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Home My WebLink About1751 MAIN STREET (COTUIT) - Health 1751 MAIN ST. _ COTUIT A = 016 027 S J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address W1 of(o-ozq Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David J. Burnie use the return Name of Inspector N Y N4 r� 0 David J. Burnie mgmt Inc. �y Company Name 3 perry's way Company Address a r t E. Harwich Ma. 02645 City/Town State Zip Code -~a 1-866-980-1440 S1386 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 3-31-12 pector's Sig Ka 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. t5ins-11/10 Title 5 Official In*Fo .. Sew ge Disposal yst • age 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is Newton Center Ma 02459 3-31-12 required for every 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: System working as designed.THIS SYSTEM HAS A GARBAGE DISPOSAL AND IT SHOULD BE REMOVED. THE SYSTEM IS DESIGNED FOR A 5 BEDROOM HOME. IT IS NOT SIZED FOR A GARBAGE DISPOSAL. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of.Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name ;t information is required for every Newton Center Ma 02459 3-31-12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water 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 cesspool is less than 6"below invert or available volume is less than %day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityfrown 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.] ❑ z The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑' Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 bedrooms- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 gpd. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon Septic tank, 1 distribution box and leaching 15x50x2' maximizers. permit#97-603 Number of current residents: Seasonal Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage 2011 59.000 gal g ( y g (gpd)) 2010 57.000 gal Detail: water feed from main house........2011 = 162 gpd...................2010 57.000 gal = 157 gpd .............water records are for both the main house and the studio unit. THE SYSTEM HAS A GARBAGE DISPOSAL AND IT SHOULD BE REMOVED. THE MAIN HOUSE IS A 5 BEDROOM AND DESIGN FLOW IS 550 GALLONS. THIS SYSTEM IS NOT SIZED FOR A GARBAGE DISPOSAL Sump pump? ❑ Yes ® No Last date of occupancy: Seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day Y(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.' 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: seasonal Date Other(describe below): General Information Pumping Records: Source of information: None. owner. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Truck site glass and permit#97-603 Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 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. x inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEFT approval. ❑ Other(describe): L9mS-.]]f 10 Title 5 Officaal Inspection Form:Subsurface Sewage Disposal System--Papa 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: permit#97-603.......1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 27"feet . Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10' plus feet Comments (on condition of joints, venting, evidence of leakage, etc.): Ok Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) Septic tank is H10 rated and should not be driven on. Tank is in grass area away from driveway. Covers were raised to within 6" of-grade during inspection. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 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 30" Scum thickness 2-4 Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape 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 should be serviced every 2 years. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: concrete 0 metal (] fiberglass ❑polyethylene ❑'other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): System pumped at time of inspection. Tank should be pumped every 2 years. 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 ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address . Jeremy Pozen 61 Montvale Road Owner Owne.r.s Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityfrown 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 Box was at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was located opened and is located in the driveway. The box is H2O rated and ok to drive on. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Located and viewed using a sewer camera thru the distribution box, could not find any access thru the field, standing water estimated to be 2 to 3 inches. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 12 Maximizers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching Melds 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.): Estimated 2 to 3 inches of standing water, viewed using a sewer camera. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection D. System, Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): None. 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.): None, minor standing water in the leaching field, estimated to be 2 to 3 inches. I , t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name: information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately F t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE Q LOCATION I �,SJ� �ll��II6% Cam'Z_W1/ SEWAGE VILLAGE C �7 Q— ASSESSOR'S MAP dot LOT INSTALLER'S NAME&PHONE NO. �/P�Ce % CD`Jsr.' W-7:�39Y SEPTIC TANK CAPACITY c� G� .: LEACHING FACILITY: (type) (size) SSW X�o L X a -. NO.OF.BEDROOMS BUII.D R C7WNER Af �O ZeN :�'.'.-PERMTTDATE: Ae—Z 2 COMPLIANCE DATE: & Separation Distance Between the: -Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -------------- Fo �L - rs Jr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown 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: 12' plus prior report dated.6-17-97 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: prior report dated 6-17-97Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: prior report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: prior reports 6-17-97. No water at 12'. bottom of leaching chambers @ 6' no water at 12'. have a 6' seperation. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z 1751 Main St, Main house Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 :w'♦ �v4 No. — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS Appritation for ;Mi,9pogaf .6p5tent Con$trUttion Permit Application for a Permit to Construct( )Repair(' )Upgrade(✓)Abandon( ) QComplete System ❑Individual Components Location Address or Lot No./.� �y%��T Owner's Name,Address and Tel.No. Assessor's Ma/Parcel 5 `1 �P% ®7 L LO4 P Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 'gmf 7`74ol�41 Gdr�y�` 7 7/- 3 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �.S✓.Y;��7 �.('Z� Description of Soil /Z meXJir//L Nature of Repairs or Alterations(Answer when applicable) WL'GJ✓�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this o o Signed Date Application Approved by 4 Date /,2 -j. -`1 Application Disapproved for W folio ng reasons Permit No. 7 (1 0 2) Date Issued ------------ THE COMMONWEALTH OF MASSACHUSETTS 9 —02 BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CE TIFY t the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by O4 -,6elj1 _ at /7�/ IW4//l S%• CD ram/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7c-(n O dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the syste� function as designed. Date /` Inspector i --------------------------------------- No. —V � 15216 f�Z Fee —J C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Mi5posa1 *pgtem Con!5trUttion Permit Permission is hereby granted to Construct( )Repair( )Upgrade,( )Abandon( ) System located at 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 this permit. Date: /r7 a- - Approved by .� 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address oD-�I 0 p, 01 Jeremy Pozen 61 Montvale Road f Owner Owner's Name information is t required for every Newton Center Ma 02459 3-31-12 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. r Important:When A. General Information filling out forms on the computer, p ` use only the tab 1. Inspector: key to move your cursor-do not DayidJ. Burnie use the return key. Name of Inspector r w David J. Burnie mgmt Inc. -V Company Name I 3 e 's wayg Company Address .E. E Harwich Ma :44 645 � g Cityrrown State Z Code 1-866-980-1440 S1386 Telephone Number License Number B. Certification I certifythat I have personally inspected the sewage disposal system at this address and that the P Y P 9 P Y 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 -31-12 I ectoes SigrA t 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. t5ins•11110 Title 5 Official InspectiontFace Sewage lisp sjiSystel-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owners Name information is required for every Newton Center Ma 02459 3-31-12 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" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owners Name information is required for every Newton Center Ma 02459 3-31-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Citytrown 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. [Phis 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 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Studio 1 Number of bedrooms(actual): Studio 1 DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): unknown t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon Septic tank, 1 distribution box and 1 500 gallon leaching chamber with stone around it. permit date Town of Barnstable 7-17-2000 Number of current residents: Seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2011 59.000 gal g ( y g (gp )) 2010 57.000 gal Detail: water feed from main house........2011 = 162 gpd...................2010 57.000 gal = 157 gpd .............water records are for both the main house and the studio unit. Sump pump? ❑ Yes ® No Last date of occupancy: Seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day Y(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..' 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: seasonal Date Other(describe below): General Information Pumping Records: p 9 Source of information: None. owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 12 yrs per permit dated 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 23"feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10' plus feet Comments (on condition of joints, venting, evidence of leakage, etc.): Ok Septic Tank(locate on site plan): Depth below grade: 18 inches, covers at 6" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Septic tank is H10 rated and should not be driven on. Owner advised to place a landscape timber in front of it to prevent parking on or within 10' of tank.Covers brought to within 6"of grade at time of inspection. Both the inlet, outlet and the distribution box. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Ism Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 0" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 0" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? 0" 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 has seen minor use no sludge or scum buildup at all. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts PEA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is Newton Center Ma 02459 3-31-12 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Distribution box is clean and dry. used seasonal, box looks new 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.): none Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Located and foud dry, no acess to chamber. hand dug to verify. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 1 with stone ❑ 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.): None, leaching dry and clean. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J� 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owners Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): None. 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-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page_ Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 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 Wq d n� I do 1-r'� z 4 t5ins•f 1f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owners Name information is required for every Newton Center Ma 02459 3-31-12 page. Cityrrown 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: 12' plus prior report dated.6-17-97 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: prior report dated 6-17-97 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: prior report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: prior report no water 12'The bottom of the leaching chamber is 4.5' below grade per prior report dated 1997 verification of no ground water to 12'. This allows at least a 7.5' seperation to the dry 12' depth from the bottom of the leaching chamber. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1751 Main St, Studio unit at rear of main house. Property Address Jeremy Pozen 61 Montvale Road Owner Owner's Name information is required for every Newton Center Ma 02459 3-31-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Z 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 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE � LOCATION 7�a3�� I C>!l1d�I �T+, SEWAGE # VILLAGE CD/ Gr/ II //ASSESSOR'S MAP & LOT 04—2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l S�dO / LEACHING FACILITY: (type) f S-0' lead i k1ka4ize) NO.OF BEDROOMS %J,h BUILDER OR OWNER AgxL.,t au`TuY,*,L Je:i atraJ1-i d PERMITDATE: COMPLIANCE DATE: 1,04(.J43,D 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 I� I Will !63 z 3 �a' 3 0' y d3'6" 36 `/ TOWN OF BARNSTABLE LOCATION l��n/ 1 f SEWAGE # VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) C NO.OF BEDROOMS 7 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by { 17 Y/J i►�r�� ' LOCATION SE A RMIT N0. VILLAGE I N S T A LLER'S NAME a ADDRESS d U I L D E R OR OWNER BOX INC, D A T E PERMIT ISSUED DENTERVILLE.MA 026ut _ DATE COMPLIANCE ISSUED p w�tr� v .M A 1 N S 7' e e-r No. ` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Digool *pgtem Cow5truction Permit Application for a Permit to Construct(.V/)Repair( )Upgrade( )Abandon( ) Vcomplete System ❑Individual Components Location Address or Lot No. � Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. f3 Type of Building: Dwelling No.of Bedrooms / 6074AVOf Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ,S7� No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow gallons per day. Calculated daily flov4 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1$PD G g!/ Type of S.A.S. "S7j0 g aO 6447^16_:/' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Zhs j.`/ /S—®d t- 19✓eq90l Ze-,Pd e,4ewd_,,P Hof stuc�la Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his Boaritof fjpalth. Signed Date 01f Application Approved by Date 7�-j? 6�, Application Disapproved for the ollowr reasons Permit No. Date Issued No. / Fee CZ ' THE COMMONWEALTH OF MASSACHUSETTS Entered in comp e es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for �Btgogar 6pgtem Congtructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon Vomplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name, ddress and Tel.No. Type of Building: �' 1 Dwelling No.of Bedrooms Lot Size ` sq. ft. Garbage Grinder( ) Other Type of Building t_: n-ZIOV/WI�f No. of Persons Showers( ) Cafeteria( ) Other Fixtures '7 c Design Flow ,;, gallons per day. Calculated daily flow gallons. Plan Date Number of sheets .Revision Date Title Size of Septic Tank _ Type of S.A.S. Description of Soil �r / ,<�; <'; I � y'ii•- - r Nature of Repairs or Alterations(Answer when applicable) 5 �� i Date last inspected: -Agreement: + : ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date _ Application Disapproved for th ow re ons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS 7 `;,. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( V)dlepaired( )Upgraded( ) Abandoned( )by at has been constructed in accordance with the rovi ions of tV d the or Dispo al gys em 4nstruction Permit No. dated Installer Designer ° The issuance of this permit shall n t be construed as a guarantee that the s stem will function as de f ed//,; r 7 Date >/ Inspector --------------------------------------- No. _ U Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigool *pgtem Congtruction Permit Permission is hereby granted to Construct(, ,vRepair( )Upgrade( )Abandon( ) System located at t✓ ✓ , f . ' 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 this permit. Date: L Approved by 0 No. ?7— Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 01pprication for Mqual *pgtem Congtruction permit Application for a Permit to Construct( )Repair(^ )Upgrade(✓)Abandon( ) E/complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. !�7,5-1 m�i��sr- ��ee Assessor's Map/Parcel Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. �irf. Gv�57� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building esj, WZ,e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1112 gallons per day. Calculated daily flow .�J�l� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil /Z. Nature of Repairs or Alterations(Answer when applicable) Z1'7-lt°J7—',V4G/�e_ 00, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this o o / / Signed Date J101-7— � Application Approved by Date b2_1.-,x Application Disapproved for t54 follo ng reasons Permit No._q t'o C'> Date Issued No. L i �,... Fee(IJ \7 z,. . THE�COMMONWEALTH OF MASSACHUSETTS Entered in computer: `-PUBLIC HEALTH DIVISION - TOWN OF 6ARNSTABLE,;MASSACHUSETTS Yes 01ppYication for Migpooaf *p!6tem Construction Permit 1 Application for a Permit to Construct( )Repair( ' )Upgrade(Abandon( ) LJ Complete System [IIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. poZ Assessor's Map/Parcel �h `O 4s , Installer's ame,Address,and Tel.No. / Designer's Name,Address and Tel.No. Aof Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building r e�.�C� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow llele) gallons per day. Calculated daily flow J s� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank l Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .4 A Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place th'e�system in operation,until a Certifi- cate of Compliance has been issued th;s o o a I. ..� D p Signed � � Date Application Approved by �"' Date' Application Disapproved for t e follAing reasons f I Permit No. d Date Issued ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO C TIFY, th t the On-site Sewage Disposal System Constructed( )Repaired( ) Upgraded Abandoned( )by & 1'rV J at / 7.5�-/ Al4'/i1 5,7. e,'DA�K17- - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 77, 0, dated, Installer Designer The issuance of thi5 permit s 11 not be construed as a guarantee that the syste ,y I function as designed. Date � Inspector --- --------------------------- —7 -------- No. // -vet Q�6 0� , Fee _- C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS x1h6pogal *p! tem Construction Permit Permission is hereby ranted to Construct( )Repair( )Up rade( )Abandon( ) System located at !7S ��✓�� s�- �'D , 17- 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 this permit. Date: z o ~a.a-- - 7 7 Approved by .� O l / to 7 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1, ear- �-r�7D/�®� 7 ,hereby certify that the application for disposal works construction permit signed by me dated Zl,'7 , concerning the property located at 1�5i1 meets all of the following criteria: /There are no wetlands located within 100 feet of the proposed leaching facility :/There are no private wells within 150 feet of the proposed septic system :,/There is no increase in flow and/or change in use proposed There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 19, B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert I� ✓'Y lu 10 D' i O O O r isc j 7� AAA''a ST TOWN OF BARNSTABLE :'' LOCATION J 75/ Mel,,,Ve� C��`�i SEWAGE # VILLAGE C 0 1 a! ASSESSOR'S MAP& LOT all 7 INSTALLER'S NAME&PHONE NO. �/P�C4 % �Ofl'S7✓ 7 '7 �.391�' SEPTIC TANK CAPACITY 1 � LEACHING FACILITY: (type) �� kr (size) SSW X �O�LXa�D NO.OF.BEDROOMS <.. BUII.DER OR6WNER R C i 2L' �O ZeN PERMTTDATE: �� Z 2 0 COMPLIANCE DATE: !4 `Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Fri TOWN OF BARNSTABLE LOCATION 1 7 S^I C>!I YI �✓"�, SEWAGE # 2edd,�'/j7 VILLAGE CO�`L!/ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) l Spa � 'CG� C�0�1ize) NO. OF BEDROOMS 1't A 7 ri BUILDER OR OWNER laves .,t o6ruru,C PERMITDATE: '7 —�� COMPLIANCE DATE: 1,0411@J11D 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 bt e Fe C-1 CTD 0 s' �rsnoq J 0 LN-0-,J COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIAIvt F.WELD TRUDY CORE Govemor Secretary ARGEO PAUL CELLUCCI 9 B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ^ missioncr PART A O CERTIFICATION R`' 7 Property Address: 1 751 Main Street Cotuit ,Mass . Address of Owner: JUL Date of Inspection-6/17/97 (If different) S Name of Inspector: Joseph P.Macomber Jr . ,� To�►,ofe 1997 "r I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15. Company Name: _J.P.Macomber & Son Inc. Mailing Address: Rny ()h A 1 Telephone Number. Ge tervi��e�Mass, 02632 g Q, 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: Zpasses _ Conditionally Passes Needs Further Evalua ion By the Local Approving Authority Fails t Inspector's Signature: Date: ^J7� 7 The System Inspector all 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 flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: 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. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: _XzL 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not Neaf, The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:llwww.magnet.state.ma.us/dep 0 Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1751 Main Street Cotuit,Mass . Owner: James Diggins Date of Inspection:6/1 7/97 BJ 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced AD 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 C) FURTHER EVALUATION 15 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: �Jp 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. �f The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance 1161 (approximation not valid). 3) OTHER The sewage system consists of two block cesspools ; All no , o aragrap section (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1751 Main Street Cotuit,Mass . Owner: James Diggins Date of Inspection.6/17/97 D) SYSTEM FAILS: You must indicate ei;-.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 0h1R 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ZUd Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy-is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No /f� the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) 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 04/25/97) Page 3 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: James Diggins Owner: 1751 Main Street Cotuit ,Mass . Date of Inspection:6/17/97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. None 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. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, tWuding the Soil Absorption System, have been located on the site. 21 2¢ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Pegs 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:James Diggins Owner: 1751 Main Street Cotuit,Mass . Date of Inspection: 6/1 7/97 FLOW CONDITIONS RESIDENTIAL: Design flow: #4"P R.p,d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_ o Laundry connected to system (yes or no) i'- Seasonal use (yes or no):_ n Water meter readings, if available (last two (2) year usage (gpd): 1W,5 91��q Sump Pump (yes or no): I" /9$'' 7.0i4X'0444eiA s) = )i ,7X e .� Last date of occupancy: tl 7 COMMERCIAUINDUSTRIAL: R Type of establishm nt: .6J1 Design flow:�gallons/day Grease trap present: (yes or no)., % Industrial Waste Holding Tank present: (yes or no)AO' Non-sanitary waste discharged to the Title S system: (yes or no),d)—� Water meter readings, if available:_�,� A1A Last date of occupancy: 10 OTHER: (Describe) A)4 Last date of occupancy: GENERAL INFORMATION PUMPING CORD sour f infor atyon: . /- System pumped as part of inspection: (yes or n ) S If yes, volume pumped: gallons _ 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: James Diggins Owner: 1751 Main Street Cotuit,Mass . Date of Inspection:6/1 7/97 BUILDING SEWER: (Locate on site plan) 1/ Depth below grade: ) �� Material of gonstructi0 cast iron /40 PVC bother ex lain) Distance from private water supply well or suction line W,21L_ Diameter -.41_ omments: (condition of joints, venting, evidence of leakage, etc.) No signs of leaka e at the joints : System vented throu h the house vents . SEPTIC TANK:-4b(J- (locate on site plan) Depth below grade:-d& Material of construct ion:/el6oncrete,V, rtneta1 0i berg Iass XIA Polyethylenei�dother(explain) If tank is metal, list age&B Is age confirmed by Certificate of Compliance, (Yes/No) Dimensions: Sludge depth:k_ Distance from top of sludge to bottom of outlet tee or baffle: 4 4 Scum thickness:ZW Distance from top of scum to top of outlet tee or baffle:fL Distance from bottom of scum to bottom of ou l t tee or baffle:�/� How dimensions were determined: f� 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.) SPntio tank ig not nrPSPnt GREASE TRAP: 4Zyi✓e, (locate on site plan) Depth below grade:�1 Material of construction:;�/4concrete4/Ametal/I*ibergl ass&Polyethylene,�other(explain) Dimensions: 44 Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:ti� Date of last pumping: 161� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not present (revised 04/25/97) Page 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 751 Main Street Cotuit Owner: James Diggins Date of Inspection: 6/17/97 TIGHT OR HOLDING TANK:1ADTank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: �A Material of construction;()&concrete-j i metal/Fiberglass !�*olyethyleneOVVother(explain) Dimensions: 4 0 Capacity: 4/!4 gallons Design flow:gallons/day Alarm level: /U� Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanl�s are not presen . DISTRIBUTION BOX:2,j'W)Q- (locate on site plan) Depth of liquid level above outlet invert: 414 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box is not present PUMP CHAMBER:_,LeW✓ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is .not present (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 751 Main Street Cotuit Mass Owner: James Diggins Date of Inspection: 6/17/97 SOIL ABSORPTION SYSTEM (SAS):z (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: leaching pits, number:Q leaching chambers, number: leaching galleries, number: leaching trenches, number,length: _ leaching fields, number, dimen ions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cotuit Sand :No signs of hydraulic failure or ponding: All vegetation is normal. CESSPOOLS: ' (locate on site plan) 6"s�e�oaY�r Number and configuration:_ 5��h4�,c><,Q czuer Depth-top of liquid to inlet r�Yert:_ Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Inflow cesspool was pumped o. signs 51 water Intrusion Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cotuit sand: No sins of hydraulic failure or ponding: All vegetation is normal I i P R IVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids:�I * Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present (revised 04/25/97) Page 8 of 10 • t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1751 Main Street Cotuit,Mass Owner: James diggins Date of Inspection: 6/17/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 .S VW W \ Vg li I (revised 04/25/97) Pag• 9 of 10 SUBSURFACE SEWAGE DISPO .:',L SYSTEM INSPECTION FORM I,..:. C • SYSTEM INFOR`- ,[ION (continued) Property Address: 1751 Main Street Cotuit,Mass . Owner: James Diggins Date of Inspection: 6/17/97 Depth to Groundwater ,vcFeet Please indicate all the methods used to determine High Groundwate: _ration: Obtained from Design Plans on record 2Observation of Site (Abutting property, observation hole, base:. t sump etc.) izDltermine it from.local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Ground.. r Elevation. Must be completed) Have installed many system on main Street Cotuit. Water was never encountered at 121 . 746 Main # 90-364 825 `Main # 90-253 882 Main # 92-539 968 Main # 93-291 975 Main Street # 85-300 978 Main # 77-175 1019 Main # 70-461 1119 Main 85-297 1141 Main # 93-607 1160 Main # 83-1 103 (revised 04/25/97) Pag. of 10 �G W z THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatigns as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by P The Department of Environmental Protection. June 8. 1995 Acting Director of the ' ton of Water Pollution Control 1 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE CO fal'7- ASSESSOR'S MAP& LOT ®i/--©Z 7 INSTALLER'S NAME&PHONE NO. 1P �o � SEPTIC TANK CAPACITY ev LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 6EDER OR 16WNER Ar l ea. (Po 2�� PERMITDATE: I� Z 2 —� COMPLIANCE DATE: A0 v $ ,7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,83 � ° C� i1 i