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HomeMy WebLinkAbout1169 MAIN STREET (COTUIT) - Health 61i9{ MainN�Strzeet�(Cotult) a� ,n � �v� t 'N I� E i i i f Jk 47 M o 1 f i 1 I e,� S b TOWN OF BARNSTABLE LOCATION f 7S /y74/r/ ST SEWAGE# ® P O VILLAGE CO%y iT ASSESSOR'S MAP&P�CF,L — O O INSTALLER'S NAME&PHONE NO. ✓ 2. — 7/5�2 SEPTIC TANK CAPACITY 1,500 VA-t LEACHING FACILITY:(type) ya (size) '9°2- 6 NO.OF BEDROOMS OWNER tn/ PERMIT DATE: COMPLIANCE DATE: o 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 f 10 q)q o ID ® �x ° ? � n� J► o TOWN OF BARNSTABLE LQCATION S SEWAGE# 19 01 o VILLAGE l;'Q'Tu i-r ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 412,wA,,V0j0 "66r�>9Jt SEPTIC TANK CAPACITY /DSO® LEACHING FACILITY.(type) Vo Oil) b> 'FUS (size) �°„1•�X ✓�� NO.OF BEDROOMS y OWNER n/ 1 L L PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) I Feet FURNISHED BY �j l���l� Ud ceAV7,e alz— i) 923 ' �S"y , .3) '77 3> 10-7 y) y� 5-) 3.0 Oui y El nev TOWN OF BARNSTABLE LOCATION P114IN ST► SEWAGE # C719 -1 '�df VILLAGE C_ ® T_ ASSESSOR'S MAP LOT 0 Lc)T 1 INSTALLER'S NAME PHONE NO.. SEPTIC TANK CAPACITY li. LEACHING FACILITY:(type) (size) NO. OF BEDROOMS I PRIVATE WELL OR PUBLIC WATER (1J�LL BUILDER OR OWNER D L) 'z�1 DATE PERMIT ISSUED: #Q v4E dwN,91� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No a,1 1 C i 7' F 1 1 f ' No. tf 6 Fee THE COMMONWEALTKOF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppfitation for ]Disposal 6pstem (Construction 3dermit Application for a Permit to Construct( ) Repair( ) Upgrade(i) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No. /(q Wig / Ow e A dress and Tel.No. < Assessor's Map/Parcel /30 00 Y. IJG C,0 TV,R /-Wff Installer's Name,gddress,and T o. ��, D signer's Name Address and Tel.No. Ak,"A's D 1/tc. wr.- P, .7�8 fy!/f ,2 Hac�s,1nr�z�rcNPO 6oAA R1 5) 5,4^'�0rCH /y1A 02S 3 > Type of Building: �!� �, �� J �c0 X� 4 Dwelling No.of Bedrooms `J sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) � Other Fixtures Design Flow(min.required) 8 90 gpd Design flow provided gpd Plan Date�ao& _Number of sheets Revision Date Title Size of Septic Tank !2) PSOo 6, Type of S.A.S. g /IouJS D 5� /�FUS wiz S Description of Soil 17, Nature of Repairs or Alterations(Answer when applicable) L v r !I/2uc.1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed C^ Date Application Approved by — Date % Application Disapproved by Date for the following reasons Permit No. Do Date Issued .� .. ��..,.♦.rn 'w1..r-..y...�,,,.'rWIw.:W{K ^ E.� L.ti"'VM- N'�raM=,-.[YTwOM'MfM1"aV""..r'M.^sW �..-.'++_VrirA ^.—._w-_•- ._. �..,.y�.. "r-A ___—_ .ti.`-'.nTM''•"A�Yti71 No. 1 6^ Fee t THE COMMONWEALTH'OF MASSACHUSETTS ,,,- Entered in computer:. `+ PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for ]Disposal *psterrt construction hermit -Application for a Permit to Construct( ) Repair( ) Upgrade(7O Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / (,9 �Y/,4/✓�� Owne ' :,"Address,and Tel.No. I�gff�Y Assessor's Map/Parcel opq O/ 114 /r/A id 57— Co7v� IWstaller's Name,I•Qpddress,and Te_j.No. p �j�� _ D signer's Name,Address,and Tel.No. /ZMAN0D V fGENTI� d / {�4/Z,AI �y�r%.e'!2 � stia�=�� raouSi�}aaw�ctl 02s6 3 'PO /1�a 981 C-ins; 5-A""L" S"3 > Type of Building: 2 iv,49 ; �6i v� G(cs Sf is�r c> (�a-r Dwelling No.of Bedrooms b Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures �� Design Flow(min.required) D 0 Q gpd Design flow provided /I / Q gpd Plan Date_ Ls-, aa00 c' Number of sheets Revision Date Or Title \\ Size of Septic Tank 9 ) ISDoCs Type of S.A.S._ �� 1106J5 0 F 5�1�/FFvs iu�r S Description of Soil 6f0,-,9 f Nature of Repairs or Alterations(Answer when applicable) C o w-61P UC.% A1,71j S I/57 pryz ://I,? f // 5 Date last inspected: „t+" Agreement: , v t. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in , accordance with the provisions of Title 5 of the Environmental Code and not to place the system in•operation until a Certificate of/ Compliance has been issued by this Board of Health. Y ; Signed Date*z. �i �i�/ D. Application Approved /b PP b Y f Application Disapproved by Date for the following reasons Permit No. LU a �`1 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at r f i.. ,� has been constructed in accordance with the provisions of Title5 and the for Disposal System Construction Permit No. a 010^02V dated Installer V.U,, P Designer #bedrooms / Approved design flows gpd v The issuance of this permit)shall not be construed as a guarantee that the system will J ction as d lsigned. Date Inspector J/ ?f v ^ - No. a U1 o N- Fee OU THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION ..BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i9ermit Permission is hereby granted to Construct( ) Repair( U ade( ) Abandon( ) System located at i Nv-� SA C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit- Date ( Approved by ( /J ( "41 Town of Barnstable Regulatory Services �. Thomas F.Geiler,Director • swtttvereBLL Public Health Division Tee►��'�' Thomas McKean, Director 200 Main Street,,Hyannis,IVIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 7 e Sewage Permit# 901 b -02Y Assessor's-Map\Parcel 011 Designer: Irf?-Yi el(,- Installer: 42MA.✓p6 01 1i/L Address: TO �I Address: °.Z3 SfiAtg,,t 14ou5lr rzd On / a /p iAnniaMyo UiUF,-V7;E was issued a permit to install a (date) (� /� �j (installer) �v' septic system at I &t P") J - based on a design drawn by (address) Y e-1 Q,,(I e dated 0l 2_7 l,O (designer) \ 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and,'or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow., OF DA�R N (Installer's Signature)' No 1140 I � NdTAR 0 '[ (Designer's Signature) U (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU Q: Heal th/Septic/DesignerCertification Form 3-16-adoc l _ vA Commonwealth of Massachusetts qYTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 I AAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cltyrrown 11J28/09 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms ma not be altered in any way. Please see completeness checklist at the end of the form. W Important When filling out A. General Information p hen forms on the computer,use 1. Inspector: ? —� only the tab key to move your cursor-do not DOUGLAS A BROWN P= use the return Name of Inspector ; Q key. DOUGLAS A BROWN INC H -n Company Name - f� P.O. BOX 145 P11 Company Address CENTERVILLE It MA 02632 e0" City/Town State ZipCode - 508-420-4534 S14297 rat 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 11/28/09 41nspe7iggn!at�,,e 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. � I fSms•09A8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal tem•Page of 17 t 1 c' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. City/Town 11/28/09 B. Certification (cont.) State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 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•09iD8 Title 5 Official Inspection Form:Subsurface Sewage Dsposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ya. 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cltyrrown 11 State Zip Code Datea of 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): 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. I. 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 l5ins•09I08 Title 5 Official Inspection Form:Subsurface�Sevagge Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. Cltylrown 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 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 Y2 day flow t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts lTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28109 every 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 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•09= Tide 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 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cityfrown 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): unknown Number of bedrooms(actual): unknown DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•09/O8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts UV Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: SYSTEM APPEARS TO BE A SINGLE CESSPOOL IN VERY POOR CONDITION WITH WOOD OVER THE COVER TO KEEP IT FROM CAVING IN Number of current residents: 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 years usage(gpd)): Detail: HOUSE IS VACANT Sump pump? • ❑ Yes ❑ No Last date of occupancy: 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•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I E ' Commonwealth of Massachusetts Title 5 Offici al Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. City/Town 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: 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) I ❑ 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•09/D8 Title 5 Official Inspecton Form:Subsurface Sewage Disposal 8 Po System•Page 8 of 17 1 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT requiredfor MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal list age:g years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-09)08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 09 every page. City/Town Date o Ins State Zip Code Date of Inspection D.-System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): i 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every 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.): 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 El 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•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r( 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every 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 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.): 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: t5ins•0938 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 "t 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): SYSTEM APPEARS TO BE A SINGLE CESSPOOL THAT IS IN VERY POOR SHAPE AT THIS TIME 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•09/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cltyrrown 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.): FROM WHAT I WAS ABLE TO LOCATE SYSTEM CONSISTS OF A CESSPOOL THAT IS IN VERY POOR CONDITION AT THIS TIME AND HAS WOOD OVER THE COVER TO KEEP IT FROM CAVING IN CESSPOOL IS @3 FT DEEP 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-09/08 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 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09 D8 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 '< 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•091U8 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 1175 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Clty/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•09iD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a � „ �� � r °� � ��-c k r �r-. �2 1 I V ti , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /IAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every 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 Q way. Please see completeness checklist at the end of the form. a _ C:) Important: A. General Information -When filling out forms on they computer,use only the tab key 1. Inspector: ° �. to move your DOUGLAS A BROWN � t cursor-do not �n use the return Name of Inspector key. DOUGLAS A BROWN INC g m Company Name P.O BOX 145 Company Address CENTERVILLE MA MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 11/28/09 *bSignalrre— 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•09I08 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. City/Town 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 APPEARS TO HAVE HAD VERY LITTLE USE AT THIS TIME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for`des", "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): Sins-09/D8 Title 5 Official Inspection Form:Subsurface ace Sewage Disposal System mPage 2 of 17 ' I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °< 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Citylrown 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): { 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 detenrines 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•09108 - Title 5 Official In spection Form:Subsurface Sewage Disposal System•Page 3 of 77 L i Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cityfrown Date of 09 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 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 YZ day flow t5ins•09)08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) . 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 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•09MB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA- every page. Cityrrown 11/28/09 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): 3 Number of bedrooms(actual): unknown DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 1177 MAIN ST COTUIT a Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND A 7 FT DEEP PIT Number of current residents: Does residence have a garbage grinder?* El 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 years usage(gpd)): Detail: HOUSE VACANT , Sump pump? ❑ Yes ❑ No Last date of occupancy: 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: t5ins•09/08 ' Title 5 Official Ins , -pectiion 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 1177 MAIN ST COTUIT Properly Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cdyrrown 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: 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 1994 ACCORDING TO AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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) El Yes ❑ No Dimensions: Sludge depth: t5ins•09/08 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 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cost.), Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IS VERY CLEAN AT THIS TIME AND STRUCTURALLY SOUND 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•09I08 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 '- 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cityrrown Date o lI 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-09= 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 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. City/Town 11/28/09 State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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: t5ins•09M 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 °< 1177 MAIN ST COTUIT Properly Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. City/Town 11/28/09 State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number. ' ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp,soil, condition of vegetation,etc.): PIT IS EMPTY WITH NO SIGNS OF HYDRAULIC FAILURE AT THIS TIME 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. City/Town 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'f 1177 MAIN ST COTUIT Properly Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cily/T Date own Date of 09 State Zip Code 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 t5ins•osios Titie 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 °w 1177 MAIN ST COTUIT Properly Address ESTATE OF JAMES SOUZA wner's Na Owner Ome information is required for COTUIT MA 11/28/09 every page. Cltyrrown 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09= Title 5 Official Inspection Forth: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 1177 MAIN ST COTUIT Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. CityrTown 11/28/09 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•091DB Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ,� i r�� SSE ,S'3r" s-"'1AP N0. PARCEL ! �p i L L UCI I K SEWAGE PERMIT NO. M f ) G E 1 S T A l E R'S N ME fi : 'A rD i\D(` R E S S C. Lf B U I L D R OR OWNER o e. DA T E PERMIT I S S U ED t � � DATE COMPLIANCE ISSUED �� -- ——--- _._...------------- 4 417 -,.r:�� > ilk►' '/ i`� o _ 3 n q8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. CttylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A, General Information forme the computer,use 1. Inspector: only the tab key d � to move your s cursor-do not DOUGLAS A BROWN - s use the return Name of Inspector key. DOUGLAS A BROWN INC 1 Company Name P.O. BOX 145 Company Address CENTERVILLE MA ? City/Town 02632 State Zip(bode — 508-420-4534 S14297 '0 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 11/28/09 Inspe 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. t5ms•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 . b L � i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address. ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cltyrrown 11/28/09 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 wilt pass inspection if it is structurally sound, not leafing and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•osiaa Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA . 11/28/09 every 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): f 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•OWS Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of V S � v t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. Cdylrown 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 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-09/08 Title 5 Official Inspection Fonn: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 1169 MAIN ST Property Address - _ , ESTATE OF JAMES SOUZA f Owner Owner's Name information is required for COTUIT MA. /09 every page. Cltyrrown Code Date o of State Zipf 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? f - ® ❑ 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 unknown unknown (design): Number of bedrooms(actual): DESIGN flow based:on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•09/08 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 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cltyfrown 11/28l09 State Zip Code Date of Inspection D. System Information Description: SYSTEM ACCORDING TO AS BUILT CARD CONSISTS OF A 1000 GALLON TANK D-BOX AND A 1000 GALLON LEACH PIT Number of current residents: 0 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 years usage(gpd)): Detail: HOUSE IS VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 09 every page. City/Town Date o Ins 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: 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•09108 Tide 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 >Y 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cityrrown 11l28l09 State D. System Information (cont.) Zip Code Date of Inspection Approximate age of all components, date installed(if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) TANK IS LEAKING LIQUID LEVEL IS AT THE SEEM IN THE MIDDLE OF THE TANK 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•09M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? S 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 IS LEAKING AND SHOWS SIGNS OF HEAVY CORROSION 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•osma Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA every page. Cityrrown 11/28/09 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 ❑ pol eth lene Y Y ❑ 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•09= Title 5 Official Inspection Form:Subsurface Sewage Dis . _ _ 9 posal System•Pape 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cltyrrown 11/28/09 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 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.): 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: t5ins•09108 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 1169 MAIN ST Properly Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA 11/28/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PIT SHOWS DEFINATE SIGNS OF HYDRAULIC FAILURE, HEAVY STAINING TO THE TOP 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•09iD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. City/Town State Date of Ins 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•09IO8 Title 5 Official Inspection Forth: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 1169 MAIN ST m Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. Cltyrrown State Zip Code Date of 09 . . 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 j 4 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is required for COTUIT MA every page. City/Town 11/28/09 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next.page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachuse tts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1169 MAIN ST Property Address ESTATE OF JAMES SOUZA Owner Owner's Name information is COTUIT required for MA 11/28/09 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tsins•agroe Title 5 Official Inspection Form:Subsurface Sevrage Disposal System•page 17 of 17 �/� SSESF'SAP N0. PARCEL L C A r 10 K-- v SEWAGE PERMIT N0. VIIILAGE I S.TA L ER0S N ME a ADDRESS. �'-�'�� _1934I I �� • U I L D R OR OWNER —� DATE PERMIT ISSUED �... DATE COMPLIANCE ISSUED 1 -- � --� � 7�' No.._'4/1 . 0 } - `� F� .... ....... .......... THE COMMONWEALTH OF MASSACHUSE-rTS BOARD OF HEALTH TOWN OF BARNSTABLE A liratiuit for U aml Nor! � ut it�� � i � t rnrtt n �(�eruttt �1 Application is hereby made for Permit to C nstr ct ( ) or Repair an Individual Sewage Disposal System at ..............f ..:.... o v-- S rt-�- � --------------- ••--•---•--•--.....•-- •-•-•••••--••••••••••-•-••-•------•-•-----•-•-••-•--••----••••----------------.....-----.......-- ...._...L c ion-i\ddr or Lot No. ±.. a..�T,elh.eQ- L-C`� Q\�'4,.---��-: A dr ssC. Ks,��_ `P •Y_!_��lr.���o y Installer Address Type of Building Size Lot............................Sq. feet �t Dwelling—No. of Bedrooms............. -----------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____-_-___________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity------------gallons Length----------- .... Width________________ Diameter................ Depth................ x Disposal Trench—No. .................... Width....___...._._._____ Total Length-- .... Total leaching area...._...............sq. ft. 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. I----------------minutes per inch Depth of Test Pit_................. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.........._............. 04 .........................................•-••••-•........•••••-•.....-••-•-•r......•-••.....-•-•••••......................................................... Descriptionof Soil. ...-•�� - ------------------------------------------------------------•--------------- x -------- ............... fit-------------------- .-----•----•----------------------.-------•••---•----••-- W --- ------------ U Nature of Repairs or Alter s ns\ r� n applicable------ _ .. E:` lQd. ------..._�Y ,S -•------_._ ..r.l�---f-- . -----------.�-Q.� •c�.-c1:,--------------.6.Q-Q-------a ` V ------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Cornplikrry has been issued by the board of health. Signed .. - --- - --`\\ T '�t ---------- ...... �^ Application Approved ByCtil ,1 -`meµ-.. . ��.." te 7 ................................................................................ Date Application Disapproved for the following reasons: ........................................................................................................... ------------- --------------- I.�.--. ~9 .... Date Permit No. - 1� ✓....--- Issued ..........�..�........ ..'....... Date No..f5r/ Fic2 .............. THE COMMONWEALTH OF MASSACHUSETTS ' l �. BOARD OF HEALTH k i - TOWN OF BARNSTABLE Apphratiou for Diripwial Mnrk.s Towitrnrtiun ramit Application is hereby 'Made for a Permit,to Cdnstruct ( ) or Repair ( " an Individual Sewage Disposal _`System at: "(ej ........ .................. L.:+an�orn,-Addrgss.]� or Lot No. ......................\�Vl . � ?!,.J t'�....f ............................. Ow ei Address "t�S rn�,k- S� . ... C > �e VY).. a�(o Installer Address UType of Building Size Lot............................Sq. feet a, Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------- --------------------------...------------------------------... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter---------------- Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 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-..__._----__-_----_---- Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•---•------•----------------•--•-----•-••...••••----•-•--•-•--------•-•-••......•--...-----•----......................................................... 0 Description of Soil............. ... .. _ 1 --------------------------------------------------------------------------------------------------- ►y �� Vv vim„ ...._.... ------------ W / V Nature of Repairs or Alterat zls— �nswer when applicable--------- u se-,___-____--.lc `. 5 .;La......._��--- . ..................---1 C� �`L------------.---.--•. --`....( �------------� a ---•--...... CQ_r~?l� `;�`�------------ ��Q �- - �-t ��.= y Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. D...Signed -- f ------ -- g / Application Approved BY - ---- -------- -%----*1-I! --.-- -------------------------------------- ----- -- ----- -------------- Dace Application Disapproved for the following reasons: ................................./------------------------------------------------------------ - :... ................. _------------------------------------------------------^---- ----1 1 ......... ..�.�.�(...... C� Permit No. ..... ..."/..................�'� ---- 1 Issued ----------� 1----....�.�-----------Da-------- Dace a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (frdifi ate of Tomplian e THIS)IS TO CERTIFY That the Individual Se a e Disposal System constructed or Repaired J g P Y ( ) ( ) ----------(....C�:.�c-..\. �. .................' -- ...._ C Z�S. - ------------------------------------------------------------ byInscallcr at .................... ��...vv :c.', `....... ------------------ CG' -.-W C, = has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .. _.. ... :.._.�<7..' .. dated ^�`. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI��ON SATISFACTORY. , .... Inspec DATE -------- � r ..�A ; A . .... ... - _ - � . -------------------------------------------- -------------- ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 0 No. FEE.. �------.----- Disposal nrkii Tun trndbn ramit Permission is hereby granted-----� ��....---Yv...........1------. C� ` to Construct ( ) or Repair (')—ap Individual`Sewage Disposal System at No..................11*61. _v ........................... street- as shown on the application for Disposal Works Construction Permi �"� '._15;..... Da .�..__.. . .. /.4... Board of Health DATE..... )--- -------17�-V- -•----------•------------- U FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS SSE;StR-"AP NO. _PARCEL l Y- CA� I i K SEWAGE PERMIT NO. � 'TILLAGE n -4- ST A L ER'S N RLE i ADD.RSE,SS � � � 3 +1 i w � �� 7, � �) ep t MI L D R OR OWN ER RATE PERMIT ISSUED DATE COMPLIANCE ISSUED -- -- � 0 135 S8` a _ TOWN OF BARNSTABLE LOCATION (�-� WA k% w S ` SEWAGE IVILLAGECO ASSESSOR'S MAP & LOT I g L 13 0"64 t INSTALLER'S NAME PHONE NO. Ckr SEPTIC TANK CAPACITY ®®® ' k f LEACHING FACILITY:(type) - (size) NO: OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER AQ_�r S DATE PERMIT ISSUED: o d 10 � I � o 7 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,�' � e.':-��.. R 1. ` 1 ��L. 0 ' �9 0 �® CNo._07..G. ? b � '3 p Fps. ......_............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �)T. . .......................OF..........................._...._..-...-----------------------•------..................... Appliration for Dhip i al Works C oni3triarttntt Prrmit Application is hereby made for a Per it to Construct ( ) or Repair Individual Sewage Disposal ""`—`System at: ...- ------- . • •. ...............•----------------------- ... -•---•----------•----•--..........� , ......------....... ----- ...N �_. ---- ----- - --- - Location•Address or Lot No Or I i e Address ` Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures -------------------------------- . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. fx Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—�?o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) I Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. l..._------------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........................ •-- . O Description of Soil-------------- �v-1..................--........------------------------------.------• .... --- -------------------------•------- "� W ------------ --------------- -•••--•-••-------- --...••-•-•------------------------------••--•-•••••.........••---- ................... i t V Nature of Repairs or Alterations—Answer when applicable_-___----, ______-------------------- .................[...................... .._... Q 1 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ITT LE, y g g p y of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has b issued by the board of health. Signed !- `^'_`....-•--- `-? ',. ''" --•-- [ r� Application Approved By-•-...---- e � ._... .. ;....... ----------------------ate-------------- Date Application Disapproved for the following reasons-..............................=......................................................---------•---------------- -•-------------•--------••-••••--------•...-----...--------•--•---•••••••...•--•......_..--- Date PermitNo......... 7_'__ _ ................. Issued_....................................................... Date ASl_ (J ,. No.... {�... �•� C� + Fps Q► Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ...................OF.......................................... ... Appfiration for Bispoiial Works Tomitrurtiun Vrruat Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage Disposal System at: ` .......... ......... ......... Location-Address or Lot Nor ( (� G YY 1 S. Z. C-., I d l G*. W 0 ... .. .. M-�a�.<r c_�'�^�r t. l'? Y c.. er - •._- Address ....................................•-•---••---• ' __._...------............__._......-- ---------•---------------------- ----- ---------------------------------•-------- Insta.fer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.................___________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- - _ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area------------_-------sq. ft. 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-._---___-_-_--______--- Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ti--- ........IN . Description of Soil----•-------. ------------ ------�s- x UW ---------------------------------------------------------------------------------------------------------------------------------------1•--••--•- -------------------•••-----•-----• .... _.. Nature of Repairs or Alterations—Answer when applicable........... _ _ � __________________�_ ' _____ ........ -'j t L Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of T?T E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e issu d by the board of health. Signed---...._..',,, ��..............................................................., ✓� J, ?—� O E- Application Approved BY__.____._. ....�D...:�r - ................................ .e _JDate D Date Application Disapproved for the following reasons:-------•------------•-•---------------------------------------•-------------------------------------....._---- -------•----•--------------------•-•----.....-----••---•-------..............----------........---------------•--.........-•••--•---------•-•----------•-•--•-----•-----------------•••--•-----...--••-- Date PermitNo.... .. .............................................., ..5' Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �7 ............. ...0...............oF.......... .. ..I............. ..�.. ! .......--•-- dr Tutifirttte of Tuntpfiana THP IS TO CE TIFY, That the c�'ividual Sewage DispTal�System constructed ( ) or Repaired by..--•--•..,-O-..`r--------- ................•-•--...�"�--�.....----................... Installer tt V-y"i �. . �. a� t... has been insmiled in accordance with the provisions of TIT-~ j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........................." ��� dated-------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... �7•............. Inspector.------------. .................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...OF................ 1 �.7 7 ................................. ...._.._.........--•--------•......-•--................ _ o No.. .................... FEE...... ©........ Bispovil Workii Tons Ir rt rrrmu : Permission is hereby granted__._ 61'_ , �I_ ,S to Construct ( ) r Repair•�, ) an Individual S.w ge Disposal Sys�n � � , {{ �r . CC ••-•-•. .---------------•----•----••--•----------------------•----•-•••-------------------•-----•.........Q.... Street as shown on the application for Disposal Works Construction Permit No. Dated..... .....•--.....•-••...............A.-C _ --------•-•--•-••--------. O $ Board of Health DATE................................. .............................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE LOCATION , # .,6,� VILLAGE a� SEWAGE t� ASSESSOR'S MAP 6i LOT64 INSTALLER'S NAME aSz PHONE NO. SEPTIC TANK CAPACITY 100 O LEACHING FACILITY:(type) ` L--size) NO. OF BEDROOMS____PRIVATE WELL OR PUBLIC BUILDER OR OWNER �� ( WATFR DATE PERMIT ISSUED: { o I � b DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes NO w---% i 39 / _ f l Il _ j TOWN OF BARNSTABLE LOCATION I `�'�� VIA, , w '�V - SEWAGE VILLAGI ,A to ASSESSOR'S MAP LOT i INSTALLER'S NAME &z PHONE NO. �tl�' I �v4L. � ►� v ��``S j SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) (size) 1 � � NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Q-w-I r S DATE PERMIT ISSUED: o d a 7 I. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes. No 16CA i I i `I Town of Barnstable r# y' Departinent of Regulatory Services > Public Health Division Date o 3 200 Main Street,Hyannis MA 02601 Date Scheduled I'll I/0 -. Time I Fee Pd.' Ud oil Suitability `Assessment fog- Sewage Disposal Performed By: Ge v fYiY\ . i Witnessed By: LOCATION& GENERAL INFORMATION Location Address f Owner's Name Malv►. �} €. . I�oM�, AyL( eya.,7-I,i,;, Address. Assessor's Map/Parcel: �CiCa•"p/i q�_:VA .2�/.y D l T, /3 d '' U Engineer's Name arl;`en Meurer NEW CONSTRUCTION REPAIR _ Telephone# C5�� 3G.� Land Use G •Slopes(R'o) `<Z(� Surface Stones') Y Distances from: Open Water Body � Zoo'ft Possible Wet Area �Z�}}t Drinking Water Well Drainage Way property Line y I�` ff Other o ft' SKETCH:(Street name,dimensions of lot,exact locations of fest holes&pere tests,locate wetlands 1n,proximity to holes) pn��pO� Cesspools essp° M� 0`y i- p o�9I�2� OONGn 0°s� Bop o f ce P I I gxisten9 p) sue' N71-45100"W 5 385.12' GASLINE SHED C,4. - 1--asoo•--� . �� M ,.rfs•,e M j .I EC AS '3 W .._ / E sc WPSER� O LO %TO.f.v39,77 38':'. ^�i T.O.F.e3¢.7U' 0) 7 N 3 6.H.W. _ #1175, rp M M M CV_ Z 20' WAY wATERUNE -, N71'24'45"W 136.21' KATERLINE , pO�E S67'52'15"E 231.99' r Parent material(geologic) (ili l Oils Depth to Bedrock Depth to Groundwater. Standing Water in Hole: �. Weeping from Pit Face Estimated Seasonal High Groundwater f�V DETERNIINATION FOR SEASONAL HIGH WATER TABLE . Method Used: Depth Observed standing in obs.hole: in. Depth t0 soil mottles Depth to weeping from side of obs.'hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj:faetor Adj.Groundwater 1ovel PERCOLATION TEST NO I Observation Hole# ( Time at ry�r. Depth of Perc :. P Time at 6'. Start Pre-soak Time @ Time(9"-6') End Pre-soak G Rate MinJlnch �� Site Suitability Assessment Site Passed l� ;' Site'Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--- ----= ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTTCVERCFORM.DOC DEEP,OBSERVATION HOLE LOG Hole.# Depth from Soil Horizon Soil Texture Soil Color i Soil Other Surface(in.) (USDA) (Munsell)` Mottling (Structure,Stonea,Boulders. ns istdncy,% ravel 011, b9km*11.�441 10 t. _3/Z. /VA Ib 1►_ 32,E 3 And 11 � o" t DEEP OBSERVATION.HOLE LOG Hole# Depth'from Soil Horizon Soil Texture Soil Color.` Soil' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% ravel - a4 Iov 3/ 1J k DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color, Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Con i to c Gravel DEEP OBSE ATION•HOLE LOG le# Depth from Soil Horizon. Sot exture Soil Color Soil Other Surface(in.) (USD (Munsell) Mottling (Structure,Stones,Boulders. Consistency. i Flood Insurance Rate Man: y Above 500 year flood boundary No— . .Yes Within 500 year,boundary No X Yes,;r,� Within 100 year flood boundary No x Yes Depth of Naturally Occurring Pervious Material Does at least four of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If riot,what is the depth of naturally occurring pervious material? Certification I certify that on Q I (date)I:have passed the soil evaluator examination approved by the Department of Environniental Protection and that the above analysis was performed by me consistent with . the required tr ini pertise and experien a described in 5 10 CMR 15.017. Signature Date 2_4�1 l (� Q:1S.EPTIWERCFORM.DOC . F GIG �/Z0 g 0 C,OIL r� G c � � � 69 s r L . a cc TO t T i l r PARCEL ID: w 019/094 i SHELL LN. I 1 PARCEL ID: 019/093 N SITE rn' PARCEL ID: 019 127 PARCEL ID: STK. / OP9 PARCEL 10-02 O0) 019/130-001 /0)1.4 O'101 BPZ( / = O p� 5 Op'� BENCHMARK: CORNER OF C � W CONCRETE PAD=36.00' GIS± Existing S f m / 7�- STK. Opp 9 Ys r•n -- -------- �� �o b PARCEL ID: "' TEi-I 034/061 LOCUS MAP N.T.S. C7 \'`•, - SyFO 38512, (Note 10)ysfem BENCHMARK: LOCUS INFORMATION NExisting s� ;tq�. TOP OF CB DH=36.00' GIS± >j.... / �'�ti �� pc COV. TITLE REF: C158789 IN ZONE II . ..y �j ! °"" out Existin Ces pool PARCEL ID: MAP 019 LOT 130/001 .� , (Note 0) Nil• 4, 20. ' ,�,;`�c4_ \ �"�R S OFC o , As ?� o;�-''69- 36 UPOLE . ... SEPTIC SYSTEM - . ,. 36•,6 ,,,;;,Qa REPAIR PLAN Ole leleOo "' _ LOCATED AT: .PARCEL ID: �'A�''��',�._ �. ;TpF•• :, 019/162 /VF'��:�� 3p•....a3 WATERLI _ "'- ....s's#��---i„ 'S 'o� E �30" q�.� ^^' 1169 & 1175 MAIN STREET GENERAL NOTES: MAPLE,, y COTU I T M A UPOLE�=.�, �Sssi.� ` =�_ .. - , Ile 1. ALL.CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL .. ..,. BOARD OF HEALTH AND THE DESIGN ENGINEER. `s6)• - f ,�� �• 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS S2'1 '% \= ; OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE `S �' Incy �p� SCALE: 1 .=40 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: O '� �y 310 CMR 15.405 (1) (B): z �` JANUARY 25, 2009 1) A 1.21 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING TO BE •y M c� \\ / 4.21 FT BELOW GRADE VS REQ'D. 3 FT. (H20/VENT PROVIDED) REV: Ol/2 /2010 ADD EXIST. SYSTEMS/NOTES PARCEL ID: 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 019/164 DESIGN ENGINEER. � OFMgSSgcyG OF 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING a EDW M.A FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN UPOLE A. R`, o R ENGINEER BEFORE CONSTRUCTION CONTINUES. 8 ONE N STONE 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. NO. ONE No. 1E40 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF O THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF I �Oc• �R HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. CB Fs � QiST 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. A AD Sol TAR\a� 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY " THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 10. ALL EXISTING FACILITIES AT 1169 AND 1175 TO BE PUMPED.- CRUSHED AND FILLED PER TITLE V. r D A R R E N M. MEYER, R. S. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION k 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM•PURPOSES ONLY P.O. B 0 X 981 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING EAST SANDWICH, M A. 02537 1; 14. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. OTHERWISE) 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE GRINDER (5 0 8)3 6 2= 2 9 2 2 16. INSTALLER TO FIELD VERIFY H2O CERTIFICATION PRIOR TO INSTALLATION. 17. INTERIOR PLUMBING TO BE RAISED ON #1169. (PLUMBING PERMIT REQ'D) 1$t ANY ADDITIONAL OUTLET PIPES PRESENT AT #1175 TO BE TIED INTO PROPOSED TANK (INSTALLER TO VERIFY) SHEET 1 OF 2 SEPTIC SYSTEM PROFILES NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE:, MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:28.79 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING N.T.S. FOR A DISTANCE OF 15' AROUND THE PIPE INVERTS' PRIOR TO CONSTRUCTION PERIMETER OF THE S.A.S. BLDG #1 169 2) TANK AND D-BOX SHALL BE SET LEVEL AND TRUE TO SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. ON A MECHANICALLY T IX. GRADE CALLY COMPACTED S T.O.F. EL.=36.26 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION,-PORT OVER INCH CRUSHED STONE BASE, AS SPECIFIED IN OUTLET AND SET TO 6 OF FINISH GRADE SET TO 6 OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. 310 CMR 15.221(2), F.G. EL.=32.50t F.G. EL.=33.0f F.G. EL: 33.0f F.G. EL: 33.0-32.0(MAX.) VENT 3) INSTALL INLET & OUTLET TEES AS REQUIRED " 4) PLUMBING ON UNIT 1169 TO BE RAISED ��V\1 OF Mgss9� +" 9 MIN COVER/ TO ELEVATION SHOWN (PERMIT REQ'D) 9G L 10 t L 115' L = 15'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) o DARKEN M. s 0 S=1X (MIN.) 36 MAX COVER 0 S-l% (MIN.) 0 S=lX (MIN.). MEYER 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVCNO. 10" a 11.3" TO 14" Q INV.= 30.5 48"LIQUID INVERT LEVEL INV.=30.25 NITAR�a� PROPOSED INV.=28.75 PROP. SEWER OUTLET GAS e'°`� D-BOX 8 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE = 32.0'/ROW EL. 31.0 INV.=29.0 DB-9 -201 INV.= 28.40 PROPOSED 1.AgarLigm 500 GALLON SEPTIC TANK SOIL ABSORPTION SYSTEM (PROFILEFit RESTORE VEGETATIVE COVER T.O.F. BLDG #1175 BACKFILL WITH CLEAN -PERC SAND EL.=35.7 f F.G. EL.=33.0t TO TOP OF CHAMBERS Imo-- 75" BREAKOUT=TOP ELEV.=28.79 L = 10'"t 9" MIN COVER/ � + 36" MAX COVER L - 115' INV. ELEV.= 28.40 ® S=IXCIH4 (MIN.) ® SCH4 (MIN.) EXISTING SUITABLE 4"SCH40 PVC 4"SCH40 PVC BOTTOM ELEV.= 27.46 • 2,g3' MATERIAL 1011 Bpd FLE 14. CONNECT T D-sox 5' MIN. ABOVE BOTTOM OF 31.50 48"LIQUID (SHOWN ON DETAIL ABOVE) T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 8 x 2.83' = 22.64 �� 76" _ As BAFFL �INV.=31.25 7.86 PROVIDED - LEVEL 1,000G ( ) USE 8 ROWS OF�5 HIGH CAPACITY. EXIST. SEWER OUTLET �cAPAc�rr I 50oc BOTTOM OF TH EL.=20.75 - ADS BIODIFFUSER UNITS-NO STONE __ PROFILE i CAPACITY W/ CONTOURED WEDGE EL. 32.78 PROP, 1.500 TWO COMPARTMENT SEPTIC TANK -TYPICAL SECTION 16" x.Ts. 111.2" SOIL LOG. P#; 12815 DESIGN CRITERIA i NUMBER OF BEDROOMS: 8 BR ,EXIST. (48R IN 1 169/48R IN 1 175(TWO FAMILY)) DATE: JANUARY 13, 2010 SOIL EVALUATOR: DARREN M. MEYER R.S., CSE. 16.14 N TI SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN. # � END CAP . , WITNESS: DAVE STANTON, BARNS. BOH DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 880 G.P.D. �„� Elev. TP-1 Depth Elev. TP-2 Depth GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 16 HIGH CAPACITY (H-20) BIODIFFUSER UNIT 34.0 LOAMY SAND 0° 31.75 A LOAMY SAND O" MODEL 16" HICAP PROPOSED SEPTIC TANK: 33.17 10YR 3/2 toll 30.0 10YR 3/2 21„ " FOR 1 169: USE SINGLE COMPARTMENT 1,50OG SEPTIC TANK FOR 440G B B LENGTH 76 NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT FOR 1 175 (2-FAMILY): USE TWO COMPARTMENT 1,50OG TANK (1000G/500G) FOR 440G LOAMY SAND LOAMY SAND EFFECTIVE LENGTH 75" TO CHANGE WITHOUT`NOTICE. PRODUCT DETAIL MAY 1OYR 5/8 10YR 5/8 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (880) = 1189.19 S.F. 31.33 32" 28.42 C 40" SIDE WALL HEIGHT 11.2 C " 74 OVERALL HEIGHT 16" DISTRIBUTION BOX: 9- OUTLETS (MINIMUM) MED. SAND MED. SAND OVERALL WIDTH 34" 4640 TRUEMAN 8LVD _PRIMARY S.A.S. 2.5Y 7/4 2.5Y 7/4 13.6 CF HILLIARD, OHIO 43026 USE 8 ROWS OF 5 - 16" ADS BIODIFFUSER 160OBD H-20. UNITS-NO STONE CAPACITY (101.7• GAL) ADVANCED ORMNAGE SYSTEMS, INC. AND EXTENDED 0.75' W/ CONTOURED WEDGES (H-20) PERC 028.50 PROPOSED SEPTIC SYSTEM SITE PLAN BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) (BIODIFFUSERS) 40 UNITS x 6.25 LF x 4.70 SF/LF = 1175 SF 1169 & 1 175 MAIN STREET, COTU IT, MA (CONTOURED WEDGE) 8 ROWS x 0.75' x 4.70 SF/LF = 28.2 SF 24.0 120" • 20.75 132" . TOTAL AREA = 1203.2 SF PERC RATE <2 MIN/IN. ("C" HORIZON) DESIGN FLOW PROVIDED: 0.74GPD/SF(1203.2SF) = 890.37 GPD > 880 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN DARRENM.MEYER,R.S.' R.A.S. Survey Inc. NTS D.M.M. V • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant'to.310 CMR, 15.017 Route 6A PO BOX 9Bf to conduct soil evaluations and that the above analysts has been performed by me consistent with the EAST SANDWICH,MA 02537 CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. �STSANOW/CH,MA02537 DATE: 508-382-2922 (508) 527-3600 01/25/10 D.M.M. 2 of 2 „ 4 REV: 01/26/2010 ADD EXIST. SYSTEMS/NOTES r