times-a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
_Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS.SCOTT SCUDDER
Date of Inspection: 2/20/04
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and 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 n/a
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
f
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS. SCOTT SCUDDER
Date of Inspection: 2/20/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution•box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NOT IN THE LAST YR PER OWNER.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well..
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water.quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X 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.
A
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS. SCOTT SCUDDER -
Date of Inspection: 2/20/04
Check if the following have been done. You must indicate "yes"or"no as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
_ X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out
X _ Were all system components, excluding the SAS, located on site'?
X _ 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
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 941 MAIN ST COTUIT 02635
Owner: MR.S. SCOTT SCUDDER
Date of Inspection: 2/20/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 years usage(gpd)):to"
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment:n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: NOT IN THE LAST YR PER OWNER
Was system pumped as part of the inspection(yes or no): NO.
If yes, volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
_Septic tank, distribution box,soil absorption system
X Single cesspool
X Overflow cesspool
_Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components.,date installed(if known)and source of.information:
1936 PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS. SCOTT SCUDDER
Date of Inspection: 2/20/04
BUILDING SEWER(locate on site plan)
Depth below grade: 16"
Materials of construction:_cast iron 40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Conunents(on condition of joints, venting, evidence of leakage, etc.):
TOWN WATER
SEPTIC TANK: (locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: n/a
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Continents(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a .
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS.SCOTT SCUDDER
Date of Inspection: 2/20/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
CoiTunents(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.):
NONE
e
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
" R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS. SCOTT SCUDDER
Date of Inspection: 2/20/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
6' X 6' BLOCK CESSPOOL overflow cesspool, number:
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE OVERFLOW IS STRURCTURALLY SOUND AND WAS EMPTY AT THE TIME OF THE INSPECTION.
TTHE STAINS LINES INDICATE THE PIT HAS NOT BEEN MORE THAN 1/2 FULL. BOTTOM IS AT 8.6'
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: 6' X 6"'
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY.CESSPOOL WAS EMPTY AT THE TIME OF INSPECTION. RECOMMEND PUMPING EVERY
TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
9
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS.SCOTT SCUDDER
Date of Inspection: 2/20/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
(q �l CIS
tA,A l�
AA
in
Page 11 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN ST COTUIT 02635
Owner: MRS. SCOTT SCUDDER
Date of Inspection: 2/20/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
design NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER WAS DETERMINED BY HAND AUGER-NO WATER AT 12'
tt
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
V /
ti VV
Q
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
=i. PART A
' CERTIFICATION
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner's Name: SCOTT SCUDDER
Owner's Address: P.O.BOX 333L COTUIT,MA.02635
Date of Inspection: 8/6/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX M8-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furt valuation by the Local Approving Authority ,
Fails
x
Inspector's Signature: Date: 8/6/01
The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be
sent to the system owner and copies sent to.,the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM.
RECOMMEND THAT COVER BE RAISED ON SECOND PIT. RECOMMEND SYSTEM BE PUMPED NOW. '
****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.
fit
I
..tar.
• 'Title 5 Gcnrr•tinii,l'nr•m (,/1 5/`?Mfl `�'� '' �
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
z CERTIFICATION (continued)
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER it
Date of Inspection: 8/6/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM.
RECOMMEND THAT COVER BE RAISED ON SECOND PIT.RECOMMEND SYSTEM BE PUMPED NOW.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair„as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20'ears`old* or the septic tank(whether metal or not)is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is'available.
ND explain: n/a
4
s
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND explain: n/a
n/a 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 Hof Health)
_broken pipe(s)are replaced
_obstruction is- removed
1,I F.
T
ND explain: n/a ,i} ,l
t,T
f`t
Page 3 of 11 {
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and 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.
,A
_ The system has a septic tank�and SAS and the SAS is less than 100 feet but 50 feet orinore from a private water
supply well". Method used to determine distance n/a
"This system passes if the well'water analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicate§t}iat the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal toior less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attachedto this form.
3. Other:
n/a
f
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
D. System Failure Criteria applicable'to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nla.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy,is"within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool,or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that-facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
(Yes/No)The system fails;I.have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails°T,he 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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone II of a public water's`upply 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(lie large`system ha's 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.
.fiir fp 1t 'f
t
I
Page 5 of 1 I
t.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No
X _ Pumping information was;provided'by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
_ X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site?
X _ 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?
4
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?
a ;
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ X Existing information.For exaiiiple,�a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria_related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
rt
M
is
,•y
S
Page 6 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 j` Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 0 a?
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system�(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a .
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203.):n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: ri/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
,t. GENERAL INFORMATION
Pumping Records '
Source of information: n/as_ ' {
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons -How was quantity pumped determined?n/a
Reason for pumping: n/a
.z
TYPE OF SYSTEM
X 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) 4 q
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components;-date'installed(if known)and source of information: `
1936
Were sewage odors detected when arriving at the site(yes or no): NO
lrY;
Page 7 of 11 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN STREET COTUIT,MA 02635 ;
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
BUILDING SEWER(locate on site plan)
Depth below grade: 16"
Materials of construction:_cast iron 40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal 'fiberglass jolyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate)
Dimensions: 6' X 6' BLOCK CESSPOOL"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
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.):
MAIN CESSPOOL AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND. RECOMMEND
PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. RECOMMEND SYSTEM BE
PUMPED NOW.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a `
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,'inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a T
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons 4`t:
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on'site plan)
Depth of liquid level above outlet invert: n/a
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into
or out of box,etc.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
p ki
t
Q
Page 9 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
6 X6 BLOCK PIT leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a t innovative/alternative system
F. ,Type/name of technology: n/a
v
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY.PIT IS EMPTY NOW AND HAS NEVER BEE
MORE THAN HALF FULL. RECOMMEND COVER BE RAISED ON PIT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no)--'NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
'L
PRIVY: (locate on site plan)
Materials of construction: n/a '
Dimensions: n/a
Depth of solids: n/a ,
Comments(note condition of soil,signs}of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
s Q
Page 10 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: 941 MAIN STREET COTUIT,MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
A
Page I 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 941 MAIN STREET COTUIT, MA 02635
Owner: SCOTT SCUDDER
Date of Inspection: 8/6/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
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e101 Qi 0514
DATE
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SECOND FLOOR PLAN
SCALE:1/4"=V-0"
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SEPTIC TANK DETAIL: 1 ,500 GALLON DISTRIBUTION BOX DETAIL: NOT TO SCALE LEACHING TRENCH DETAIL: NOT TO SCALE REVISIONS
SOIL TEST PIT DATA: 4/7/06 NO. DATE DESCRIPTION
NOT TO SCALE NO. OF OUTLETS : 5
TEST PIT 1_ TEST PIT -. � 5. INLET AND OUTLET TEES TO BE CAST IRON, FINISHED GRADE 36" MAX .COVER
NOTES: 1. SEPTIC TANK SHALL BE STEEL SCHED. 40 PVC OR CAST-IN-PLACE CONCRETE. FINISHED GRADE
GRD. EL 84.1 GRD. EL. 84.0 REINFORCED CONCRETE.EST. HIGH GW. 74.1 EST. HIGH GW. 74.0 2. SEPTIC TANK TO WITHSTAND H-10 LOADING TEES TO BE CENTERED UNDER MANHOLE COVER. REMOVABLE 2" WALLS NOTES: LOAM & SEED DISTURBED AREAS
UNLESS UNDER PAVEMENT, DRIVES OR COVER
A A TRAVELED WAYS, WHEREIN H-20 LOADING �;,a , . �q; ;„ ;,� ;, " 1. DIST. BOX TO WITHSTAND H-10 LOADING CAP ENDS
L. SAND
SHALL APPLY. 2 UNLESS UNDER PAVEMENT, DRIVES OR " . . 4 $BF � 4QVC== .00T . • . GENERAL NOTES:
OYSAND
3 D3 1OYR3 3 3. ALL PIPE CONNECTIONS AND CONCRETE " T 4 PVC • -• • 1. THIS PLAN IS FOR DESIGN AND
/ 10 2-24 DIA CONCRETE.MANHOLES TRAVELED WAYS WHEREIN H-20 LOADING •+ e •+ • oo+ e e+ e e e • o • e+ e e e e e •
CONSTRUCTION SHALL BE WATERTIGHT. aqf oo��agt q�ppa 4to(a4f°ek„9 o 'aoy�c o��g fq�agf q of �E CONSTRUCTION OF THE SEWAGE
12 W/ METAL HANDLES BROUGHT 15" SHALL APPLY. Q, ��b ��6 'O•"54 �b �'b �O��b �C�i `�c'4 '� W XPIM DISPOSAL FACILITY ONLY.
4. FILL ALL UNUSED KNOCKOUTS WITH TO 6 OF FlNISH GRADE •+ • •+ • e e+ e+ • e+ • • e e+ • e •+d •�� • • •
B B MORTAR. TEE TO BE UNDER 12" MIN 6" 5,5" OUTLETS
9. 8" 2• PROVIbE INLET TEE OR BAFFLE WHERE ° ° ° / 2. ALL CONSTRUCTION METHODS AND
L. SAND L. SAND 32" M.H. OPENING SLOPE OF PIPE EXCEEDS 0.08 FT./FT OR LEVEL BOTTOM MATERIALS SHALL CONFORM TO MASS.
D.E.P TITLE 5 AND LOCAL BOARD
1 OYRS $ � " '• •' e e e+ e+ IN PUMPED SYSTEM. 38, wi 3. ALL PIPES LOCATED UNDER PAVEMENT
10YR5/8 / � � � 3 �•°'°�+�"� . � �� �� I- 2" 3. FIRST TWO FEET OF PIPE OUT OF DIST. OF HEALTH REGULATIONS.
RAISE M•H W�L-.. 4" BOTTOM ON LEVEL " PROFILE OR TRAVELED WAY SHALL BE SCHEDULE
10'-6" 6 MIN. 3/4 TO BOX TO BE LAID LEVEL.
30" SEWER BRICK e. •�- -;- - •- STABLE BASE CRUSHED
- e - -:?e .,-:' • 40 OR EQUAL.
do MORTAR r CROSS-SECTION 4. ALL PIPE CONNECTIONS AND CONCRETE 36" MAX. - 12" MIN. COVER 4. THERE ARE NO KNOWN PRIVATE WELLS
EL = 81.6 EL = 81.33 10'-0" 12 STONE BASE
NORMAL WATER LEVEL CONSTRUCTION SHALL BE WATERTIGHT. LOCATED WITHIN 150 FT. OF THE
3" 5. FILL ALL UNUSED KNOCKOUTS WITH MORTAR. 21K MIN. FINISH GRADE 4" MIN. LOAM & SEED PROPOSED LEACHING FACILITY NOR
57" 60" PRECAST SEPTIC TANK 10" 14" ANY KNOWN WELLS PROPOSED WITHIN
d INLET lEE 5 5'-1" 30 1 2" 150 OF ANY KNOWN LEACHING FACILITY.
C _ _ _ / _ _ 5. WITHIN LIMIT OF EXCAVATION REMOVE
M. SAND V-2" 4'-6" w e 5'-8" 15' MIN _ _ _..
C 10YR7/4 _ _ 4-0 MIN. �+' 15 1/2" r ,, ° .� 2" MIN. OF 1/8" TO IMPERVIOUS MATERIAL.
lb ALL TOPSOIL, SUBSOIL AND OTHER
M. SAS - " (cns 0jxA Q
5-8 z �' LIQUID DEPTH 24 RESERVE 24' r 1/2" WASHED STONE
1 OYR7 4 :� PRECAST DIST. • • e •+ 6. REPLACE ALL EXCAVATED MATERIAL WITH
BOX �i �� CLEAN GRANULAR SAND, FREE FROM ORGANIC
't e � � • MATERIAL AND DELETERIOUS SUBSTANCES.
INDICATES �: -. 3/4 TO 1-1/2 DOUBLE
" " :- : •;,F-:__a .�-:: �_' -:,; 2 2 WASHED STONE (NO FINES) MIXTURES AND LAYERS OF DIFFERENT CLASSES
120 12p ESTIMATED e •+ 3" �- '"-�, TYP TYP NOT CONTAIN ANYOF SOIL SHALL MATERIALT BE LARGER THAN
EL = 74.1 EL = 74.0 SEASONAL HIGH Q a BOTTOM ON LEVEL STABLE BASE ° 6'
DATE: DATE: GROUND WATER PLAN VIEW " " � �, �,' //�i'.>LC1b'• � 7 1/2 1- _ I TWO INCHES. A SIEVE ANALYSIS, USING A #4
4/7/06 4/7/06 INDICATES s MIN. " S To CROSS-SECTION VIEW PLAN VIEW
1 1/2" STONE CROSS-SECTION SIEVE, SHALL BE PERFORMED ON A
REPRESENTATIVE SAMPLE OF FILL. UP TO 45 q6
TEST BY: TEST BY: -� OBSERVED BY WEIGHT OF THE FILL SAMPLE MAY BE
THE BSC GROUP, INC. THE BSC GROUP, INC. - GROUND WATER
RETAINED ON THE #4 SIEVE. SIEVE ANALYSES
' ALSO SHALL BE PERFORMED ON THE FRACTION
TOWN OF BARNSTABLE NEW REGULATIONS OF FILL SAMPLE PASSING THE #4 SIEVE SUCH
WITNESSED BY: WITNESSED BY: ANALYSES MUST DEMONSTRATE THAT THE
INDICATES ro .1H OF �' I DESIGN CRITERIA• MATERIAL MEETS EACH OF THE FOLLOWING
DON DESMARAIS DON DESMARAIS PERC. 73•g2 REQUIRE SOIL EVALUATOR TO INSPECT . ' +sr I
PERC. RATE: PERC. RATE: TEST 48» W 14 BOTTOM OF EXCAVATION PRIOR TO ANY ?� MARKD. 'cyN SPECIFICATIONS:
_2-MIN./INCH -MIN./INCH ' DESIGN FLOW: 1001G MUST PASS E4 SIEVE
9.gT DIBB �n „ C'IM A. (4.75 mm EFFECTIVE PARTICLE SIZE)
INSTALLATION" AND ALSO PRIOR TO FINAL 0 CIVIL E FELD 6 BEDROOMS AT 110 G.P.B./D 660 G.P.D. 10%-100% MUST PASS #50 SIEVE
SOIL EVALUATOR SOIL EVALUATOR INDICATES No.45937 �'
MARK DIBB, P.E. MARK DIBB UNSUITABLE '` .. BACKFILLING. f ' (0.30 mm EFFECTIVE PARTICLE SIZE)
07d-20T MUST PASS #100 SIEVE
MATERIAL Q/BTB �' 5 mm EFFECTIVE PARTICLE SIZE)
SOIL CLASS: SOIL CLASS: uo 0�6-576 MUST PASS200 SIEVE
REQUIRED SEPTIC TANK:
`' (0.075 mm EFFECTIVE PARTICLE SIZE)
660` X 200% = 1320 GAL. . EXISTING UTILITIES WHERE SHOWN
1500, AL. IN THE DRAWINGS ARE APPROXIMATE.
L.T.A.R. L.T.A.R.
S / p SEPTIC TANK PROVIDED: _ THE CONTRACTOR SHALL BE RESPON-
0.74 G.P.D./SQ.FT. 0.74 G.P.D./SQ.FT.
_ . �.
•- �� � ` SIBLE FOR PROPERLY LOCATING AND
COORDINATING THE PROPOSED CON-
w. A -
DATUM: .
[SIZE OF LEACHING FACILITY REQUIRED: STRUCTION ACTIVITY WITH DIG-SAFE
ry
i �7
AND THE APPLICABLE UTILITY
s� --' ./ COMPANY AND MAINTAINING THE
VERTICAL DATUM: ASSUMED t
�t / DESIGN PERC RATE: MIN INCH
_. w. ry,
<2
` .,..., _. g�4,54» - LONG TERM APPL. RATE 0,74 .P.D/S.F.
.-- EXISTING UTILITY SYSTEM IN SERVICE
Q11
GDIG-SAFE R
BENCH MARK SET: CATCH BASIN RIM 4N
.,... � .v.�.�, ,...� .a,::. �, 4 r ,x ; � � ....,,, w � �,°,. THE STATE SOF MASSACHUSEITS HALL BE NOTIFIED E
ELEVATION 97.8 w _" •o _ - "` f & °A µLL -WATER - 200'S�� } _ STATUTE CHAPTER 82, SECTION 409
METER
660 GPD 0 74 GPD/SF 892 S F AT TEL 1 888 344 7233. THE
a
rm
PIT �':�� ENGINEER DOES NOT GUARANTEE
PROFILE: o..
• "`° fi,-,, �,.•° THEIR ACCURACY OR THAT ALL
NOT TO SCALE ° ^'~ " 16" ELM UTILITIES AND SUBSURFACE STRUCTURES
-..._"„_,�, SIZE OF LEACHING FACILITY PROVIDED:
" "°�. ARE SHOWN. LOCATIONS AND
=' UTILITIES
EL=A ," W:e PROpO
FIRST PIPE LENGTH .7
T FOUNDATION w __. .►�.._._.. t SEp -
;.� 'M� ELEVATIONS OF UNDERGROUND U
w TI
OP D `"�-;�.,� �'02,, 4 x t w,,.,, TAKEN FROM RECORD PLANS THE
CONCRETE COVERS TO WITHIN TO BE SET LEVEL .. ;` " _ PROPOSFA r' �' W " 4 2' WIDE, 2' DEEP, 3 8' L 0 N G T R E N C H S CONTRACTOR SHALL VERIFY SIZE,
`� Eh y _,._.. RECONSTRUCTED y w 1 LOCU
EL=VARIES 6" OF FINISHED GRADE. FOR MIN. 2' "., - F v, LOCATION AND INVERTS OF UTILITIES
�FQ �-� ��' 4...^ ,�.� GARAG 'W/1 „ AS REQUIRED PRIOR
Elq
k. - ,4
L.=87.0-84.5 t 0. .. r. M _� _^.. _ h' E 9 PINS _. 4x(2'+2'+2')x38' = 912 S.F.
- �` ���`" TO THE START 0 CONSTRUCTION.
4 PVC PERF = p
_`V OF LEACHING AREA
..., ROP
-- - _ 4 BENCHMARK, OS BEf
w
,• 4 PV � � M -,• �yE SR <' `e, • f _ 8. THIS SYSTEM IS NOT DESIGNED FOR
SCH 40 4 P S 2--1/8--3/8- DOUBLE SHED STONE "' , ~N -- __. #- GARAGE �,� AY I p ��7 THE USE OF A GARBAGE GRINDER
, 0
.u ,
LOCUST
,,, ,, . SLAB 92 31 1,
• � Y 22 � NR�°o PROVIDED
..z:,.. ,.. �, � yG SEp ' - A GARBAGE GRINDER IS NOT
/4"-1 1/2" DOUBLE WASHED STONE ....,; T._.. .._.. .. \ ti� TRff `~` RECOMMENDED DUE TO RECOGNIZED
AC N
OUTLET I=G
=E I=H ...n. SED FACILITY.
..._ �NPROPO IMPACTS TO THE LEACHING
r I=C 5 DIST. BOX e Z . � n' t
_ T _ K
=F c 4, 0, LING TRENCHES ;'
2`2
tee: ,
SEPTIC TANK io o BOTTOM EL= J "W.__„w 2 S " ( / EXITING INVERTSARE TO BE CHECKED BY
"` -' THE CONTRACTOR PRIOR TO CONSTRUCTION.ONTR
0
E�
HIGH WATER EL=K n" THE ENGINEER IS TO BE NOTIFIED OF
�;4y
mow..
>u
41'
,,. _...,
r .�`.�
•... -: .:...,,., - CHANGES THAT MAY BE
A FIELD
,
\ REQUIRED.
LOCUS INFORMATION
�.
• ., 66171
r
pRO�
INVERT ELEVATIONS. n. i
non, �'" � �:,..,�
. ,.~ - CURRENT OWNER SCOTT M & A H. SCUDDER MC GROUP
,
« ,
a
if
TITLE REFERENCE: CERT. 173708 657 Main Street, (RT. 28) Unit 6
GARAGE SLAB 92.38 A P W. Yarmouth Massachusetts
- A 237 out
4 INVERT AT BUILDING 89 t B _ 02673
--,.`- "` PROPOSED D-BOX �•` � ,.; \ `.� �
PLAN REFERENCE L C. 19802
,y.
,may ,. , f
85.50 C � " wN 13 5087788919
5
4 INVERT AT SEPTIC TANK (IN) -°" 4 ``'� c BOOK 141, PAGE 5
A
4" INVERT AT SEPTIC TANK (OUT) 85.25 D
� ASSESSORS MAP.
,
„ 2. - PROJECT TITLE:
84.73 E ._� F,. m. .a ,°
SO 35
4 INVERT AT DIST. BOX (IN) � , � � �� Tao
,.., .�..�... „-. ,....�.,< �__...w PARCEL 11
«. 4
" .-. ,�� .�..�.,4 F'�R;OPOSED`1,500� � S �' AR SL,ggar
4 INVERT AT DIST. BOX (OUT) 84.56 F �h. � SEPTIC 92 '7 ZONING
4 _ SETBACKS. T DESIGN FOR
,
h
_a..
T K
F ` SIDE 15'
_
INVERTS AT LEACHING FACILITY.
_.
TINGW LE PII TO BE. S �, - a+ �� REAR 15
SEWAGE DISPOSAL
UPPER LOWER w. w .A._� �', AIIONS a it i ! MINIMUM LOT SIZE.
ABANDON "A((CORDI TO g, €
TI. $ REGUL e
4 INVERT AT BEGINNING _._. � � � � "`�� r ' Y
t
'
TRENCH (�
.5 G 82.25 G - � SYSTEM UPGRADE
OF LEACHING ._.,
y
� 87143 S F
83 0 EXISTING LOT AREA t (THREE
i�
� I�,W0.UN�EI�1't0� `° � � � N f � � /�� L 8 7 TFiPARCELS)
" INVERT V R T AT END _ n2 4 �, `t, RODEL SE Ctt f`
4 E _. ", fl
• M a q,F, t FEM A FLOOD
PL�AI BE�f�I►IL"5 � c,
OF LEACHING TRENCH
83.31 H 82.06 H /�
_.h
..., `� ,.,. ,'. : coQ � - ��:,.. ,r ��, y � �� ''; �� 4 ; � '''"'` ,_... �� �rx��k,.,.....� :��., , ..� .._. ��, t� ZONE DISTRICT: ZONE AS SHOWN ON PANEL #941 d 250001 0018 D DATED 7/2/92
ELEVATION AT BOTTOM
81.31 J 80.06 J
n
OF LEACHING TRENCH ~�. 67.8 ?'' f ; ,t BE" !"" K j �' °�t• OVERLAY DISTRICT: NOT A ZONE II MAIN STREET
GAcTTCH ,BA91V
- . RIM 91,7.8
ESTIMATED GROUNDWATER .�
COTUIT
EST ED ��.N. �' •
w
r
- �e �. � � � NO SCALE
74.00 K '" LOCUS PLAN.
•
r.
ELEVATION ,. w.. r v� OC N.
w
.
�F. !'f R�� f
i
r t.
�+ r � t I /��
' `
OW POINT ON LOT ._ .�... ti.. �. �1 � _� � .�. � � � .� � ��.� � T • y � M A AC S
ETTS
L 67.8
,v
r �-
3��3 ►��
+2 -
w..-
"
N
..,,y 3 M. ✓m,.....,' M1�„-...-.. ....n.,.^ �..m � v,,,,._.rr•° „v'f` F `j,,:,:,,. - '' . l t
,nx.
"�' "�� "�� `�� - �` � PREPARED FOR
VARIANCES REQUESTED. y. m
f
r
f
NONE N A LI H. M. SCUDDE
.,.w
.� ,
r
A CE & SCOTT M R
f / SCHOOL ST 14 ROSEWOOD DRIVE
i
CO�1T
- BA Y
PITTSFORD
BOARD OF HEALTH FORMAL REVIEW: . _. ' ' NEW YORK, 14534
BOARD OF HEALTH FORMAL REVIEW OF A 6 BEDROOM DWELLING REQUIRED LOCUS a
_ �A DATE: MAY 1, 2006
�• COMP. DESIGN: K. HEALY
/ CHECK: M. DIBB
/ / SHELL RD
FLOOR PLANS: PLAN VIEW / SAMPSON ISLAND DRAWN: P. HAGIST
_ �a�/ FIELD: D. GAZZOLO / J. McCARTIN
SEE ATTACHED SCALE: 1 - 20 FEET o�
/ FILE N0. B.PLAN/48803-SP,DWG
0 10 20 40 FT. �M DWG NO. 5615-03
JOB NO. 4-8803.00 SHEET 1 OF 1