HomeMy WebLinkAbout1617 MAIN STREET (COTUIT) - Health �{ 1617 .MAIN ,STREET;_,.COTUIT
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Mac 29 2015 18:28 Jim The Inspector Man 5085349919 page 1
OD�-- oo�•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Nct for Voluntary Assessments
,r±
y 1617 Main Street
r
Property Address ,
Margaret Keuler
Owner Owners Name
information is Cotuit V r
required for every MA 02635 12-28-15
page. Cityrrown State Zip Code Date of Inspection 6-i
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:fling outforms
A. General Information
filling out forms ��►ttullrtu�y
on the computer, 2 \ 14
use only the tab / 11 65 ``��� �,ZH OF F�Vo
key to move our 1• Inspector: *� •;••'" 'y�� .
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James D.Sears r��' '•N
use the return JAMES
key. Name of Inspector $v; ARS y s
CapewideEnteMrises, LLC 5
Company Name T1��;�0
153 Commercial Street ''4pF 5 i`N 8
per00��
Company Address.
Mashpee MA 02649
Cdyrrown State Zip Code
508477-8877 S 1623
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
12-28-15
rifnspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP_ The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority. ,
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
15ins•9/13 / T
VsTitle 5 Official Inspection Form:Subsurface Sewage Disposal System• of v
Dec 29 2015 18:28 Jim The Inspector Man 5085349919 page 2
Commonwealth of Massachusetts
0% Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Mar9 aret Keuler
Owner Owners Name
information is
Cotuit
required for every MA 02635 12-28-15
page. Cityffown 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:
Note :The system is for(two) 1 bed room bldg's. The system is a 1000 Gal. Tank D Box and one
pipe trench.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If`not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ina•3/13 Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Dec 29 2015 18:28 Jim The Inspector Man 5085349919 page 3
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owner's Name
information is
required for every Cotuit MA 02635 12-28-15
page. City/Town State Zip Code Date of Inspection
B._Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cant.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box, System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND.(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health In order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
151303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the.environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Dec 29 2015 18:28 Jim The Inspector Man 5085349919 page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is
required for every Cotuit MA 02635 12-28-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in jilinoust is less than 6" below invert or available volume is less
than Y2 day flow A m P/1/a
t5ins.3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 17
Dec 29 2015 18:28 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Ownees Name
information is
required for every Cotuit MA 02635 12-28-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy Is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a,public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 1.0,000 gpd to 16,006 gpd.
For large systems, you must indicate either"yes"or"no"'to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone I I of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat .
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3M 3 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 5 o117
Dec 29 2015 18:28 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments .
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is
required fcr every Cotuit MA 02635 12-28-15
page. Citylrown 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 WA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for si n
signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of.scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) 1310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
15ins•3/S 3 Title 5 omasi Inspection Forth:Subsurface Sewage Disposal System•page 6 of t7
Dec 29 2015 18:28 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is required for every Cotuit MA 02635 12-28-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:.
The system is a 1000 Gal, Tank D Box and one pipe trench
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)): Well Water
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins•3t13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 7 of 17
Dec 29 2015 1828 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owner's Name
information is
required for every Cotuit MA 02635 12-28-15
page. CityrrDwn State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons ,
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank_Attach a copy of the DEP approval.
❑ Other(describe):
15ins•3/13 Title 6 Official Inspection Forth;Subsurface Sewage Disposal System•Page 8 of 17
Dec 29 2015 18:29 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is COtUIt
required for every MA 02635 12-28-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont_)
Approximate age of all components, dale installed (if known) and source of information:
1982 Permit #82-329.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from p-ivate water supply well or suction line: rest
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank (locate on site plan):
Depth below grade: 16"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
2"
t51n5•3/13 Title 5 Official Inspeallon Forth:Subsurface Sewage Disposal System-Page 9 or 17
Dec 29 2015 18:29 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is required for every Cotuit MA 02635 12-28-15
page. CityrTown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level. Tank and covers at 16" below grade. Two inlet tee's Woutlet baffle. No
sign of leakage or over loading.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Mns 31.13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 or 17
Dec 29 2015 18:29 Jim The Inspector. Man 5085349919 page 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is
required for every Cotuit MA 02635 12-28-15
page. Cityrrown Stale Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes F1 No
15ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Dec 29 2015 18:29 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
K Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is
required for every Cotuit MA 02635 12-29-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-42" below grade Wone line out. Box is solid w/no sign of over loading or
solid carry over. g g
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes. ❑ No`
Alarms in working order: ❑ Yes' ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
` If pumps or alarms are not in working order, system is a conditional pass.
i
Soil Absorption System (SAS) (locate on site plan, excavation not required): j
l
If SAS not located, explain why: l
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Dec 29 2015 18:29 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
owner Owner's Name
information is COtUIt
required for every MA 02635 12-28-.15
page. CltylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type.
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number.
® leaching trenches number, length: 1@ 50'
❑ leaching fields number, dimensions:.
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
-. vegetation, etc.):
Leaching is one pipe trench 2' widex 50' long x 1' deep, Ck D Box and camera out line. No sign of
over loading or holdina water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 13 Of 17
Dec 29 2015 18:29 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is
for eve
required Cotuit
4 every MA _ 02635 12-28-15
page. Cltyfrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:.
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
t5ins•3/13
Title 5 Official Inspec ion Form,Subsurface Sewage Disposal System•Page 14 of 17
i
Dec 29 2015 18:30 Jim The Inspector Man 5085349919 page 15
i
i
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Ke.uler
Owner Owners Name
information is COtUIt
required for every MA 02635 12-28-15
City/Town
Cit
page, y
State Zip p 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 10.0 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
k,j
C-3
v
O � I
IL
t
Lt5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Dec 29 2015 18:30 Jim The Inspector Man 5085349919 page 16
commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1617 Main Street
Property Address
Margaret Keuler
Owner Owners Name
information is Cotult
required for every MA 02635 12-28-j5
page. Cityrrown State Zip
Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
i
❑ Shallow wells
Estimated depth to high ground water: 10
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 8-7-81
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.
T.H.on Design plan 8-7-81 water at 10'. Bottom of leaching at 4' below grade. Bottom of leaching at
6'above T.H. Depth.
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
thins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dis
pose System•Page 16 0117
I
Dec 29 2015 18:30 Jim The Inspector Man 5085349919 page 17
Commonwealth of Massachusetts
v. Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1617 Main Street
Property Address .
Margaret Keuler
Owner Owner's Name
Information is
required for every COtUit MA 02635 12-28-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E 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
t5iru•3/13
Title 5 Official tnspeclion Form'Subsurface sewage Disposal System•Page 17 of 17
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Owner ---------•••••----•-•--•-••-•--•Ad-ress
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Installer Address
i U Type of Building nn Size LotA7j-2qQ-------- q. feet
Dwelling—No. of Bedrooms-- ..rah.. Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures ......................................................
Design Flow..........1 1-0_________________________gallons per person per day. Total daily flow........9..;.1Q_.......................gallons.
WSeptic Tank—Liquid capacity i90.Q_gallons j Length................ Width----_..___..._ Diameter---------------- Depth................ P
x Disposal Trench—No. ........... Width___`............. Total Length...�_�_....... Total leaching area_:3.5�_.._...s
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (4 ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water__=__-_.-_--________---.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------------
•-----------
•-----
_------------------------
•---•--__.. --••••--•••-----•----•-•••-••••---____-•--••______•••••••__--••-
0 Description of Soil-------------------------------------------------------------------------------------------------------•----------------------------------------------------------------
x
x -------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the'provisions of TITLE 5 of the State Sanitary ode— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has iss t o•: d'-f I., alt
Signed_.A�,
Date
--
Application Approved By......... y--,�Q- ---�� 6. /�-� r�'1-
-------------•---••------•-•-----•- Date
Application Disapproved for the following reasons------------------•-------•-••--•----•-------------------------•----------------•----------..._..----------_--••-
...........-..............................................................................:--------------..
Date
PermitNo......................................................... Issued_......................................................
Date
Fxs....3 s: .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................... ................O F...................................._...........................I.._......................
Appliration for Uiopooal Works Tonotrudion .erntit
Application is hereby made for a Permit to Construct (\/) or Repair ( ) an Individual Sewage Disposal
S stem at: ,
i
/ Loca•o`_Addres r Lot No.
Owner Ad ress
Installer Address
Type of Building tt� Size Lott �:_ 9 1........Sq. feet
U Dwelling—No. of Bedrooms._....t _________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa. Other fixtures ---------------------------••••-
W Design Flow..........,(0__________________________gallons per person per day. Total daily flow........ _.......................gallons.
WSeptic Tank—Liquid capacityRC®C;__gallons , Length................ Width................ Diameter................ Dept________.___....
x Disposal Trench—No.____________________ Width__jP.__._._______ Total Length.._J____:_____.._._ Total leaching area_. ______......®
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (%/ ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................ �..
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.....................,...
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------•-----•----••--•-----------•--..__....-•-----------•---.....--•---.............................................................
0 Description of Soil................................•----•----------------...-----•--...----------------------------------------...---------------------•-------..._-----•••-----------•---• .
x
W
UNature 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 TIT12 5 of the State Sanitakn�i
ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hass8&6y t.... r _
Signed...... --------------------- ..........................-....
/ Date
Application Approved By........... � =--- - ; �° ....... ---------C-'-< /1L.--
Date
Application Disapproved for the following reasons--------------------•---•-------•--------------------•-------------------------------------------._...._-•-•-----
.....................•----•._..._....---...••--•-.....•••-------------•-----•----•-....-•-.....----------I........................-......................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtifirtttr of faontpliancr
THIS IS TO CERTik ha Individual Individual Sewage Disposal System constructed ( ) or Repaired ( )
by _- - -----(-"-,-,--.•- ---------------- ------------------------------------------------------------------------------------------------------
nsta -
at----•-----••-- -•_----• - - . - `
has been installed in accordance with the provisions of TITLP. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.--.e... _.: 3= ......... dated.......... .......................I..............
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................................................):) !.................. Inspector............... .�------....__._.....-•-•--••--........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF...............••••••-•....._..._..............._.._.__..........__..._...._.........
No... :.y .. FEE........................
Dtop000l or v Tonotrurtion rrnttt
Permission is ereby granted........... :r "=' ' ------- "'` t•-••-••---•--•------•••----•--•-••-•-•--•-•--•----•._.......••.....................
ct to Constr ) or Repair ) ,an IndivWual Sewage Dis osal System
atNo. .................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated.____..._..__..._____.___.......__....__.
Boa of Health
DATE............... ----f --....................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
r
Thomas&Betts Corporation
452 John Dietsch Blvd.
P.O. Box 2510
Attleboro Falls, MA 02763
(508) 699-9800
Facsimile(508) 695-8111
Thomas efts
August 10, 1998
Margaret H. Lloyd
524 E. 72°d Street,Apt. 28B
New York,NY 10021
Dear Ms. Lloyd:
Attached please find the laboratory results of the analysis of your well water, which we recently
sampled at your property located at 1617 Main Street in Cotuit, Massachusetts. The water sample,
designated as RW-9, was collected by GZA GeoEnvironmental, Inc. and analyzed by the Mitkem
Corporation laboratory. No Volatile Organic Compounds (VOCs) were detected in your well water.
The Department of Environmental Protection has been provided a copy of these results.
As you may recall,the contaminants of concern at the 106 Falmouth Road Site were industrial solvents
and cleaners potentially related to historic operations at that facility. To test for such materials, the
laboratory analyzes for the range of VOCs specified by the EPA's testing method. That is why the
Laboratory Analysis Report covers such a long list of organic compounds.
Beside the list of compounds are two columns of data. The first column shows the concentration of
the compound in parts per billion (ppb) found in the water sample. The letters "ND" mean the
compound was not detected. The second column shows the lowest level at which the laboratory could
accurately quantify the compound.
We appreciate your allowing us to come in and test your water. If you have any questions, please do
not hesitate to call Mike Powers at GZA(401-4214140, ext. 3404).
Sincerely
y+ J
William O. Frigon
Attachment: Laboratory Analysis Report
cc: Town of Barnstable Board of Health
Mark Wood,DEP
a
I
MITKEM
CORPORATION
D
JUL 3 0 1998 July 27, 1998
GZA GeoEnvironmental, Inc.
140 Broadway
Providence, RI 02903
Attn: Ms. Hilary Fortune
RE: Client Project#: 31751.13, Residential Well Sampling
Lab Project#: E1139
Dear Ms. Fortune:
Enclosed please find the data report of the required analyses for the samples associated
with the above referenced project. If you have any questions regarding this report, please
call me.
We appreciate your business.
Sincer ,
Edward A. Lawler
Laboratory Operations Manager
F
III
175 Metro Center Boulevard• Warwick, Rhode Island 02886-1755 • (401) 732-3400 • Fax (401) 732-3499
email: mitkem@worldnet.att.net
CORPORATION
r
Client: GZA GeoEnvironmental,Inc.
Client Project: 31751.13,Residential Well Sampling
Lab Project: E1139
Date samples received: 7/17/98
Project Narrative
This data report includes the analysis results for two (2) aqueous samples that were received
from GZA GeoEnvironmetal, Inc. on July 17, 1998. Analyses were performed per specification
in the Chain of Custody form. For reference, a copy of the Mitkem Sample Log-In form is
included for cross-referencing the client sample ID and laboratory sample ID.
All of the analyses were performed according to method specifications. No unusual
occurrences were noted during sample analysis.
This data report has been reviewed and is authorized for release as evidenced by the signature
below.
dui^'
Edward A. Lawler
Laboratory Operations Manager
t
CORPORATION
Analysis Report: Purgeable Volatile Organics
Client: GZA GeoEnvirornmental, Inc. Analysis Date: 7/22/98
Client ID: RW-9 Concentration in: ug/L
Lab ID: E1139-01 Dilution: 1
Analysis: Method 524.2
Reporting
Analyte Results bimif
Dichlorodifluoromethane ND 0.5
Chloromethane ND 0.5
Vinyl chloride ND 0.5
Bromomethane ND 0.5
Chloroethane ND 0.5
Trichlorofluoromethane ND 0.5
1,1-Dichloroethene ND 0.5
Methylene chloride ND 0.5
trans-1,2-Dichloroethene ND 0.5
1,1-Dichloroethane ND 0.5
2,2-Dichloropropane ND 0.5
cis-1,2-Dichloroethene ND 0.5
Bromochloromethane ND 0.5
Chloroform ND 0.5
1,1,1-Trichloroethane ND 0.5
Carbon tetrachloride ND 0.5
1,1-Dichloropropene ND 0.5
Benzene ND 0.5
1,2-Dichloroethane ND 0.5
Trichloroethene ND 0.5
1,2-Dichloropropane ND 0.5
Dibromomethane ND 0.5
Bromodichloromethane ND 0.5
cis-1,3-Dichloropropene ND 0.5
Toluene ND 0.5
trans-1,3-Dichloropropene ND 0.5
1,1,2-Trichloroethane ND 0.5
Tetrachloroethene ND 0.5
1,3-Dichloropropane ND 0.5
Dibromochloromethane ND 0.5
1,2-Dibromoethane ND 0.5
Chlorobenzene ND 0.5
1,1,1,2-Tetrachloroethane ND 0.5
Page 1 of 2 E1139-01 0 0
f
CORPORATION
Client ID: RW-9 Lab ID: E1139-01
Reporting
Analyte Result Limit
Ethylbenzene ND 0.5
Xylenes (total) ND 0.5
Styrene ND 0.5
Bromoform ND 0.5
Isopropylbenzene ND 0.5
Bromobenzene ND 0.5
1,1,2,2-Tetrachloroethane ND 0.5
1,2,3-Trichloropropane ND 0.5
n-Propylbenzene ND 0.5
2-Chlorotoluene ND 0.5
4-Chlorotoluene ND 0.5
1,3,5-Trimethylbenzene ND 0.5
tert-Butylbenzene ND 0.5
1,2,4-Trimethylbenzene ND 0.5
sec-Butylbenzene ND 0.5
1,3-Dichlorobenzene ND 0.5
4-Isopropyltoluene ND 0.5
1,4-Dichlorobenzene ND 0.5
1,2-Dichlorobenzene ND 0.5
n-Butylbenzene ND 0.5
1,2-Dibromo-3-chloropropane ND 0.5
1,2,4-Trichlorobenzene ND 0.5
Hexachlorobutadiene ND 0.5
1,2,3-Trichlorobenzene ND 0.5
Naphthalene ND 0.5
QC Batch: V5B0722A
Surrogate Recovery:
Bromofluorobenzene 100%
1,2-Dichlorobenzene-d4 102%
ND= Not Detected
Page 2 of 2 E1139-01
003
CORPORATION
Analysis Report: Purgeable Volatile Organics
Client: GZA GeoEnvirorn mental, Inc. Analysis Date: 7/22/98
Client ID: Trip Blank Concentration in: ug/L
Lab ID: E1139-02 Dilution: 1
Analysis: Method 524.2
Reporting
Analyte Results Umil
Dichlorodifluoromethane ND 0.5
Chloromethane ND 0.5
Vinyl chloride ND 0.5
Bromomethane ND 0.5
Chloroethane ND 0.5
Trichlorofluoromethane ND 0.5
1,1-Dichloroethene ND 0.5
Methylene chloride ND 0.5
trans-1,2-Dichloroethene ND 0.5
1,1-Dichloroethane ND 0.5
2,2-Dichloropropane ND 0.5
cis-1,2-Dichloroethene ND 0.5
Bromochloromethane ND 0.5
Chloroform ND 0.5
1,1,1-Trichloroethane ND 0.5
Carbon tetrachloride ND 0.5
1,1-Dichloropropene ND 0.5
Benzene ND 0.5
1,2-Dichloroethane ND 0.5
Trichloroethene ND 0.5
1,2-Dichloropropane ND 0.5
Dibromomethane ND 0.5
Bromodichloromethane ND 0.5
cis-1,3-Dichloropropene ND 0.5
Toluene ND 0.5
trans-1,3-Dichloropropene ND 0.5
1,1,2-Trichloroethane ND '0.5
Tetrachloroethene ND 0.5
1,3-Dichloropropane ND 0.5
Dibromochloromethane ND 0.5
1,2-Dibromoethane ND 0.5
Chlorobenzene ND 0.5
1,1,1,2-Tetrachloroethane ND 0.5 U U 4
Page 1 of 2 E1139-02
MITKEM
CORPORATION
Client ID: Trip Blank Lab ID: E1139-02
Reporting
Analyte Result Lkad
Ethylbenzene ND 0.5
Xylenes (total) ND 0.5
Styrene ND 0.5
Bromoform ND 0.5
Isopropylbenzene ND 0.5
Bromobenzene ND 0.5
1,1,2,2-Tetrachloroethane ND 0.5
1,2,3-Trichloropropane ND 0.5
n-Propylbenzene ND 0.5
2-Chlorotoluene ND 0.5
4-Chlorotoluene ND 0.5
1,3,5-Trimethylbenzene ND 0.5
tert-Butylbenzene ND 0.5
1,2,,4-Trimethylbenzene ND 0.5
sec-Butylbenzene ND 0.5
1,3-Dichlorobenzene ND 0.5
4-Isopropyltoluene ND 0.5
1,4-Dichlorobenzene ND 0.5
1,2-Dichlorobenzene ND 0.5
n-Butylbenzene ND 0.5
1,2-Dibromo-3-chloropropane ND 0.5
1,2,4-Trichlorobenzene ND 0.5
Hexachlorobutadiene ND 0.5
1,2,3-Trichlorobenzene ND 0.5
Naphthalene ND 0.5
QC Batch: V5B0722A
Surrogate Recovery:
Bromofluorobenzene 100%
1,2-Dichlorobenzene-d4 104%
ND= Not Detected
Page 2 of 2 E1139-02 U
CORPORATIONMATK
Analysis Report: Purgeable Volatile Organics
Client: GZA GeoEnvirornmental, Inc. Analysis Date: 7/22/98
Client ID: Concentration in: ug/L
Lab ID: Method Blank, V560722A Dilution: 1
Analysis: Method 524.2
Reporting
Analyte Results Limit
Dichlorodifluoromethane ND 0.5
Chloromethane ND 0.5
Vinyl chloride ND 0.5
Bromomethane ND 0.5
Chloroethane ND 0.5
Trichlorofluoromethane ND 0.5
1,1-Dichloroethene ND 0.5
Methylene chloride ND 0.5
trans-1,2-Dichloroethene ND 0.5
1,1-Dichloroethane ND 0.5
2,2-Dichloropropane ND 0.5
cis-1,2-Dichloroethene ND 0.5
Bromochloromethane ND 0.5
Chloroform ND 0.5
1,1,1-Trichloroethane ND 0.5
Carbon tetrachloride ND 0.5
1,1-Dichloropropene ND 0.5
Benzene ND 0.5
1,2-Dichloroethane ND 0.5
Trichloroethene ND 0.5
1,2-Dichloropropane ND 0.5
Dibromomethane ND 0.5
Bromodichloromethane ND 0.5
cis-1,3-Dichloropropene ND 0.5
Toluene ND 0.5
trans-1,3-Dichloropropene ND 0.5
1,1,2-Trichloroethane ND 0.5
Tetrachloroethene ND 0.5
1,3-Dichloropropane ND 0.5
Dibromochloromethane ND 0.5
1,2-Dibromoethane ND 0.5
Chlorobenzene ND 0.5
1,1,1,2-Tetrachloroethane ND 0.5
U �6
Page 1 of 2 E1139-MB
CORPORATIONMIT
Client ID: Lab ID: Method Blank, V5B0722A
Reporting
Analyte Result limit
Ethylbenzene ND 0.5
Xylenes (total) ND 0.5
Styrene ND 0.5
Bromoform ND 0.5
Isopropylbenzene ND 0.5
Bromobenzene ND 0.5
1,1,2,2-Tetrachloroethane ND 0.5
1,2,3-Trichloropropane ND 0.5
n-Propylbenzene ND 0.5
2-Chlorotoluene ND 0.5
4-Chlorotoluene ND 0.5
1,3,'5-Trimethylbenzene ND 0.5
tert-Butyl benzene ND 0.5
1,2,4-Trimethylbenzene ND 0.5
sec-Butylbenzene ND 0.5
1,3-Dichlorobenzene ND 0.5
4-Isopropyltoluene ND 0.5
1,4-Dichlorobenzene ND 0.5
1,2-Dichlorobenzene ND 0.5
n-Butylbenzene ND 0.5
1,2-Dibromo-3-chloropropane ND 0.5
1,2,4-Trichlorobenzene ND 0.5
Hexachlorobutadiene ND 0.5
1,2,3-Trichlorobenzene ND 0.5
Naphthalene ND 0.5
QC Batch: V5B0722A
Surrogate Recovery:
Bromofluorobenzene 106%
1,2-Dichlorobenzene-d4 104%
ND= Not Detected
607
Page 2 of 2 E1139-MB
MITKEM CORPORATION
Lab Project#: E1139
Client Name: GZA GeoEnvironmental, Inc.
Client Proj#: 31751.13 Logged In By: i
Client PO#: 3-02068
Project Name: Residential Well Sampling Reviewed By:
Date Due: 7/23/98
Total Price: $ - Date: Time:
Project Mgr: PAS
Salesman: PAS
Del Req'd: Std. & Raw Data
Completed?: YES
Lab ID Client ID Matrix Analysis Sampled Received TPH JR DINA Herb EM Wet Me V-GC V-MS 5-gh
-01 RW-22 AQ 524.2 7/16/98 7/17/98 1
-02 Trip Blank AQ 524.2 7/16/98 7/17/98 1
TPH Ili BNA Herb EM Wet Met V-GC V-MS SILh
NOTES: 0 0 0 0 0 0 0 0 2 0
ORIGINAL REPORT GOES TO: INVOICE GOES TO: ADDITIONAL REPORT GOES TO:
GZA GeoEnvironmental,Inc Attn: Hilary Fortune Same None
140 Broadway Phone: 401 421-4140
Providence,RI02903 Fax: 401 751-8613
C?
G
00
7/17/98 3:47 PM Page 1 of 1 Lab Project#: E1139
.WHITE COPY-Original YELLOW COPY-Lab Files PINK COPY-Project Manager N/,0, # ;r,
E
I `CHAIN-OF-CUSTODY RECORD (for lab use on
v ( I" , ANALYSES REQUIRED
i Sample Date/Time Matrix
-•,;;>a -,. I D �* - m o i 1 1 7 err
r + t -i 4J s=Soil
J g H c m 7. 8 m:• .
i J _ (Very Important) GW= eG, dw. m $ o a y� Total
sw=s.ne.e w. o . . .„ a #of Note
ww-waste w. o o - tL A',. g
Ow=orinkingW. n m m _ ', cm _ J q Cont. #
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t CONTAINER TYPE (P-Plastic,G-Glass,V-Vial,T-Teflon,O-Other)' ;
RELINQUISHED BY filiation) D EITIME RECEIVED BY: Affiliation) NOTES:Preservatives,special reporting limits,known contamination,etc.:
� (Unless otherwise noted,all VOA vials have been preserved w/1:1 HCL.)
RELINQUISHED BY:(Affiliation) DATE/TIME fqFrEIVED B :( ffiliation)
j RELINQUISHED BY:(Affiliation) DATE/TIME RECEIVED BY:(Affiliation)
;i
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PROJECT MANAGER
TURNAROUND TIME:❑Standard ❑ Rush Days,Approved by:
GZA FILE NO. P.O. N.O. 190 Z p 6P
GZA GEOENVIRONMENTAL, INC.
ENGINEERS AND SCIENTISTS PROJECT
t ) 1 140 Broadway l /�
PROVIDENCE,RI 02903 LOCATION —
(401)421-4140
FAX(401)751-8613 ! —. FO�/;1/�,�' OF
r. COLLECTOR(S) SHEET / _ C_—
MITKEM CORPORATION
Sample Condition Form Page of
Received By: Reviewed By: Date: MITKEM Project: ( 3
Client Project: r� Client:
Sample ID Preservation(pH) Comments/Remarks/
Condition: Lab Client HNO3 H2SO4 HG NaOH Corrective Action*
1)Custody Seal(s) PresenFAent v2CoolerIntact/B
2)Custody Seal Number(s)
3)Chain-of-Custody resen Absent
4)Cooler Temperature
Coolant Condition
5)Airbill(s) Presen Abse
Airbill Number(s)
6)Sample Bottles Inta
Broken
Leaking
7)Date Received
8)Time Received 3(�a
9)Project Due Date
* See Sample Condition Notification/Corrective Action Form yes/ 0 11 n
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