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HomeMy WebLinkAbout1262 MAIN STREET (COTUIT) - Health ` Main Street'(Cotuit) Cott P - A = 033 039 Sy I i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments , 1262 Main Street ti? Property Address �y James McCarthy �t Owner Owner's Name information is required for every COtUit MA 02635 tf page. City/Town State ZipCode 11-17-17 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. General Information filling out forms on the computer, \\`\` P��H10f use only the tab Inspector: M key to move your � . •••... •. cursor-do not James D.Sears ny '' key. Name of Inspector use the return .. = " JAMES C.c,- Ca ewide Enterprises ="' ra Company Name 153 Commercial Street �� rf i,"Iix1/F 5 I N 3PEG\p�`�� Company Address w Mashpee Cityrrown MA 02649 508-477-8877 State Zip Code Telephone Number 51623 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 1S.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority spector's Signature 11-17-17 Date Thu syslielll ItlSptrutur shall submit a Copy or Mir.InSpedli66 e6port to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "*` This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t5ins.doc•rov.6116 Title 5 Offkial Inspection Form:subsurface sewage Disposal system-Page 1 of 17 ZZ a5ed Xed dH 8t7ZZ L 60Z 61 ^oN b` Commonwealth of MdssachuSeLLS Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. Cityrrown 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 system is a 1500 Gal. Tank D Box and two pits 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 M yPar.S n1d*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.doc•rev.61'8 Title 5 otfxJal Inspect on Form Subsurface Sewage Disposal system Page 2 of 17 Ez a5ed Xe:1 dH 6t7Z2 L 1.02 61• AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 1262 Main Street Property Address James McCarth Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): L distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken Pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 151na.Coe•rev.6116 Title 5 Oftel Inspection Form:Subsurface Sewage Disposal System-Pape 3 of 17 bZ a5ed xed dH 05:ZZ LLOZ 61 ^ON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-No f Y t or Voluntary Assessments 1262 Main Street kvi Property Address James McCarthy Owner Owners Name information is required for every Cotuit MA 02635 11-17-17 page. Citylrown State Zip Code Date of Inspecilon 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 dnd the SAS is'wlthin a Zone 'I 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 aseptic 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 determ ine.distance: 'R This.system asses if the well P e water analysis, performed at a DEP certified laboratory, for fecal li 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 is less than 6" below invert or available volume is less than Y day flow p, r;S t5ins.dac.rnv RHR Title J Offiudl InsNuUWtl Fuller Suo9urgea 59WBgO U1006t l System•Page 4 of 17 gZ abed xed dH 052Z L Me 6 6 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street. Property Address James McCarthy Owner 6J v er s Name information is requited for ev ery ryCotult MA 02635 11-17-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal r_nlifnrm hartaria inrrie A99 absent and the pr2egristp of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 ilnrier 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. 15ins.doc•rev.6116 True 5 0mcial Inspection Fonn:Subsurface Sewage Disposal System•Page 5 of 17 gZ abed XeJ dH I.S:ZZ L1.0Z 6l, ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy Owner Owners Name irHormation is required for every COttlit MA 02635 11-17-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out In the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan.at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 16.203(for example: 110 god x#of bedrooms): 550 t5ins.doc-rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17 - LZ a5ed xej dH 29:2Z LL02 66 AON Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. Cityrrown State Zip Code Date of Inspection D. System Information . Description: 1500 Gal, Tank D Box and two pits. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present 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 Nan-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rcv.Gila Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 8Z a5ed xeJ dH £52Z LU 6l, ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1262 Main Street Property Address James McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. City/Town State Zip Code Date of Inspection D. system Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Ycs ® 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.dcc•rov.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal systerr•page 8 of 17 62 a5ed Xed dH IVSZZ L L02 6 t AON Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street Property Add ress James McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 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: permit#82 -607 11-2017 New D Box 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: 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: 21" feet Material of construction: ®concrete ❑ metal ❑ fiberglass n polyethylene M 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-10 Sludge depth: 2" t5ins.aoc•rev.efte Tllle 5 Official Inspection form:Subsurface sewage Disposal System•Page g or 17 06 abed Xed dH �9:ZZ LM 66 ^ON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy Owner Owners Name information is required for every Cotuit MA 02635 11-17-17 page. City/Town State tip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 181, How were dimensions determined? Asbuilt-Tape Sludge Comments (on pumping recommendations, inlet and outlet tee or bale co d t Judge baffle n, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and outlet cover at 21" below grade wlinlet cover at 7". Inlet tee outlet tee. No sign of leakage or over loading. 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 15ins.doc•rev.6/16 Title 5 Officlel Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 6£ abed xe� dH 99:22 L60Z 66 AON Commonwealth of Massachusetts kvTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments aztvi 1262 Main Street Property Address James McCarth Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. CitylTown State ZipCode 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 ❑ lene of eth P Y Y El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm prcacnt: ❑ Yes ❑ Ntf Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping; o ate Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5in5.doc-rev.era Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 or 17 Z� a6ed Xe� dH 55Z2 L 60Z 6 6 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy Owner Owners Name information is required for every Cotuit MA 02636 11-17-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) 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.)- 0 Box is 16"x16"-32" below grade wltwo line's. Box is now 11-2017 wlcover at 8". Pump Chamber(locate on site plan): Pumps in working order: t ❑ 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: I5im.doc-rev,ell e Title 5 Official InspectonForm:Subsurface Sewage Disposal System•Page 12 of 17 EE abed xed dH 95ZZ t 60Z 61, AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy - Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit#1 -Pit and cover at 30"below grade w/30"water. No high stain line. Pit#2-Pit and cover at 23"below grade. Pit is dry. No sign of over loading or high stain line 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sevrage Disposal System-Page 13 of 17 ,yE a6ed XeJ dH 95:ZZ L We 6 6 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Y 1262 Main Street Property Address James McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 11-17-17 page. Cityrrown 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.doc-rev.6!',6 'itle 5 Officlat Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 CE abed xed dH LW2 LWE 66 AcN Commonwealth of Massachusetts 19 Title 5 Official Inspection Form " a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy Owner owners Name information is required for every Cotult MA 02635 11-17-17 page. CRy/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 FA R pe PCy I. 0 e /3 a 1'3_, 3 yi- �� ✓ V-3 = 18 0e o ` . J L5ins.doc•rev.6116 Title 5 Official Mspectlon Form:subsurface sewage Disposal 9Syslam•page 15 of 17 gE abed Xed dH 85:2Z L 1.0Z 61• ^oN Nov 20 2017. 19:01 HP Fax page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1262 Main Street Property Address James McCarthy _ Owner Owner's Name information is required for every COW it MA 02635 11-17-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells r/D Estimated depth to h ground water:hig feet e 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: 10-12-82 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 10-12-82 - 12' no G.K. Bottom of pit#1 at 8'-6" below grade. Bottom of pit# 1 at T-6" above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form.Not for Voluntary Assessments. 1262 Main Street Property Address James McCarthy Owner Information Is Owners Name required for every Cotuit MA 02635 11-17-17 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 tsins.doc-rev.6116 Title S Otficial Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 gE abed xed dH 69:ZZ L 60Z 6 6 ^ON No. r 1 —" Fee- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9pplitation for ]Disposal *pBtrm Construction 3permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. I;t to?, (LI Al tJ VT Owner's Name,Address,and Tel.No. to-rUj7 =3Q#^CS + PAUSC-iL(A X1GdA:P-_rNy Assessor's Map/Parcel Q-33 03 PO 1D)C -70 C'O'Tu LT "A Installer's Name,Address,and Tel.No. 508-4T 7-6 97,1 Designer's Name,Address,and Tel.No. 153 014" <T S61269 Type of Building: Dwelling No.of Bedrooms 10 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /A gpd Design flow provided fil9� 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) XW S—tAU, SAO CId1" 7105 b CJ D L7'r Ug r Z057*cu NGLc> H-;Lc) p oX Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Si Date Y — 2 Application Approved 6y Date �3/ Application Disapproved b Date for the following reasons Permit No. 7_.0 I (iC Date Issued ,�,}..n'�;C't�--.,'.-..�i."�;.••�.'.+.{�1t...t,roktfir. .e� �.!;y-`"'Y+y 4,1r'�"�,'o`�.`.`'r r�`.. '.�r.a.�,rt+ . .:�,.. - r r . -..�., ?w �.�_�:t.:�-`..�,� - _Yk L10 No.G)( -4 W Fee THE COMMONWEALTH OF MASSACHUSETTS Entered,-in computer: PUBLIC HEALTH DIVISION TOWN-OF BARNSTABLE,'MASSACHUSETTS Yes 2pplicatlon for 33ispoSaY 6pstem Construction Permit Application for a'Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System f Individual Components Location Address or Lot No. (;t" (N,4 I/J S*T Owner's Name,Address,and Tel No. CoTvc-T OAmC-S + pA.15CJLZA Ae-& W-1 Assessor's Map/Parcel 033 O3 PO GQC 1 10 CCSTU Cr MA Installer's Name,Address,and Tel.No. So ts'�f 7 7-8 8 71 Designer's Name,Address,and Tel.No. C:��cvrAE 1E1� I��i4 Type of Building: Dwelling No.of Bedrooms NA Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 04 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) ><J STi4t.L, SAS nr6" � 0 CS) C7 y'r U977 MEU-) H-aO a-r�a�c }, Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Signed { "" Date j 1 "( -10 '7 Application Approved by � -�— Date Application Disapproved b,} Date for the following reasons Permit No. 1-0 1 y 00 Date Issued { l!-3I 7-0 1 a •4 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CCERTIFY,.that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by"' (2,yQPF_W t_b c- -�C2VR LS ES - at QL" MAJN) Sr Q t T - has-been constructed-in accordancewith the provisions of Title 5 and the for Disposal System Construction Permit No&17-00 dated Installer CAPEW(Or—, &WTWMZ_ Designer wA #bedrooms tjA Approved design_flow — IUA and The issuance of this permit shall not cbe con'sttr^u~e�d as a guarantee that the system willfimctionlas de is geed. Date 1 1 / / Inspector --------- ------------------------- ------------------------ No.&i- 7 OV +, Fee / .dP THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposai 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(A Upgrade( ) Abandon( ) y �a(oa• MAW STAgEr <10-roc � t System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the,following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 1( � 13 1 20 1� Approved by -------- t / , r Crocker, Sharon From: Crocker, Sharon Sent: Monday, October 16, 2017 4:06 PM To: Crocker, Sharon Subject: -1262 Main St, Cotuit 7 NOTE TO FILE: Ms. Chris Dolly, Cotuit Fire Dept, 508-428-2210, called. An attorney or new owner is researching the above property and would like us to verify whether a fuel tank has been removed from this property. I do not show any tank in the Fuel Tank D.B. They have already checked with Fire Dept and Town Clerk and Assessors. The odd part is the caller said they switched to Gas (must be referring to utilities) in 1994 and no evidence that a fuel tank was removed. No underground storage tank on record. Possibly, it was a oil tank in a basement and possibly the Gas Co. included the removal of tank with their installation. If none in basement,would expect it to be a closed issue. 1 DATE: 8/26/02 -- PROPERTY ADDRESS:1262 Main Street - Cotuit,Mass.---__-___ 02635 ------------------------ On the above date, I inspected the septic system, at the above address. This system consists of the following: 1 . 1 -1500 gallon septic tank. 2 . 1 -Distribution box. RECEIVED 3 . 2-1000 gallon precast leaching pits. ( 6 'X10 ' ): Based on my inspection, I certify the -following conditions: AUG 2 8 2002 4 . This is_ a title five septic system. ( . 78 Code ) TOWN OFBARNSTABLE 5. The septic system is in proper working order HEALTH DEPT. at the present time. 6. Pumped septic tank at time of inspection. . 7. #1 Leaching pit.Waste water is 42" below the invert pipe. #2 leaching pit.Waste water is not present. Pit is dry. SIG NATUR Name: J . P. Macomber Jr. ---------,------------- CoaiQ any: Jos eph PJ_ Macomber & Son, Inc. Address:__Box -fzk_----`------- __ Cen��rv_i115�,_ba _Q.2_632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. _Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections _ P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:1262 Main Street Cotuit,Mass. 02635 Owner's Nametgancy Rowan Owner's Address: Same Date of Inspection: 8 27 02 Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name:J.P.Macomber & Son Inc Mailing Address:Box 66 CPnt-Pryi 1 e,Mass. 02632 Telephone Number: 508_77S_3338 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of the inspection. The inspection was performed based on my rrainine 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 Conditiorially Passes Needs Further Evaluation by the Local Approving Authority Fails g InsP ector's Signature: Date• The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority: Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that itime. This inspection does not address how the system will perform in the future under the same or different conditions of use. a Title 5 Inspection Form 6/15/2000 page 1 I Nee 2 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 262 Main Street Cotuit,Mass. 02635 Owner:Nancy Rowan Date of Inspection: $12 6/0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D S stem Passes: f 1 h ve not found any information hich indicates that any of the failure criteria described in 31 O CMR 15.303 or in 3101 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The sept-iG system is in proper worki ng 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please explain. The septic tank is metal and over.20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: A0 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: /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 obstruction is removed ND explain: 2 r Page 3 of'l I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM-- PART A CERTIFICATION (continued) Propem Addres5:1262 Main Street C8tuit,Mass. Owner: Nancy ol�wan Date of Inspection:, 8 C. Further Evaluation is Required by the Board of Health: Conditions exist which require funher evaluation by the Board of Health in order to determine if the system !s failing to protect public health, safety or the environment. I. S%stem Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner wbich will protect public bealtb, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh 2. S*Nstem 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: AJd The system has a septic tank and soil absorption system (SAS) and the SAS is within100 feet of a surface water supply or rributary to a surface water supply. /UD The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple Xk 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 arid the SAS is less than 109 feet but 5 feet or more from a private %rater supple well, Method used to determine distance "This s stem passes if the well water analysis, performed at a DEP cenified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that faciliry and the presence of ammonia nitrogen and nirrate nitrogen is equal to or less than 5 ppm, provided that no'other failure criteria are [riggered. A copy of the analysis must be anached to this form. 3. Other. 3 Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 262 Mai n St-rppt- Catuit- _Macc n26-- 5 Owner: Nanry Rowan Date of Inspection:R�/2r, /Oa D. System Failure Criteria applicable to all systems: 'k 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 _ : esspool ' —IDG�1�5 iquicl depth in c*&Veol is less than 6'below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pip e(s). Number of times pumped ny 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 ater supply. ;�y portion of a cesspool or privy is within a Zone 1 of a public well. �!J y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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.) r (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 Z e system is within 400 feet of a surface drirtkingywater supply system is within 200 feet of a tributary to a surface drinking water supply r� _ he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 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. 4 Page 5 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST - e Property Address: 1 262 Main Street Cotuit.Mass. 02635 Owner: Nancy Rowan Date of Iospectioo:8/27/02 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No �P mping 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 ? _ Y Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the faciliry or dwelling inspected for signs of sewage back up ? _ 'Was the site inspected for signs of break out ? —Z Were all system components�:�i�cluding 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: Yes no Existing information. For example, a plan at the Board of Health. L _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (3)0 CMR 15.302(3)(b)) 5 Page 6 of*1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 262 Main Street Cotuit,Mass. Owner: Nanct Rowan Date of Inspection: 8/2 7/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual); , DESIGN flow based on 310 C 15.203 (for example. 110 gpd x #.ofbedrooms): 6n/ID c��d " ' ACV, Number of current residents: Does residence have a garbage grinder(yes or no): t7 Is laundry on a separate sewage system, (yes or no):,I.Lo[if yes separate inspection required] Laundry system inspected (yes or no):ZaS Seasonal use: (yes or no): �&l Water meter readings, if available (last 2 years usage(gpd))200 0-186, 000 gallons=509 . 59 GPD Sump pump(yes or no): i(,� '2001 -209, 000 gallons=564 . 39 GPD Last date of occupancy:7� ",4 . COMMERCIALq"USTRIAL Type of establishment: Design flow(based on 310 CNfR 15.203): 4M gpd Basis of design flow(seats/persons/s ft,etc.): Grease trap present(yes or no): �� Industrial waste holding tank present(yes or no):AO Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): If yes, volume pumped; 2Qgallons -- How was quantity pumped determined? Reason for pumping: Heavy scum & solids layers were Present. TY E OF SYSTEM Septic tank,distribution box, soil absorption,system d Single cesspool ilia Overflow cesspool , ,{J 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 Q,}ttained from systt owner) _Tight tank _Attach a copy of the DEP approval /UV Other(describe): Appr imate ate of all c m onents,date installed (if known)and source of information: z � Were sewage odors detected when arriving at the site(yes or no):1111d 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 262 Main Street Cotuit,Mass . 02635 Owner: Nancy Rowan Date of Inspection: $f 27 02 BUILDING SEWER (locate on site plan) Depth below grade: :3 `.;. Materials of construction: Fast on.f/ 40 PVC other(explain): Distance from private water supply well or suction line: 1&4 Comments(on condition of joints, venting, evidence of leakage, etc.): T^; ntc appear tight, No evidenee of leakage The system is vented through the house vents. . / SEPTIC TANK: (locate on site plan)C,6Bdr('19G<G�(f Depth below grade: / Material of construction: concrete 1� meta6Vd fiberglass polyethylene ,(� ther(explain) ,f If tank is metal list agle::,_Q Is agee+confirmed by a Certificate fi of Compliance(yes or no):A�.(attach a copy of cenDimensions: lG�a �GS� V`�< �� •l ' V�� �/!/�/� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 0> Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Piimp thP septic tank P-vpr)z year-_ Garbage aigpoSa I ig DrPqPnt Inlet a nutiat toos are in place.The tank is- Rtr13r_ti3r;all,, sound and shows no .evidence of leakage. GREASE TRA9e,),jLe.(locate on site plan) Depth below grade:" Material of construction;&concretKJ�metaL!/4 fiberglasslJ�olyethylen /J other (explain): /Ulf Dimensions: �Jj9 Scum thickness: Distance from top of scum to top of outlet tee or baffle: X41 Distance from bottom of scu to bottom of outlet tee or baffle: f,39 Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels , as related to outlet invert, evidence of leakage, etc.): Grease is not =rP.S,ent, i 7 Page 8 of I I OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 262 Main Street Cotuit,Mass. 635 Owner: Nancy Rowan Date of inspection: 8/27/02 TIGHT or HOLDING TANK!(IW-44ank must be pumped at time of inspection)(locate on site plan) r- Depth below grade: —/.�/ Matcrialofconsrruction:p9/4 concrete metal/,�4fiberglass�polyethylene,, other(explain): Dimensions Capaciry: gallons Desien Flow: gallons/day Alarm present (yes or no): Alarm level: _Y,-0 Alarm in working order(yes or no): Date of last pumping: A)14 Comments (condition of alarm and float switches, etc,): Tight- nr hnl rli nq tanks are not present, DISTRIBUTION BOX: (if present must be opened)(locate on site,plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any.evidence of leakage into or out of box, etc.): Distribution box has two laterals .No evidence of solids carry over.No evidence of leakage into or - outo e ox PUMP CHAMBER6"(locate on site plan) Pumps in working order(yes or no) .Alarms in working order (yes or no) ,,pp Comments(note condition of pump cffa'rfi6er, condition of pumps and appurtenances, etc.): PilMn rhamhPr is not present- ' 8 1 Pape 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 262 Main Street Cotuit,Mass. 02635 Owner: Nacy Rowan Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) 2-1 nnn c;a l l nn p rPr•aGt 1 parhi ng pi tG_ 8 'X1 0 ' If SAS not located explain why: L-or 1ted e See page In Types _✓ leaching pits, number: leaching chambers, number: leaching galleries, number: _jo a teaching trenches, number, length: 0 leaching fields, number, dimensions: D overflow cesspool, number: t innovative/altemative system Type/name of technology:z/j,-t)e xye, Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy loam to medium coarse sand No signs of hydraulic failure ar =nnding Soi1S ar dry Vegetation is normal CESSPOOLS46A�(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 laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): C'eCCnnnl C era not I1rPSPrit _ PRIVY/&X(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.): Privy is net es e=t 9 Pig( 10 0( 11 OFFICLAI_ fNSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM fNSPECTION FORM PART C SYSTEM INFORMATION (conlinvcd) Piop(rry Aooicsil 262 Main Street C'�tui t ,Mass 635. OwccrRanay Rowan 'J�ic 01 In)pccli00: 8/27102 SKETCH OF SEWAce DISPOSAL p i A L SYSTEM Pco. oc c ckcich of the 1cwlfc 0i)polcl iyllcm Inclvding lIct 10 11 Icill topertncm rcrcroancNnvki Lo< c r � clli wHhi w cncc IdnCn+,x, o,whccc pvblic w►1cr ivpply cnlcri the bviloin6. yea \ � U W ` ,gyp IO Page I 1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 262 Main S at- Pnt-ni Owner:Nancy Roviza Date of Inspection: R1427,i )2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water� feet Please indicate (check)all methods used to determine the high ground water elevation:. NO Obtained from system design plans on record.- If checked, date of design plan reviewed: YES Observed site (abutting property/observation hole within 150 feet of SAS) N_rZ Checked with local Board of Health-explain: W-4 YFq Checked with local excavators, installers- (attach documentation) . & Accessed USGS database-explain: http: // town,barnstable,ma,us. You must describe how you established the high ground water elevation: Ised: Gahrety & Millar Model 12/16/94 round wa r 1 va inn above sea level _ tsed: USCG' Ohcarbat-inn well rJata 7ttna 1 492 tsed: US r — - water elevations.January 1992 Leaching Pit Groundwater r,eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is feet. 11 :••T.'1T^Rf'lTT.•1T� TT.—JT.•RiLR?Tr:"tT.TT:•.lr•I•:T4TT:TITSTTT TfLT44Jl"P�ISS• .. .• 'FOWN OF Barnstable WARD OF HEALTH SUI)SUNFACF SFHA(;F DISPOSAL SYSTPM INSI'FCTION FORM - PARTED - CERTIFICATION •••—•••-T••.•'•i��.fly^.�T.r.r-n•n:rn1••i1r.rrr:'Trn-r�.•t*-t,'s+s�s a.�nr Tt'TCRae RTSRSIsetTTer7 nm n'tmr•rtrils•TTT�trtr.::rrr•r•:. —..� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 1262 Main Street Cotuit,Mass.02635 ASSESSORS MAP , DLOCK AND PARCEL #0.33-039 OWNER' s NAME Nancy Rowah PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. ------------- COMPANY NAME J.P.Macomber & Son Inc-.4' COMPANY ADDRESSBox 66 Centerville,Mass. 02632 Street Town or City Stat• iIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 _ 1578 CERTIFICATION STATEMENT I certify that I have personally' inspected the sewage dieposaj system at this address and that the information -reported is true , accurate , and omplete as of the time of •-inspection . The inspection was'- performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : _AklSystem: PASSED The inspection which .I have conducted has not- found any information which indicates that the system fails to adequately protect public health or l:he. environment as defined in 310 ,CMR 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspect ion , which I have conducted has found' that the system fails to Protect the Public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , ool 0.h. Inspector Signature r Datecopy of this rt.ification must be' provided to the OWNER, the BUYER re applicable ) and the BOARD OF iiEAL711, * If the inspection FAILED , the owner or"" 'p' arator shall upgrade ' the ayatem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 ChIR 16 , 305 , partd . doc r� �- TOWN OF BARNSTABLE \, LOCA7',.ON SEWAGE VILLAGE ASSESSOR'S MAP & LOTD '®Of t � INSTALLER'S NAME& PHONE NO. . ls` sG SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS tr 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 e c Faci,li+ty (If wetlands exist within 300 e e c� ty) - Feet Furnished by ` i ' s � - \ 1 <\ IV- 1 5E W PERMIT UO. IW5TQLLER5IJ©Nl ADDRESSCI-9 n BUILDERS IJ &"E &DDRI=S DATE PERMIT ISSUED O — D ATE COMPLI &&ICE ISSUED : L�3 OPT A, C7 f a F V L�J a�T10N ' 5EW6,C4E PERMIT QO. -- VILLAGE IMSTQLLE 5 W&L AE �,ADDRESS �ff .1� Uri BUILDER 'S Q &M 4,DDRE55 Soo DATE PERNA T 155UED •— — _ _ — — _ — D-Q.TE COMPLLL. dCE ISSUED : _ — ��i� S� i t �� � �� �d ��� `��� `�, \V V� v J `�� c (� _ ✓ �:1. \\v// r' ����� ► . , r ra .. _� rr ' No.��......��..,�. ~� ��' ; Fins.. .............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....... .... .......--................OF..........................._............. , pphra#ion for Dispaii al Works T nstrur#ivaa amit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: ..... - --•----------------------------------------------------------- ............... or �� .....Iyocation-Addyes ..............................Lot ... Owner Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_._.........................................Expansion Attic ( ) Garbage Grinder ( ) '_l Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures .................................. _ W Design Flow.......... ............gallons per person per day. Total daily flow.___...S. . ........................gallons. W Septic Tank—Liquid capacity�Sdo..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width....../............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... _...... Diameter-------6_......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing�nk ( Percolation Test Results Performed by.... ---..134.................................................. Date...------------:... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-••-•••--••--------------•-••••••••••••----••••--•-•••--•....-•--•••----._......••••---•-•••------.._..----•••-••........----••--••••-----•--•--•--•--...... 0 Description of Soil........................................................................................................................................................................ x V W U Nature of Repairs or Alterations—Answer when applicable--______________________________________________________________________________••-••-•-----__. -•-•• •••••••••••••••••••••-••••••-----•••..••-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary C/de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beA issued by the board of health. ig ®.d••--•-••-•----•...................••--•- - IT,',,-,,,,,,,--,*----------- 6.�A Application Approved BY . . .'•--v•••-•••••--- p� Date Application Disapprdved or e following reasons:------------------ --- PermitNo................................•••-----..._•----..._._. Issued_..............................................==....... Date �r.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...•.......................................O F.......................................... Appliration for Disposal Works Tomstrnrtion Vrrmit Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewage Disposal System at: .....StATAT.....4..W&rM000............. --- h. ------ ----•------------ - . L• ation-Addr • or Lot No Owner Address W Installer Address UType of Building Size Lot............................Sq. feet r� Dwelling—No. of Bedrooms......:___..................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a Other—Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ................ ................ ----------------- r------•------------............... .� .................................... W Design Flow.......... .___ ._.....gallons per person per day. Total daily flow.................. .......................gallons. WSeptic Tank—Liquid capacityr�......gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width....../............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___--_2---------- Diameter........6--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t nk ( ) Percolation Test Results Performed by.. ? j -------------------------------•----••--•---... Date_..................................... a Test Pit No. I----•--•---..___minutes per inch Depth of Test Pit..................•. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' .......... •...............•••-•-_----------------------------------- -.-----•---•---------•----...... 0 Description of Soil............................................................................. = x W ----------------------------------------------------------------------------•---------------------------•-------------------------------------------------------......------------------------------•... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------•-------------•-----•--•------••-----------------.......---............---------------------------------......-------------•--.........-•••--••------•-••••••••••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gned--..........................................-....................-------............... ....-/ ------ Application Approved B •--• ----------••••-- ;. �f ' '" PP PP - _"� Date Application Disapprevved -or a following reasons: . --r; . ------------------- .............•••-------------••. ......-----------------•--------•-•----•------......------...--•-------••••--••--•-••-•-••••---•---•-•-•-•-----••••---•---•--••-•-•-•--•-•••----•-••----••---•----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �f BOARD OF HEA TH ................................OF... :... ................................................ f9rdifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( tror Repaired ( ) by---• i 4 Installer at. ...2.... .... ....... N._ A--------•---- ... .-.. ---•-- -------- has been installed in accordance with the provisions of TI �5bhe State Sanitary CodAe, bed in the / Papplication for Disposal Works Construction Permit No......................................... da.ted _..__%. _............_... THE ISSU CE THIS CERTIFICATE SHALL NOT BE CONSTRUE A ARANTEE THAT THE SYSTEM V!/ L FU TION SATISFACTORY. DATE... - -------•-------------•------•------•------------- Inspector........ ---------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ell_ BOAR ®F H A H .......................................... No. c FEE... . .............. Disposal Works Tnnotnutinn Vvrrutit Permissionis hereby granted.............................................................................................................................................. to Constr or Re lrr ( ) an I ivldual 'Sewa D• posal System j Street ,,,•6®/� /v�j� l as shown on the application for Disposal Works Construction Permit No..................... Dated..:_._._�}_t_.__.`�./..................... ------------------------•--• ........................................................... Board of Health DATE -�� -1'=�/� ........ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS + TYPICAL SYSTEM PROFILE i AREA PLAN FON TOP FINISH GRADE= �C� NOT TO SCALE IIC �. + t. , FINISH SCALE : I = FINISH GRADE OVER TANK= 4 '�' GRADE OVER PIT- -1 .. .. „ . ._z � ._.... .r. i _.._.„.. .. .._... . C I TEE • • • • PVC OR q�.�� O O e 0 v S �(o • • • • • • • • e '� =�•'' � - -� ?. " ' ... BSMT "1 � ��r 15©Q • • 1 0 • o TQ �`I FLR ' GAL. 4 • ''`.�" �G�. ^ -` • • r e • • • • • e e REINFORCED DIST. BOX • e 1 • • • • • • 0 1 eLi CONCRETE 8 TO BE INSTALLED ON ° ' ' ' ' • • • ' ' ° ' A LEVEL STABLE BASE • e 1 • • 1 0 • ° • .' �~ _ ' •::> - SEPTIC TANK f Liz' . 1 1 ° • TO BE INSTALLED ON A • • • • • • ° 1 -- -_- LEVEL STABLE BASE t t __. ., u_ n Ir • 1 • • • • • • • • 1 1 t•49 S TREE �t� BRICK a.MORTAR COURSES AS AROUND FREE OF IRONS FINES ' ' ' ' • • ` ' 1 ' ' LOT 5T 1 �"� ~�- - REQUIRED TO BRING COVER TO GRADE AND DUST IN PLACE I (� �' __.....,.� "C. I II LEACHING PIT 3 t ac•,� _ 1___(1 i ----w.. _ 24 C.I. MANHOLE COVER a 3/4 TO 1-1/2 WASHED CRUSHED FRAME - SEE DETAIL STONE ALL AROUND FREE OF BASE TO BE LEVEL 2Q o4�# ! "-- ' "�}� �k+ .. "" .„�-• .r } � ''"'3i:: t IRONS FINES AND DUST IN ' (2- PLACE1• CJI� t FOR FIN. GRADE Tbti," NA �} --- ` SEE SYSTEM PROFILE SAIL AND PERCOLATION vv 0� t t •t^ ' tit ,l J� ; rrr ., _ 411 DATA PERC. RATE :, tPAk M I IN. � 15c�-_1 c,rs�z.. . . , II � ° INV ELEV SEEl13 �- �' �77 - 4 FOR N.Cs • t _.�z r� Pr"+C Awlk I, TAKEN BY C. D. SPOHR �, +� , , YSTEM PROFILE�.i`".,.' 39 �n>� L I N E T � S t . MrMgt ,cam =' • o o II ° ' ,° ti1k. Jr7H'.WITNESSED BY 4° D 0P NIN S W/4-I/8 „ ,OUTER DIA. a I -3�4 0 _ DATE _ t �1 �� :� 7' I ; ° o INSIDE DIA. o TEST PIT-GND ELEV. ` ' '� 7 6 o TOTAL Y _ (—Y — p AREA v ?- 1UsIIR 1 —` F - - p D 0 ° / �1 ' . T c 772'- i C ar � r • - ° 0 0 0 0 �'. t . 0 D 0 ° 115 1'I DF _ T„ il �' ,0 0 0 0 0 0 • - s ARP-A IFOk k s:,F`kY 0 I I (ft i s 1t._ � s -� ;�.. 6 - 6 O IA. — f LUT 5 ' —. i ► BOT. PERC. HOLE 70. -Is ; I Q , EFFECTIVE DIA. ,��jtit€. 7 I � I TE(V�� � �-_� Ci..,1URTS s �-r�- ►s -ors' w t , _ oowN 5 � +I ., ;� , ^ _ +SI+ c� LEACHING PIT SECTION iq_cl'' U `) . $" 1 2 ��- NO SCALE DESIGN DATA : <L I NOTE: DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM 1777 NO. OF BEDROOMS -� LiLl N DISPOSAL _ P LEACHING PIT NOTES: EST. TOTAL DAILY EFFLUENT =''}' GALS. i I . CONC. TO BE 4000 P.S.I a 28 DAYS . SEPTIC TAN K I-900 G AL. 2 . REINF. W 6 II x 6 II 06 GA- W. W. M. — 3. 2 'AND 4 1 SECTIONS ARE AVAILABLE FOR GENERAL NOTES GREATER DEPTH REQUIREMENTS ? 1 . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN { NOTE : + 4- ACCORDANCE WITH TITLE OF THE STATE SANITARY CODE EXCAVATE TO ELEV. OR LOWER AS DATED JULY 111977 a ANY LOCAL RULES APPLICABLE. — _ — - _ _ _ ^ _ ` -^ — - - _ REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING 2. ANY CHANGE TO THIS PLAN MUST BE APPRV IN MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL WRITING BY MR. CHARLES D. SPOHR. WITH CLEAN,CLAY FREE GRAVEL, MECHANICALLY COMPACTED IN PLACE. I r-' 11 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING, n ^ nn '' SIDE AREA = 19 8 S. F.0 '4 S. F./GAL ` 2 GALS NOTIFY THE ENGINEER AND BOHRD OF HEALTH FOR INSPECTION, OV) I V ER- BOTTOM AREA=- 1B -7 S.F.@ I • 0 S. F./GAL GALS 4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED. ti'IK k'� A'I-F"V-1 W. �3WAK. TOTAL AREA = S. F. TOTAL =� GALS 5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTEN 1 _3 ` C H�� �A•,�� LA�..���1_ ���1 �,.�- APPROVAL BY CHARLES D. SPOHR. LEGEND 6. FOUNDATION INSPECTION READ. WHEN EXCAVATED. 7 (7) -Ay, ♦ 50.0' EXIST. GROUND ELEV. ice L . p t - , -g } 50.0' FINISH GROUND ELEV.2'UNDERLINED" 47507 PIPE INVERT. ELEV. REV. DATE DESCRIPTION [� (�' Q TEST PIT LOCATION SEWAGE DISPOSAL SYSTEM B. +`�r• ' `+( TE • o o SEPTIC TANK FOR MR. MRS. SLATER W. SWARTVl _),�C) E --L:. E3A i_U C)IJ `JTL\K = �X( `-, ❑ DISTRIBUTION BOX g� ���. 'o U NA tj � Poi_E #.qtv�� ----";MQs�gc LUT# ►� �yR T E R MAIN S E E E T 50. C)© e 4 " C. I . PIPE COTU 11, BARNSTABLE u'':;site^ S'.`-i m i Fit♦- 4 BIT. FIBER PIPE -TIGHT JOINTS ;,'Ir MACC`, .i, - -- - PROPERTY LINE "; 1' DESIGNED: C•D.SPOHR DATE:111_ cx'.T: .� DRAWING NO. MIN. CODE DISTANCE � ` .. DRAWN: SCALE:ASSHOWN ( I n MAP SEC PCL LOT HOUSE •�E• �.,_ , � v CHECKED: C. D. S