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HomeMy WebLinkAbout1424 MAIN STREET (COTUIT) - Health f 1424 MAIN STREET, COTUIT i i Commonwealth of Massachusetts ,l Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,k u � 1424 Main Street " v + Property Address Y. William & Michele Landes # Owril Owner's N e a k information is required for every Cotuit 7 MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A flli�g . Inspector Information Sl#t 11503* ' i:•d�ift forms on the computer, use o.n,[y_the tab Michael T Bisienere 1 ketorove your Name of Inspector M cursor ado not Cape Septic Inspections _4 " use thereturn Company Name 52 Rivers End Road Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.34Q of Title 5 d r $tl ryYGu (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address y listed above; the information reported below is true, accurate and complete as of the time of O my� 7 < t inspection; and the inspection was performed based on my training and experience in the proper function ` and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes ,r }, 3. ❑ Needs Further Evaluation by the Local Approving Authority ..- 4. ❑ Fails 5.�40 tad s'fit. f /2.020 Inspector'sS 3 ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to 9Y p t the buyer, If applicable, and the approving authority. '' Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15,3 ; o " it, f5 nsp.'tloc t rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page yY of 18 ; , Commonwealth of Massachusetts �- Title 5 Official Inspection Form Ilk Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary =` S Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 7 bedroom home has an H-20 2000 gallon septic tank, an H-20 1500 gallon pump chamber with a D-Box feeding (9) leaching chambers with stone. At the time of the inspection no visible-fai lure----- criteria was found. The septic tank and pump chamber has covers at grade in the driveway. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements,..Gf"not - determined," please explain. ti The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass- inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): ins:};ri t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J L C Vic,V � 1424 Main Street ; Property Address William & Michele Landesjiv Owrier Owner's Name information is required for everyCotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ElPump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. •.J'1:. ❑ Observation of sewage backup or break out or high static water level in the distribution box.due, • .. r to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. Sys,,,gT. Il': pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below); ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): _.CE4 ii!V-`d'11tt 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of:18)^ I , t`,-;,,-p C - Commonwealth of Massachusetts = —P Title 5 Official Inspection Form +, �ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 1424 Main Street u� Property Address William & Michele Landes Owner Owner's Name requir dforis Cotuit MA 02635 11/12/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water r = ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within, - I''' 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. s ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or: more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis.must ii;;E?rrr?cd%i.,•. be attached to this form. c. Other: .... 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 io:, �.r;„fir, •., , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` u— 1424 Main Street Property Address William & Michele Landes Owner' Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No =.. == Static liquid level in the distribution box above outlet invert due to an"overloaded z- ❑ -_ or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than '/day flow ��`` ❑ ® Required pumping more than 4 times in the last year NOT due to clogged obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater;than,;50 feet... from a private water supply well with no acceptable water quality arYr, sis-1[-tris system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will,be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility tn+tith,'a' design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply eY El El the system is located in a nitrogen sensitive area (Interim Wellhead"F%iection 1 Area—IWPA) or a mapped Zone II of a public water supply well r- t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 df 18 ' .,, .gym-•,�u it 1'�YrliY' D G...- �•.� Commonwealth of Massachusetts � 'A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1424 Main Street u— Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page W Cityfrown State Zip Code Date of Inspection I C. Inspection Summary (cont.) i If you have answered "yes" to any question in Section C.5 the system is considered a significant' threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No " ® ❑ Pumping information was provided by the owner, occupant, or Boardof Healthf ❑ ® Were any of the system components pumped out in the previous tw8,," ks? ❑ ® 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. y' ` ` ® ❑ Were the septic tank manholes uncovered, opened, and the interior cif 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. ® ElDetermined in the field (if any of the failure criteria related to Part C is at issue u approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts n Title 5 Official Inspection Form i1; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tlyy 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 9 Number of bedrooms (actual): ? DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): J+'IGPD lus Description: 11 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes,® No Does residence have a water treatment unit? " ❑ Y�esN_.�.. No If yes, discharges to: -- - -.Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): town water Detail: The first half of 2020-50,000 gallons were used and in 2019- 140,000 gallons were used' Sump pump? ❑ Yes ® No Last date of occupancy: seasonal use Date - t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page of 18_r;. Commonwealth of Massachusetts ., . Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) .r . 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ElYes °�] No Water treatment unit present? ❑Ye ❑:._No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): ... Alt.;Y .. .. 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? eA, Reason for pumping: t5insp.doc•rev.7,126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form += 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: s-- ® Septic tank, distribution box, soil absorption system Single cesspool r ❑ 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. 4 ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts j �n Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w ! , 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 5 6. Septic Tank(locate on site plan): Depth below grade: 2411feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-20 2000 gallon Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 1311 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's Name required is Cotuit MA 02635 11/12/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 0 wrier Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, strucfural irfierify�, liquid levels as related to outlet invert, evidence of leakage, etc.): - 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page¢11�of t:: + Commonwealth of Massachusetts ;, �t Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's m O e s N a e information is required for every Cotuit MA 02635 11/12/2020 Page. . - Cityrrown State Zip Code Date of Inspection D. System Information (cont.) --- 8. Tight or Holding Tank(cont.) =:i", :y ' Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0° ju Comments (note it box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): yy At the time of the inspection the liquid level was at working level and there were no visible signs of a leakage or solids carryover. of t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,.)o�w* ;a ran the pump and tested the alarm. `-- * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El leaching pits number: ® leaching chambers number: 9 :.,r,`,r ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-paged3)of 18 r✓Vr�lE�r f�'°� Commonwealth of Massachusetts I_ Title 5 Official Inspection Form { nsp Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�V % 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. t 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration _ Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,__ etc.): y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <��I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y rY 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information required forevery Cotuit MA 02635 11/12/2020 `.'W page.ix: Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: -> Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;- �;•a:rr,:su etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I, Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1424 Main Street Property Address William&Michele Landes Owner Owner's Name information is COtUIt required for every MA 02635 11/12/2020 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) „ vow 14. Sketch Of Sewage Disposal System: k � f^ 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 O O O O A s.^�-..•�... LAY O '�� � p- 9trs �p,ya.o 0-'I�rr.m _ Nip g o 0 0 e-r &rr t'r o 157,01 girls; 3 , rf' ' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1424 Main Street Property Address William & Michele Landes Owner Owner's Name ° information is required.forevery Cotuit MA 02635 11/12/2020 page.`:. ..,; Cityfrown State Zip Code Date of Inspection D. System Information (cont.) J 15. Site Exam: ® Check Slope ® Surface water ® Check cellar i Z Shallow wells nc,u irpa•:1C. i et Estimated depth to high ground water: f plus feet _ feet - Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: i ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: -_- I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 ;,r< I i Commonwealth of Massachusetts Title 5 Official Inspection Form - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1424 Main Street Property Address William & Michele Landes Owner Owner's Name information is required for every Cotuit MA 02635 11/12/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 3; ® A. Inspector Information: Complete all fields in this section. W y -5-_1- ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Ti ht/Hoidin Tank—Pumping contract attached _ 9 9 P 9 „ For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form cc o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 page. Cityrrown State Zip Code Date.of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please'see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector. key to move your VVV vvv cursor-do not Kevin J. Sullivan use the return Name of Inspector key. Ready Rooter, Inc. „y Company Name P.O. Box 371 Company Address Sandwich MA- 02563 Cityrrown State Zip Code 5087888-6055 SI 13517 Telephone Number License Number B. Certification I certify that I have personally.inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as.of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority April 24, 2014 Inspector's Signa re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" sec' n need to be replaced or repaired. The system, upon completion of the replacement or pair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the foll ing statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic to (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tan ailure is imminent. System will pass inspection if the existing tank is replaced with a complyin eptic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is ucturally sound, not leaking and if a Certificate of Compliance indicating that the tank is less t 20 years old is available. ❑ Y ❑ N ❑ ND( lain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Hea 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 istribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distr' ution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ D(Explain below): ❑ obstruction is removed ❑ Y ❑ N ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ❑ ND(Explain below): ❑ The system required pumping mo/than4 a year due to broken or obstructed pipe(s). The system will pass inspection if(withe Board of Health): ❑ broken pipe(s)are replace ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Furt/anation is equired by the Board of Health: ❑ 'Cont wh' h require further evaluation by the Board of Health in order to determine if the aili to protect public health, safety or the environment. 1. Spass unless Board of Health determines in accordance with 310 CMR 15.3at the system is not functioning in a manner which will protect public health, safe environment: ❑ ool 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 Com monwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 0.5635 March 27,2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall unless the Board of Health (and Public Water Su lier,if any) determines that the system is functioning in a manner that prote the public health, safety and environment: ❑ The system has aseptic tank and soil absorption system (S )and the SAS is within 100 feet of a surface water supply or tributary to a surface w r supply. ❑ The system has a septic tank and SAS and the SAS i ithin a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the AS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water nalysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th 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 ElF® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 05635 March 27, 2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet. from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence is equal to or less th an 5 m of ammonia nitrogen and nitrate nitrogenq pP 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 CM 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 f ility 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 fo wing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surf a drinking water supply ❑ ❑ the system is within 200 feet of ributary to a surface drinking water supply 0 ❑ the system is located in a ' rogen sensitive area(Interim Wellhead Protection Area—IWPA)or a map d Zone II of a public water supply well If you have answered"yes"to any ques' n in Section E the system is considered a significant threat, or answered"yes" in Section D abov he large system has failed.The owner or operator of any large system considered a significant t at under Section E or failed under Section D shall upgrade the system in accordance with 31 MR 15.304.The system owner should contact the appropriate regional office of the Depa ent. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 05635 March 27, 2014 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? system components, excluding the SAS, located on site? Were all s s 9 ® ❑ Y P ® ❑ 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? ® El information 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): 9 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x#of bedrooms): 990 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property.Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 05635 March 27, 2014 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes N . No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No 2012=439 GPD Water meter readings, if available(last 2 years usage(gpd)): 2013=1151 GPD Detail: Sump pump? ❑ Yes ® No 11-21-2013 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203), Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes El No Industrial waste holding tank present ❑ Yes ❑ No Non-sanitary waste discharged the Title 5 system? ❑ Yes ❑ No Water meter readings, if ilable: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 05635 March 27, 2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): Genera Information Pumping Records: Source of information: No pumping records available Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: gal on 9ns How was quantity pumped determined? Sight Tube Maintenance 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): 'Pump Chamber Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 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: Installed 2/14/2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.50' Depth below grade: 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.): Septic Tank.(locate on site plan): 2.00' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 12'x 6.5'x 5.5' 2000 gallons Dimensions: 4" Sludge depth: Commonwealth of Massachusetts Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is .Cotuit MA 05635 March 27, 2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" 10" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" 7o Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure&dip tube Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet&outlet PVC tees/baffles in place. Liquid level outlet invert. H-20 tank with lids to grade for inlet and outlet. Grease Trap(locate on site plan): Depth below grade: fe Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of o et tee or baffle Distance from bottom of scum to ottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 05635 March 27, 2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, struct al integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumpe/glassEF (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ yethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pump' g: Date Comments(c dition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet.invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, 3 outlets concrete H-20 D=Box. No sign of leakage.No sign of high water staining over outlet invert Concrete cover on 20" riser to within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 1500 Gallon H-20 pump chamber in good condition. No signs of high water staining. *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: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owners Name information is Cotuit MA 05635 March 27, 2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number:. (9)500 gallon ® leaching chambers number. chambers 81'x12' ® 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.): No signs of hydraulic failure above leach field. Cesspools (cesspool must be pumped as part of inspection) (locat n 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 groundwat inflow ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, co ition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition o/signs aulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is required for every Cotuit MA 05635 March 27, 2014 page. Citylrown 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 RoNr _ Io oa A r \ r Ai, q&'&" Aa:s3( y=q,&,, i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1424 Main Street Property Address Tara O'Keefe Owner Owner's Name information is Cotuit MA 05635 March 27 2014 required for every + page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: `5' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,date of design plan reviewed: August 31, 2000 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: Test hole done 08/31/2000 120"no sign of ground water. Before filing this Inspection Report,please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 1424 Main Street Property Address Tara O'Keefe Owner Owners Name information is Cotuit MA 05635 March 27,2014 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file cc o N . -�r— Fee-4S—�-�---------- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*r Veil Con9tructionj3ermit Application is hereby made for a permit to Construct (e1, Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Address 0?/4 a;?TVj -------------------------------- Installer — Driller Address 0 ZL Type of Building r/ Dwelling------------------------------------------------------- Other - Type of Building No. of - . Persons---'-S------------------------------- ---__- ------ Type of Well— �P -�- Capacity_-----------� - - Purpose of Well----—7 44-1`- -----__ C� Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate.of compliance has been issued by the Board of Health. Signe ---------------- to Application Approved By date Application Disapproved for the following reasons:— ------------- -- -- ----- ------------------------------------------------------------------ date �- Permit No. � �����`_ _ Issued---------------I�---- -----�� —�---- --- --date �----------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ✓j, Altered ( ), or Repaired ( ) by --rk C.- ------ / , Installer _ -------- ------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.U)M\- O--Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—_-- - Inspector-- ----- - -----------—- �.,. r....,... "'. :..:_A., ( N. -��-- -- ' Fee-- 5------------- BOARD OF HEALTH r TOWN OF BARNSTABLE 1pplication1br' ell: Congtruct ion Permit , Applicat' n is hereby made for a permit to Construct( Alter ( : ), or Repair ( )an individual Well at: r. /W7�q/lu __5 T - C'o.7-0�77 Location Address '/� Assessors Map and Parcel 90 1i�/p/ Address l l l t i Q �� �5/liGr— L 4U C a7� 3 �lLci�rv5 »� .a - 4 - ------ OwneDriller �---�---------_-� -------- Installer ` Address Type of Building; Dwelling — ------------------ ------------------------ Other -.Type of Building -'=- -- - = No. of Persons---- ------------------------- Type of Well. N�OT7/3XC�— -=_° — _� Capacity------ - ------------------- '• Purpose of Well -T.2 lei_ CrT(D �- --- Agreement: The undersigned agrees to install .the aforedescribed individual well in accordance with the provisions.of The Townof Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of C ompliance has been issued by the Board of Health. Signe - —------------- - - 1 te Application Approved By date Application Disapproved for the following reasons:=--------=----=---------------_______—____ __—_______ 1 --- - -- - - ------------------ - —---- ------ l ----- � date AG Permit No. n ' Issued-- date iTir'!i!!el�4R�ilrl�Vi4.�M.@i'!i}iK8o4a �a:4ii�bo4dli! irPili�ilieilBliliMiOi�ali!�ifiFTM1YTi"JbTYCy`Il,VYM.Nt•MQOIitiK�6VilbdlAN3lG1i}8@iOf�7lRR�Mi!Mli9J1'i�C!A4S�6Ti4iao+4e+": BOARD OF HEALTH 1 TOWN OF BARNSTABLE a Certificate'®f Compliance THIS IS.TO.CERTIFY, That the Individual Well Constructed( ✓j Altered ( ), or Repaired ( ) F5/�tON© i�/C4C _ a .eiGC/n Ti(�C by Installer S _ has been installed in accordance with the provisions of the,Town of Barnstable Board of Health Private Well Protection -Regulation as described.in the application for Well Construction Permit No.U_= , Dated!U- -+ THE.ISSUANCE OF THIS CERTIFICATE.SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—== - —= _- Inspector:_- - - --- -- -�—�------- 'f,m�.'s'KK^°,is7►�A.ra.4`ar9�s.`iRia�C57ic9aasstti.iraYirAsaa0iT46�`^49e•b!sPi^sea.N4awaaHS4a.slirpw!�i�w ►.tar+wsief!+a14-w4r�eserrota rf'd..l�Ala.�.rs'Ai.� ..iei�:�Gr�ilie�".°seYewTiiR.r.(:wMe�E6os�c�e Raek.F= l BOA'R.D:OF HEALTH TO W"W OF. BARNSTABLE yell (Con5truction'Permit Fee.yr --- . 'Permission is hereby granted —__--_— to'Construct (' Alter ( ); or.Repair ( ) an Individual Well-at: ya i�rl .�T Co?zi i�"` No. — ----- -—--- -------------------- Street as shown on the application for a Well Construction Permit r, -1-- Nti: Date �I_ � �_ ! ' Board of Health -DATE - Ul;l—lt3'LUU! II1U !! ;Llj rl'I rHA 1W. r, ul/u1 `M.BC9F`N r g I I ot / I '�Oi��Nd�N,„pta 0 r 9 f ' n r Massachusetts Department of Environmental Management Office of Water Resources. 104665 ' TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE ' Address at Well Locati6rj: `f m��A i - Property Owner: Subdivision-Name Mailing Address k Citylrown. Citylfown: /�?Qcl-t r; Kr Assessors Map Assessors Lot# �I NOTE Assessors Map and Lot# rriandatory rf no streetcad%iress available; ti Soartl ofi Health permit obtained Yes = Not Required.0 Permit Number Qd� fo Date•Issued`:� "� . .. _t e _ 1 WOR PEAlFOAMED _: °`PRQPOSED-USE 4. DRILLING METHOD. t _New Well ❑ Abandon &`Domestic ❑ Irrigation ❑ Cable uger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer—\'q' Direct Push ❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud'Rota ,�) .❑ Other 5.WELL LOG ( Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks with distances) Permeability T Y d From (ft) To (ft) High low � m Other Rock Type + `� lN� 404 7.WELL CONSTRUCTION' - 8. CASING _ o Total Depth Drilled From (ft) To (ft) Casing Type.;and Material Size O.D. (in) Well Seal Type Date Drilling Complete "'�"� ` I '5C'k b A/C 9. SCREEN _ From (ft) To (ft) Slot Size -/S�creen_Type .and Material Screen Diameter 10 FILTERm PACK/GROUTe/ABANDONMENT MATERIAL 11. ADDITIONAL . ELL INFORMATION Developed? -Yes ❑ No From (ft) To (ft) Material Description'. ? Purpose Fracture Enhancement? ❑ Yes ' �. Method Disinfected? ❑ Yes ❑ No 12 WELL°TEST DATA(PRt RUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS) Yield, ,Time Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM),�`(hr's'°& min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 14 PERMANENT PUMP,',, AVAILABLE} 15.NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description A, Horsepower Pump Intake Depth b (ft) Nominal Pump Capacity (gpm) 16. COMMENTS �~• . 1.7 W ,©RILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules e and regulations, and this repo; is complete and c rrect to the best of my knowledge. Driller: ' Ut X J � pervising Driller Signature: �� Registration #: 6 Firm: ' U �E -- -�� Date: `- Rig Permit#: NOTE. Well Completion Reports.must a filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY b � � O b 1ppl o4Z I SON t - . TOWN OF BARNSTABLE LOCA-11ON �f�2 y/ AlA� S� S.EWAGE # a�Ov 52 YFLLAGE e_01-r6r4! ASSESSO,f2`S MIAP & LOT 01-7-01 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a2000 T 4MO. A�� i1. Cam• LEACHING{FACILITY: (type) • C (size) fZ XP� NO. OF BEDROOMS BUILDER OR OWNER H "' 010 PERMIT DATE: Id—oo COMPLIANCE DATE: t' d2. Separation Distance Between the: `� t M y,. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Teaching Facility (If any wells exist on site or within 200 feet of leaching facility) t Feet Edge of Wetlard and Leaching Facility (If any wetlands exist -a within 300 feet of leaching facility) Feet Furnished by d KILO o 0•,�6 — G z-d A•�r� 9'4 4s-o . o•Rr9-8' . G•CS � � � s 0 � e 7 � 9 �STo,eq• z- TOWN OF BARNSTABLE LOCATION ��7Z� 04,'vl -2r SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 0/7"D/Z- INSTALLER'S NAME&PHONE NO. 24 1s .6 a e" , SEPTIC TANK CAPACITY 7l'Zd/S00 C-A / -Zo )30X, LEACHING FACILITY: (type) I (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 P Jam/ if c e� No: Fee J/UG GO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprtcatton for Mtopossal 6pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(X )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /ya�f m(,Li h S f. CO f a��— Owner's Name,Address and Tel.No. �t rncs /�oecK a 'TQra G't'ee fe Assessor'sMap/Parcel Mxlp O/ Arid O/a. /y-3y maJn St. eafu/t m# 0-2143S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Peter Su//�'YQh Pt �SU//i vrir� En9.Inc . 7 Pa.r-/,ecr leva,[, o"s fcrv,%/G 50f- ya,J-3.31/ Type of Building: Dwelling No.of Bedrooms_� Lot Size �' y A �Cscl. . Garbage Grinder(W Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow q Ro Glob gallons per day. Calculated daily flow gallons. Plan Date 3/. a000 Number of sheets Revision Date r")9 Title SfTE pLrq 4) - PA?0Po�sEJ s�"T� TrnP✓zOy£yr,�,t1TS Size of Septic Tank 02000 9 4,/ set h nk Type of S.A.S. L erceA 1X4 N AM&t r ' Description of Soil resf- Ad,, -c/ 36.S ..3 G L o4h-i 3 " _14 N L err►. C'Gtrse. mcnx /dyr. 5/3 ' /y"- qG '' ye/�;,1 h �rrt L'ct'cr.1e_ Saner /0yr S//o y 0 Ve/I,S5/t eo4rd- _Wnt Nature of Repairs or Alterations(Answer when applicable) PQ,D�r v!l [J�r� f t O-Syx Syf Z WRITING Date last inspected: IN ST p TalE 1CT T E Agreement: ACCOR O LAN' 1^VwA t The undersigned agrees t ensure thee con'9tru 'o and maintenance of the a re described on-site sewage disposal system in accordance with the p isio of Title 5 r nmen ode and t place the system in operation unti a Ce fi- cate of Compliance has en ' ued this Boar al N iAlolSigne o Date Application Approved by Date Application Disapproved for the following reas n Permit No. "` Date Issued Irl oy � Fee / G® A� Entered in computer: a THE£OMMONWEALTH OF MASSACHUSETTS { « Yes - _ s-PUBLIC,HEALTH DIVISIONS TOWN OF BARNSTABLE., MASSACHUSETTS r application for Migogar 44pgtem Cougtruction Permit Application fora Permit to Construct( )Repair( )Upgrade(X )Abandon( "),,JD Complete System O Individual Components 1 Location Address or Lot No. I u7 St. Co f li/. Owne 's Name,Address and Tel.No Assessor'sMap/Parcel /YIkp Q/ Aaree/ Q 0"145' " .Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel. o. �: J fCr sod/r�h PC' X <CiJall),yd,? y- SnG �0�+) i-rvc1 d n f ,Ty pe of Building: Dwelling No.of Bedrooms 9 Lot Size y� '3�"gt. Garbage Grinder( o : Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Igo (r,06 Design Flow gallons per day. Calculated daily flow gallons. Plan Date zgas i d i"Pa Number of sheets a Revision Date ry N Mom` Title s/7� 1'1-/9 /0 - P ZOPd,StJ SiT� 2>77 vy�rf��.UTS Size of Septic Tank 1�000 9 " l-r W L- h Type of S.A.S. e4al IJe j ' P$ . Description of Soil rest ho/c l 3U } ",3" G L as A7-7 —TTrL r17. L40_fk %M nX /Dyr. .513 5„_ qG ,,, yell,:!h ",��a:°/i Nature of Repairs or Alterations(Answer when applicable)�A.-� � / J' 1 t, S T z it Date ist inspected: _ Agre The undersigned anele,nsure the cons i and maintenance of the ore described on-site sewage disposal system ? / ~ in accordance with the 5 nth i onme ode and o to place the system in operation unt a Ce fi- cate of.Compliance hasuis Bo earo �� Date Application Approved by %7 'Y j ^ 4 '''� r Date p _ AppliA5100 on Disapprov `d for the following re o r ' Permit N, . Date Issued "w--------------------------------- �. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired Upgraded ) Abandong d by . - at /4 d 1--l0 r e G , 9 h constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N ted Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No.� �—�----------------------—Fe�/� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS migpogal *pgtem congtruction permit Permission is hereby g petl toCon�ct� )R�p�ir( )UpgraOel� Abandon ( ) System located at //``��aa�l 11 (� 1Zt and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 his p it. ADate: r Approved by r Owners Option to Install H.D. rVENT F.G.29.5 Covers to F.G. F.G.31.0 28.0 Top El.29.0 27,0 2000 Gallon 1500 Gallon ;1r Bot.EI.26.0 Septic Tank Pump 21,± Chamber • • y^' Ground Waterna E1.Less Than 5.0 Per Bedding,5 T.O.B. Ground Water Mapp Per Title,5 Bottom of Test Hole El. 20.5 DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Not to Scale Al I Components to be H-20 Loading. NOTES 1.Water Supply ForThis Lot is Municipal Water. 2 Location of Utilities Shown on This Plan Are Approx. At Least 72 Hours Prior 10 Any Excavation Far This Proied The ControctorShall Make The Reqquired FI„ish Wade Nottiicotion to Dig Safe(1-800-322-4844) 3 The Contractor is Required to Secure Appropriates Fllter Permits From Town Agencies For Construction a Fabric Compacted Fill- Fabric byThis Plan. 1/et-Ile 4 Install Risers as Required to Within 12!'of Pea Stone Finished Grade. A 5.All Structures Buried Four Feet or More or Subject ,• Leaching y M to Vehicular Traffic Lobe H-20 Loading. a Chamber 3/4 -1 I/2 ' 6 Septic System to be Installed in Accordance With ! a Double Washed 310 C MR 15.00 Latest Revision And The Town of Stone Barnstable Board of Health Regulations I 4-10 I 7. All Piping lobe Sch.40 PVC. CROSS SECTION OF CHAMBER DESIGN DATA NOT TO SCALE Single Family-9 Bedroom With no Garbage Grinder Daily Flow=110 x 9=990 GPD Septic Tank:990 GPD x 200%=1980GPD 24"0 Opening Above For M.H. Use 2000 Gallon Septic Tank V2bGalv Pipe Fbr Frame&Cow. LEACHING AREA Float Support 990 GPD/0.74=1338 SF Required r'•' : ,>i''• ;'r'•:•': Sidewall=2(12'+81')2=37ZS.F. Bottom Area=dx8l' = 972 S.F. Pump PowerB Float Control To D-Box. 1344 S.F.Total Provided Cables Installed in Accordance ( � _ LEACHING CHAMBERDESI6N With.Local Bldg.B Elec.Codes. A-11 Pipes to be Schedule 40. Use p 9-500 Gal.Leaching Chambers Ina I a 4"0 From:Septic 12•x 81'Washed Stone Field as Shown Tank.Sch.40 PVC I Precast Pump Chamber O_ o' PLAN 4'.0 Soh.40 PVC Finished From Septic Tank Grade OF KTER ..n.� SULLIVAIaf Conduit Thru Chamber Galv !� For Power a Float Chain To D-Box Ind. Storage ` Cables. Chain a� E� Emergertty 9 ii Min.2�Cover Vol.990 Gal. . C I� y a AlarmwEl.23.6 2"0 Sch.40 PVC PumponEl.23.1 Mercury Float Threaded Pipe Switchs-3Req'd A, Pum off El 22.3 Check Valve (� Secure Pi peat Top li Bottom of Chamber Bottom El21.3 a �. 6"Washed ►•: Stone Min. SHEET 2 of 2 SECTION T— HOECK—OKEEFE ( COTUIT, MASS. 1500Gallon) PUMP CHAMBER DETAIL SULLIVANENGINEERING INC. Not to Scale OSTERVILILLE,MASS. AUGUST 31 ,2000 TOWN OF BARNSTABLE LOCATION L SEWAGE # aQU 523 VILLAGE 4-074,dP ASSESS6",' -M:AP & LOT 61-7-01 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY o'10D� �C�DO�A� A. G• y r— IZ Xfr/ � T LEACHING"FACILITY: (type) • L 7/ (size) NO. OF BEDROOMS BUILDER OR OWNER y PERMITDATE: (JO COMPLIANCE DATE: 2 t' 0 Separation Distance Between the: ; Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Ma-aching 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 d AID (a o1 Id 0 . y o•rb -� o h.*lrr 0 o•o�'� o•,SG Z vd � 41•,aid-p � F (r• 1CS s 3 O b v� r Owners Option to Install H.D. rVENT Covers to F.G. F.G.29.5 --a.•__._ F.G.31.0 28.0 � Top EI.29.0 27.0 :'cr Bot.EI.26.0 6.5 2000Gallon 1500Gallon Septic Tank Pump 21,I Chamber • y�' '' Ground Waterna EL Less Than 5.0 Per Bedding as TO. Ground Water Map. Per Title 5 Bottom of Test Hole El. 20.5 DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Not to Scale At I Components to be H-20 Loading. NOTES I.Water Supply ForThis Lot is Municipal Water. 2 Location of Utilities Shown on This Plan Am Approx. At Least 72 Hours Prior to Any Excavation ForThis Project The Contractor Shall Make The Required Flnieh Wade Notification to Dig Safe(1-800-322-4844) l; 3 The Contractor is Required to Secure Appropriate Filter Permits From Town Agencies For Construction ' �+ Fabric �—Coqmc►ed Fill Defined by This Plan. .N I/2« 4. Install Risers as Requiredto Within 12!'of Pea stone Finished Grade. 5.All Structures Buried Four Feet orMore or Subject' Lsoehlne to Vehicular Traffic to be H-20 Loading. ,• a chamber 3/4«-1 1/2«' 6. Septic System to be Instolled in Accordance With Double washed 310 CMR 15.00 Latest Revision And The Townof Stone I 4-10 Barnstable Board of Health Regulations I I 12'-d' I 7. AI I Piping to be Sch.40 PVC. CROSS SECTION OF CHAMBER DESIGN DATA Single Family-9 Bedroom NOT TO SCALE With no Garbage Grinder Daily Flow=110 x 9=990 GPD f Septic Tank:990 GPD x 200%=1980GPD 24°0 Opening Above For M.H. Use 2000 Gallon Septic Tank 1/2'01Galy.Pipe Fbr From BiCover. LEACHING AREA Float Support 990 GPD/0.74=1338 SF Required +'•' : +>r' ;.'+'`•'•': Sidewall=2(12'+81')2=37gS.F. y a �1 Bottom Area= 12x8l' = 972 S.F. Pump Power 8 Float Control To D-Box 1344 S.F.Total Provided Cables Installed in Accordance _ LEACHING CHAMBERDESI6N With.Local Bldg.B Elec.Codes. ( � All Pipes to be Schedule 40. Use p = �` / 9-500 Gal.Leaching Chambers ina ',I Y. 4°0 From Septic 12'x 81'Washed Stone Field as Shown Tank.Sch.40 PVC Precast Pump Chamber 10-0° M ti "o' PLAN From 0 S Septic is PVC Finished �OF From Septic Tank Grade� LLI Conduit Thru Chamber !i �0.297'9 -4 For Power 11 Float Galv. To D Box �` II. do Emergency Storage c Cables. Chain a" Min.2 Cover V01.990 Gal. < Alarm on El. 2"0 Sch.40 PVC Mercury Float ^' Pumpon E1.23.1 y Threaded Pipet Switchs-3 Req'd Pum off El 22.3 Check Valve Secure Pipe at Top& Bottom of Chamber 1 Bottom El 21.3 a 6"Washed b:?. stone Min. SHEET 2 Of 2 SECTION. °T HOECK-OKEEFE (1500 Gallon) COTUIT, MASS. PUMP CHAMBER DETAIL SULLIVANENGINEERING INC. Not to Scale OSTERVILILLE,MASS. AUGUST 31 ,2000 l i 0 Commonweafth of Massachusetts )CIVEO -f Executive Office of Environmental Affairs DE Cpartment ofEnvironmental Protection .William F.WeldGovernor Trudy Coxe Secretory, EA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: t ya2� �a%W 57- Cl1Tc_/'lr Address of Owner: /461r u,- F,',d/,,9'q-5 Date of Inspection: /a�-�S (If different) Name of Inspecto105-z�beJ Company Name, Address and nand Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatw-e-'j/ Date: /4 . The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design floe- of 10,000 gpd or greater, the inspector and.the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should oe sen: to :ne system owner and copies sem to the buyer, if applicable and the approving au:horit). INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 i0 Printed on Recycled Paper r F ' Y f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) c i Property Address: /y,;2 q Mgfk, 57— C07-bi I Owner: Aort ,r Date of Inspection: B1 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced �T The system required pumping more than four 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 C1 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ l hP 5v5tem had a septic tanK ano sou ausorptiun system anu i5 withli i iUv fir iiv a Sulia�c 'via,- �uj�j�i� o. tribuiar,' i0 a surface Aater supply. _ The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen-, has a septic tank and sot; absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a weld water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D1 SYSTEM FAILS: / 7 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:/ /y� P'LJCu u- S% CoTLi 7 Owner: 40-- -v^ 19r4ni,94f Date of Inspection:, D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s). f Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. f`I Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The follov.,ing criteria apply to large systems in addition to the criteria above: The desien flov, of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 v`ater supply weli� The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /V d y OPV � ST COTC.ii f Owner: 64c.7k�— �l0l4� Date of Inspection: /i-as-s Check if the following have been done: Pumping information was requested of th ovine occupant, and Board of Health. fNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 4ks built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow ✓The site was inspected for signs of breakout. ✓ll system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees., material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. v 1i r facili,> o••,•, ;a•-;,' occupa!� _, if were provided with information on the proper maintenance of Sub- Surface Disposal System. • .srl` (revised 8/15/95; 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '^, SYSTEM INFORMATION Property Address: /���/ /nctl K 5r Co—l-uI% Owner: r4c.7r4 yr P''laPA"5 Date of Inspection: f a4--IFS FLOW CONDITIONS RESIDENTIAL: Design flow: 660 allons Number of be rooms:_[Q Number of current residents: Garbage grinder (yes or no):-[eS Laundry connected to system (yes or no): Seasonal use (yes or no):� Water meter readings, if available: ,?4. Last date of occupancy: ' IfSeILk COMMERCIAL]INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Neater meter readings, if available: Last date of occupancy: OTHER: (Describe; Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 7 WO 4'ec•vs System pumped as part of inspection: (yes or no)-16/ If yes, volume PLIMPPe. gallons Reason for pumping: TYPE gf-SYSTEM 1/ 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: U P YET i N Lgg0 Sewage odors detected when arriving at the site: (yes or no)L (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / Owner: r Date of Inspection: 1' SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: "concrete _metal _FRP —other(explain) Dimensions: 402< � Sludge depth: ;�L`fi Distance from top of(sludge to bottom of outlet tee or baffle: �1 Scum thickness: y; Distance from top of scum to top of outlet tee or baffler /��� Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or b ffles, d t of liquid level in rel tion to outlet invert, structural integrity, evidence of leakage, etc.) S�cv� GREASE TRAP:i� (locate on sit? plan, Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Diga,ice fro^ bottom - cni M hottnrn of outlet tee o' bailie• Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.. (revised e/_5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address:/t .1�( M41 w 57- Cd7i[ T Owner: Date of Inspection: TIGHT OR HOLDING TANK: � (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:- (locate on site plan`. Depth of liquid level above outlet invert: o �e- o� Comments: mote rf ievei and distr;out.w� eq�a, e�.dence of so,:d_ ca,r)o,er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �Ac,,,ti- Owner: AO All Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: �i leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) AJ d f' CESSPOOLS: —'4 (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 ground�Natc�. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: -J 4 (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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:/yob-1-I met,0- ST C07u i T— Owner: A-t>t kL k- Date of Inspection: . SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' , o DEPTH TO GROUNDWATER Depth to groundwater: feet A- bo, \A"5 �r�i e r p Ov�``>T•n€h 5' method of determination or approximation: (revised 8/15/95) 9 L0 �AT10N SEWAGE PERMIT NO. VILLAGE f±,2:Z aA ,',oj S Co v1 INSTT�A�LLE1R'S NAME i ADDRESS �c f OR OWNER Ag t�u k- Russ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED •, �� e . S �� b �_ , �r +# � i ` �� �/1 � � � /f � ��� 3 _ '�� ,� 1 t SUBJECT TO APPROVAL. CF ............ BARNSTABLE CC!S R!eAT! �:3 F� ZS.v b THE COMMONWEALTH OF MASS/UCffl95jE TS N BOARD OF HEALTH ..jo..................OF........164 S f..L.. Appliration for j3hip sal Works (futwunrunn Vrrmit Application is hereby made for a Permit to Construct (1/1�or Repair ( ) an Individual Sewage Disposal System at C 'L MAI#J °ST, oTLA rr t ...........- __........ ...........• -........... ---------•••..._....... .............•••.....-••-••••••••--••-•-•--•-••----...--•---•••--............•---...........••••-- Location-Address or No. !#. ........................... .... 1 ._..� ...�!?.s�.M!!<t.�'LQ+J 1!!� -•- 0 r Address W nstaller Address � Type of Building Size Lot.'24.........vvo..........Sq. feet Dwelling—No. of Bedrooms....-�-�.....................................Expansion Attic (ND) Garbage Grinder (Aid) Other—Type T e of Building No. of persons............................ Showers YP g ------•---._.--•-------.._.. p ( ) — Cafeteria (JCI) Q' Other fixtures --------•-••••. -••-••-•-•-•••• . w Design Flow.............112........................gallons per person per day. Total daily flow...... .47......................._gallons. WSeptic Tank—Liquid capacitylrPAPgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench--N ....... �r ppWidth•.................. Total Length.................... Total leaching area............... sq. ft' 3 Seepage Pit No........ . L1iat4�et�t. _/d Depth below inlet..-.,/.......... Total leaching area..-1 _sq. ft. Z Other Distribution box ( Dosing to Percolation Test Results Performed by.....r�6d�t ......ZZe................. Date........................................ Test Pit No. l.4..�_.._minutes per inch Depth o est Pit.................... Depth to ground water......................... r=, Test Pit No. 2_.4..*Z...minutes per inch Depth of Test Pit...ls ..... Depth to ground water___ �!" NQ..1NATUZ (Yi .............................•----.......................-•----..........---.................................... ........_.................••••-•i 4..... 1'4ew .... ........... O Description of Soil..........FIrLM. .-4544ND.................. x U .....••••-•-•••---------••-•------•-•-•-•••••----•--•••-•--•--••--•--•-•--•--•...••••----••-•-------••--•--•-•-•••............................................................... ..•-••-•-------•---. 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 T IT L;,,. 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. Si ne ,.....: Date Application Approved By....._ e Da Application Disapproved for the following reasons:................. ....--------- ----------------------•-------------------•-------------------.......---- ••...............................•----••----•-••---...-•----•---.............---•............--•--....•••I••....••--••.....-••-------...•--------•--••••--•--------•----•-••......---••--•-•-•........._. Date Permit No..................................................... I su ..... Date a r r 1 o...... `��:......... - ' ' t FEB............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' f ...........................................O F...................................._.. k Appliration for DispooFal Works Tonstrurtion umit Application is hereby made for a Permit to Construct (Vr or Repair ( ) an Individual Sewage Disposal System at ly2 � M&IN y ST, to'ru T 12 -cation-Address .r .... .•-.... A�e� ... ;: .. .... `�----:A�Fx�4.1r..... .rt.ilii1�.-rao-..,.MA..-----•--- r Address W a ..._-•_••--••----•••••-----•••••. •••_•...............••--............._-_.....•••••......_..-•-----•-----••----•--•........•-----.. nstaller Address d Type of Building Size Lot_79-1OQ .............Sq. feet U Dwelling—No. of Bedrooms.___'..................................Expansion Attic NO) Garbage Grinder ()J b Other—T e of Building No. of ersons____________________________ Showers a YP g ---•-----•----------------•- P ---(----)--- Cafeteria (N b Otherfixtures ..................•---------------..._..--------••----.....-------._....----------------...••-•--••......• •-•--••--- W Design Flow.................11 ................... per person per day. Total daily flow..........525.P-__..__._______.._.._gallons. WSeptic Tank—Liquid capacity_1.1500gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—N .__ jr..,_�.v�id th____._._....y.__._.__. Total Length_________ _________ Total leaching area_______._.__._. _ sq. ft. Seepage Pit No.G? - t t_____________f�_ Depth below inlet.... Total leaching area__�� -sq. ft, Z Other Distribution box ( ) Dosing otakPercolation Test Results Performed by...., L.j',r`___________________ Date._.__._...._.___.........._____._...._.. 2 minutes per inch th est Pit___________ ____ Depth to ground water Nest Pit No. 1- = f=, Nest Pit No. 2_<__=.2..minutes per inch Depth of Test Pit... `�:_.. Depth to ground water Ni*.-XY_e-r-W } F,r�14» LL' ...................... Description of Soil............. 1!ZA-. t...a44iQAAM. j;.CLEA.t '.S hL[�-= W . ----------•-------------------•-----------•----•---------------------------- --•- --------- V 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 TT T`E 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, Sie �__----•-------------------------------•_•---------•-----------_.......__- � Date Application Approved By._' -----------•--- ------- -_-}� "�I� -.:....... Date Application Disapproved for the following reasons:' -------------••----.._...-•--•-------••----------------------------•-•-•.....--•••-•-_ vi .............................•--------•-----•------...-•------=---......---------•------•----•--•-------•----••••-- ---•-•--=------•-••---•...-•-••---••-•--•-•---•--••----•------•----•.......... Date Permit No.....--•••_•----•••-- _-_..... Issued......___--••-•---•---•--••••...... -----------------------•- •'--•--- Date ... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH �ylf'j..........:OF...... ...i............................................ Trrtifirate of Toutpliatta TH S S ,�,' ERTI , That the Individual Sewage Disposal System constructed ( or Repaired ( ) by ....... --------- � i �s I taller �.... at '14 t ,' '� .�'• .._:.._..�- ! 14 ,J _ �J-l--+at' ... ----------------•----._........................ has been installed in accordance wit—ie provisions of ' 5 of The State Sanitary Code as described in the application for.Disposal,Works Construction Permit Nor ___;�_'`_1................... dated_...-/_".......0�/'}................... THE ISSUANCE OF THIS.,.CERTIFICATE: SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. Z• d ` --••_.._.. Inspector ""'�� r f THE COMMONWEALTH OF MASSACHUSETTS ,a BOARD 9F HEALTHIC7 ' �,� i /�! ....... OF.:._: i ... / ... FEE 02 .... ... a No .f'...., ...----..... tapos o ' ton ermit x . j Permission 's herebyanted.. ._ to Constr" &.( or Repair '( an Individual Se-V ge spa,, System Street as shown on the application for Disposal Works Construction P it N or, __ Dated_._,/!/V. '.�................. � R ' ? .w _ --•- ^ of He DATE... � --- .................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r main L-11�`strsgf 129 30 (J3' Wide — Public) 1 ' / Z _ 9*52 JO' E / 52.J1 st.nld.r.w 123.95 �•" I �� j01MIN. o I (b \ \ r 1 C6%i 1, �� �'• � 91 D Bpx p / p ry 1 \ I \Z•A el. L \ HOLM If 371 IN as / /mil \ I o o• 9� % J\N C? o O C44 M 000 If PtIlm \ sr• o r Nt If a \w/ 1 \ \ \ _ tjj '�•tip\ . ` C \\ \ �� ` t \\\ 1 y �B10 \\ \ \ •\\\\; \\\ q NN NI C�O�� 0�/. PLAN VIEW "= 30' " Scale � I • TESr Wol`E. EL. 3o.s 0 0 LOAM 3i1 L �H a. BR,,1, co�►ssa y'�, SHEET I of 2 0, SAND IOYR.?/3 1`+ 9 yc�,sa, era sib AR9a S��t vAN SITE PLAN y1v, SANG IO�IR NO.2973� PROPOSED SITE IMPROVEMENTS LT /gL1SM L. .� BRN. CIVIL 1 COgRs6 SAt+O IotrA `/y 1424 MAIN STREET IZd ,TEST HOtv.E BY aQ.=• 1�..��� O COTUIT , MASS. 3 pATG.: AuG.- 1# ?-QOO FOR No GROUfIo WA-fER DAMES iHOECK 81 TARA OKEEFE SCALE. AS SHOWN , DATE,AUG.31,12000 SULLIVAN ENGINEERING INC.f OSTERVILLE, MASS. 30 Main - Street � 129.30 . PY Wide — Public) 2 .31 4932 30' E +I A w sleeeo o I (�'Oj ` IOIMIN. o 0 0 1Cb PRIMARY \ . \__ VimN Tof \ 8 \�• DBO7( / O 2 . 1\�\3FRVf f J' r e�• \NITS iD. - W O ° C#4AIMB00 �R f' ` y\,\ `\ \ / it •��,,,y! ! ,JILD \\ \ A is., 11LN r / C O I' - f o \ \\\ I 7 4S. � �\ \�\\\\ \ •\ of 01, �:. ��� ��.\�o\\�\�� / roll ► \ 1N \ \\\\:N\�\``` 00 PLAN VIEW Scale : I"= 301 TEST HOLE. EL. 30.5 Q LOAM SK OF 3�/ ORM. COARSE ly,, SAND IOYR .S/-3 SULL VAN m SHEET I of 2 yet-14N. BRN. COARSE � NO.��T� yL0 •SAND 1ovR s//, CIVIL SITE PLAN 12d, CAr"G AMD 10YP. &/•, ��c/ ° ;� PROPOSED SITE IMPROVEMENTS 'TEST N OLE SY S- ,=I D�il1'li � � AT DATE: AUG. '511 Z000 1424 MAIN STREET No GR0UW0 WATER COTUIT I MASS. FOR JAMES HOECK Bc TARA OKEEFE SCALE; AS SHOWN , DATE:AUG. 3 f,,`200b 4: SULLIVAN ENGINEERING INC. OSTERVILLE,. MASS. . s iy1IfAl / •F 1 o Rptit ,z 11 ✓« �.A� O " Lowell p.�8% � P�• " Landing Qwo � rnrtber ,17p � o r Tims Timd y Pt Cove n u �Ls J4 „ �� Handy Q� n \ _ �" •"c � i,t-�. � / / I r y 1-IOOpe rS A+E �, pv�i l Nl 1 (- `' i• Beach C Z�jfxcrt; Noisy 32 arbors Pt HOOLID I- `�.- ' ► •♦ ,_ p Public g L andin • lJottllt ♦�(e Bryant hJ i Cove ao • y o'� 4� �� ,Bluff COtU11 A 39 'y *' Pt TJdaf o 4P •a , l'1' �, . I�T}l�(111 / Fla3 6` �o f I• c- _ eapu2t7 Sampsons NECK island ead " a goes S, �l - ey pyst f: o U li �•J_ ;, , & r �u Marsh Pond a � aw / _ Uo h Qo{z0 n'i• Ali L r/C�4hJ e berry + �unkhorry C • Island u+ Meadow point a , - A `S r �1,/. Thatch .'' 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