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HomeMy WebLinkAbout923-925 MAIN STREET (COTUIT) - Health 923 925 IUlain Street (Cotuit) COtUItP A = 035 01200? I� 46 Commonwealth of Massachusetts _ �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Na information is Cotuit 7 MA 02635 04/15/2021 required for 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 way. Please see completeness checklist at the end of the form. Imng out forms A. Inspector Information I I- IS r3 filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector - cursor-do not Cape Septic Inspections use the return �-� p key. Company Name 52 Rivers End Road r� Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification y I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: .1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. • i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is Cotuit MA 02635 04/15/2021 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. 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): t5insp.doc•rev.7/26/2018 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St v Property Address Cotuit Inn Condominium Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. , ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 • f I c Commonwealth of Massachusetts Title 5 Official Inspection Form 1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 925 Main St u- Property Address Cotuit Inn Condominium Owner Owner's Name information is Cotuit MA 02635 04/15/2021 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a,private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El ® due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 925 Main St v� Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary'to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 0 An portion of a cesspool or privy is less than 100 feet but rester than 50 feet Any p P Y 9 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The, system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility 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 CA. Yes No ' ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or 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? El ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form .i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 20 Number of bedrooms (actual): 20 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GPp plus Description: Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes Z No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gp ))� Detail: ` In 2020-388,000 gallons were used and in 2019-321,000 gallons were used. Most condo units are seasonal. Communicated with grounds keeper on site who infomed that most units are closed up from Oct to May and used mostly for the summer Sump pump? ❑ Yes ® No Last date of occupancy: current/seasonalDate t5insp.doc-rev.7/26/2018, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: s 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1987 town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): - . 2'81, Depth below grade: feet Material of construction:"- ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed during the inspection and it came freely t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 4000 gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle ' 3111 Scum thickness 2" 5" Distance from top of scum to top of outlet tee or baffle 13" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At the time of the inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): F 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal , ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons • Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments —u� 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Nci* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: . ❑ innovative/alternative system Type/name of technology- - t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible failure criteria found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,,condition of vegetation, etc.): y t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts (? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � .7,�.i",�-Ii�"_�I"V^,-�,,I�,I;"�-,�-..,,',�.�-K�_��I7,,,�I:,,i��,�:..I I�I:.1,:�,,::!�'�:;::,�4�,r:�..,-­:;..:.�—..,��I:I.,�.-,.��.:,1,II.-"�,:�-::.-"�,S��,1�..�.:�,-,i­:;:,-I..;:....:.,1 1I��..i::i�.:�::..�-:��,.-,��,:I�.1`,'�:,,I j...j.�"',:1�::.M..,�.�,..:`1.::,�:1..I,i�,...i�����l:..:::�1.,�":.;;�1I,I.�-�.—-��*.,:��...iCI."�.I.-!.��.�.�,��I��I...,,:-..:-�ii,;�!i­:1..'I,:,���..:�.�,:..�.,��,.""i;i-i.�1,.��.:Ii:I"i,'I�'��,,41w:,:.�:..I i��.....-�i,....;:p:-,�.,i::.�-.I:­.If p::�,,:::i,�,.,..::��I..i:-,��,J�.:��:,,,II 5,:.1:�:..:.'�1:.,��,,ii�,,i�,i�:i;.i�.—,-i..ii.,,,:.",.,i:..,.-�i:,�j..�,:�.'.',�i.;�:,I,.i;�::� 925 Main St _-,:,.:���'_I"..���,,:-.I 1.-I P,i17llI­.-jI��.­--"ii�i1%%��1;�iii, Property Address i­�]-,,.�1�i;;;,;��",,������.1,I,;."1 ;1,i,,�1.x�I�".1 I,��,�,,,.�1,,,I.I�,". ,,, ,,�,,I,.;,r,�i,:1�'�'.,. 1�T,,,,,,1,i 1.,,�I��, �a��'l�A.:�,�,,.*�"­�,:,,:_ "7,- ",,.;1,.i4f,�-,.i-K�,,'"z,,..­z,�',I_:,,,-Ii"­..iRi,,�"­:,I,",,I1 *,I `,I� ,,I' ..-�l"�-�ii-��":,'�,i­,iII;-%I-,-, ;iiL[i"� I 1 .I�;; �;..�1.;�d"-II�;,,:,I�-i:.1.*..-­,,-,0;;�,,''1.�j,��-,��:I.-".,,��,_1l�,�;,_�::�i:.:,�����.,,,—;._ Cotuit Inn Condominum Owner Owner's Name information is Cotuit .MA 02635 04/15/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ', 14. 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 I. the building. Check one of the boxes below: . . ❑ hand-sketch in the area below ® drawing attached separately . s. ,,.; ,, Zr v" x . f« r ' s. ice? 5: 9$ .� 3 l+�n�.� frp 3 3`T�F S h ffi d"Y'' Tt 1 ;e .. Y § V f � 1 1N4 6 r n , ,:,�...�._.:­I:.,7_,1..�._.17�,�"I,...1.: X .F e Y f 7M S S _ �, S 5 �4 rt t �1, 1 fl I - ,z ,, .? 5 I � } Y� L ly-Y�` : u f �' m d 5 - i Z ,. 5! rr.(yj� b f .". ." V.; S .. 1 f "1 X l 4 P K 1 n' F ^�x fr }� L�� / ' f i ,F S / t :/ ex N p _" d 3 < C ti x. _ X 8 3 r r.. A e f 2 r '� _, . . - I - . I t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 04/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 17 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed.USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominium Owner Owner's Name information is Cotuit MA 02635 04/15/2021 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included z t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 f . Commonwealth of Massachusetts 0&5-6fo2-Dili ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , f� u 925 Main St Property Address `d Cotuit Inn Condominum Owner Owner's Name information is , required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of Inspection r; Inspection results must be submitted on this form. Inspection forms may not be altered{in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �/ Bo2.� filling out forms -}� N/ on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems,After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes , 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails e Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. 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): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 C Iil C Commonwealth of Massachusetts Title 5 Official Inspection Form tI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is Cotuit MA 02635 09-24-2019 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructedpipe(s) or due to a broken, settled or uneven distribution box. System will Y 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I I Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominium Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality 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 2000 gpd- 10,000 gpd. ❑. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or 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? Z ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 925 Main St U- Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 20 Number of bedrooms (actual): 20 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GPD plus Description: Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes El No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Most condo units are seasonal. Communicated with grounds keeper on site who infomed that most units are closed up from Oct to May and used mostly for the summer Sump pump? ❑ Yes ® No Last date of occupancy: current/seasonal Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts a Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St �V Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes .® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 925 Main St u Property Address Cotuit Inn Condominium Owner Owner's Name information is Cotuit MA 02635 09-24-2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: 1987 town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): „ Depth below grade: 2;8 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting,evidence of leakage, etc.): water was flushed during the inspection and it came freely t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name ' information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of-Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 4000 gallon 411 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 51" Scum thickness lot 5„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" sludge judge 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.): At the time of the inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . !% 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of.Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 s 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St V Property Address Cotuit Inn Condominum Owner Owner's Name information is Cotuit MA 02635 09-24-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ".If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 925 Main St Property Address Cotuit Inn Condominium Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) . Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible failure criteria found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow. ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 L_ r Commonwealth of Massachusetts Title '5 Official InspectiohTorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every COtuit MA 02635 09-24-2019 page. Cityrrown - State Zip Code Date of Inspection D. System'Information '(cost.) 14. 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 61� 4i ' " F` Hj 3G 4 r3► u, 3r; U - S G 1 X t5insp:doc•rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 925 Main St Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I i Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 925 Main St V� Property Address Cotuit Inn Condominum Owner Owner's Name information is required for every Cotuit MA 02635 09-24-2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System'drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 AsBuilt Page 1 of 2 TOWN OF BARNSTABLE LOt T10N q23 3df a s f SEWAGE# VILLAGE `-U f�t ASSESSOR'S MAP&LOTa33`et�A-X, INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 5�O06 l9�t L LEACHING FACILITY:(type) Z eoe-4 T 5 (size) X 3 NO.OF BEDROOMS offO / BUILDER OR OWNER e(!�k t T PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of kaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o leaching facility)_ r Feet Furnished Y a A >. Ug o . o q� 49 6 � N�a �-���'^� http://issgl2/intranet/propdata/prebuilt.aspx?mappar=0350120OA&seq=1 6/17/2016 Commonwealth of Massachusetts. , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 923-925 Main St n r • Property Address , Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 _ page. CitylTown 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services ». Company Name P.O. Box 73 , Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes F Conditionally Passes ElFails , ♦ it • .- 3• . .. a i.c ❑ Needs Further Evaluation b e Local Approving Authority Inspector's Signatefe 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•3113 Title 5 Official Ins n Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 B-1-13 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 is in good working order with no sign of failure. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments + , 923-925 Main St u ' - Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) _ ❑ Pump Chamber pumps/alarms not operational. System will pass with-Board of Health approval if pumps/alarms are repaired: B) System Conditionally Passes (cont.): F r ❑ 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): El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ElF' 'obstruction is removed f❑`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): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if .the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a.manner which will protect public health, ' safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ' ❑' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS Is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the,SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged.SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, - 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is Cotuit MA 02635 8-1-13 required for every - page. Cityrown Stater Zip Code Date of Inspection B. Certification (cont.) r Yes - No F , ❑ ® 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. El ® 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 se 11 rving a facility with a design flow of 2000gpd- 10,000gpd:,z, ' ❑ ® The system fails. 1 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 El ❑ 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 they 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f ° M 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ®! ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as MIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of breakout? Z ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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): 20 Number of bedrooms (actual): 20 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2200 t5ins•3/13 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 ,M 923-925 Main St r t Property Address Cotui Inn Condominiums Owner Owner's Name information is Cotuit MA 02635 8-1-13 required for every ' page. City/Town + State' , Zip Code Date of Inspection D. System Information Description: - Number of current residents: • Varied Does residence have a garbage,grinder? a ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) ' Laundry system inspected? » , . El Yes ® No ~ ` Seasonal use? , z - ` ,. ��. ❑ Yes ® : No Water meter readings, if available (last 2'years usage (gpd)):r as Detail: Sump pump? F ❑ Yes ® No Last date of occupancy: [ 8-2013 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 a- Industrial waste holding,tank present?; 3 �? - ❑` Yes ❑ No i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal sysN;n•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 923-925 Main St Property Address Cotui Inn Condominiums 4y , Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 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: Owner--pumped 7-2013 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 operatorunder contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): i. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ey'ot 923-925 Main St Property Address ° Cotui Inn Condominiums Owner Owner's Name information is required for every, COtUIt r - ''' MA 02635 8-1-13 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: . 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): , 48,1 Depth below grade:_ - feet` Material of construction: ❑ cast iron ®'40 PVC ❑ other(explain): Distance from private`water supply,vvell or suction line-'* feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): 36°1 Depth below grade: feet Material of construction: '.. ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of;Compliance?.(attach a copy of certificate) - ❑ Yes ❑ No Dimensions: „ , 4000 Gal • .. 811 Sludge depth: t5ins-3113 Title 5 Official Inspection Form_Subsurface Sewage Disposal Sys4zm•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M °p 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 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 48" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name. information is Cotuit MA 02635 8-1-13 required for 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 ❑ other(explain): Dimensions: Capacity: gallons Design Flow: " gallons per day Alarm present: ❑•Yes ❑ No Alarm level Alarm in working orders ❑ 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 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pits. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If. SAS not located, explain why: t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 923-925 Main St Property Address Cotui Inn Condominiums ,., •., Owner Owner's Name information is Cotuit - '. . MA 02635 8-1-13 required for 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.): a I 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.): k *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins 3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 V, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pits. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit ' . ;:` MA 02635 8-1-13 �^ page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Type. ® leaching pits number: 3-1000 gal ❑ leaching chambers ,}. .,number: ❑ leaching galleries number: El 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.): Leach pits in good condition with no sign of back-up into d-box or surrounding stone. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of W Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923-925 Main St _ - Property Address Cotui'Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 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.): i 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.): S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923-925 Main St Property Address Cotui Inn Condominiums r '' Owner Owner's Name information is required for every Cotuit MA 02635 8-1=13 page. City/Town State 'Zip Code Date of Inspection D. System Information (cont.) - x: 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: Rry • ® hand-sketch in the area below ❑ drawing attached separately _j ,n40D ;. - � � wa. Vr8 �r 1 a r Y -.46 a as `r A t5ins•3/13,'r. ._ Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 L - . Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s e'y 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope i ❑ Surface water ; ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 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 °M 923-925 Main St Property Address Cotui Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-1-13 e 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 - S t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name ' r information is Cotuit MA 02635 8-10-10 ' required for every page. .6 City/Town - State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information ?r� 1. Inspector: a Shawn Mcelroy Name of Inspector < . Upper Cape Septic Services { Company Name = 29 Atwater Dr r. Company Address E. Falmouth MA 02536 City/Town Stat Zip Code 508-495-0905 ' SI !in n Fin Telephone Number Li c Number — -'AUG. zr7 RFrp"I�l B. Certification ey ,. I certify that I have personally inspected the sewage disposal system at this 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 land 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 ' 8-10-10 Inspector's Signature Date The system inspector shall submit a copj 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal ystem-Page 1 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's(Name information is required for every Cotuit MA 02635 8-10-10 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 is in good working order with no sign of failure. B) System Conditionally Passes: One or more "stem components o ents as describe '❑ y p d In the "Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank'(whbther metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is•available. ND Explain: ❑ Observation of sewage backup or break out or high'static water level in the distribution box due to broken or obstructed pipe(s) or,due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 923-925 Main St "`7e Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit•;_ �,•_., MA 02635 8-10-10.,. .r. page. Qity/Tpwn s state Zip Code Date of Inspection r. -B. Certification (cont.) B) System Conditionally Passes (cunt.); A�• - ❑ distribution box is leveled or replaced ND Explain: ❑ 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 s ' ❑ obstruction is removed v ;f , t c ND Explain: 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 orprivy'is within 50 feet of a surface water ❑' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board'of Health (and Public Water Supplier;if any) determines that the system'is functioning in a manner that protects the-public health, safety and environment .. . ti:w. .e. • i.4 . '3r r � .t t ,. ;rwX.a .`�..' � 'S,!; .2;u _ " ,•^"yi .-a',+•• "` -; t :' ' ❑ i The system•has a septic tank and soil absorptiofils stem"(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. t5insp official document•03/08 - n Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-10-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 El 0 Static liquid level in the distribution box above outlet invert due to an overloaded i or clogged SAS or cesspool �. El ® Liquid depth in cesspool is less than 6",below invert or available volume is less than, day flow. f, 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. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 923-925 Main St _-ar Property Address Cotuit Inn Condominiums ,:, •, t , Owner Owner's Name information is required for every Cotuit I A d s+ MA 02635 8-10-10 �. Pit !Town, "` w State Zip Code `'Date of In ection page: Y -,, P p B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes�i ,, No �j .,f (`»` w,.,{. "i i i3". . !, 'i2ti i`Y'•"}' i ❑ ® 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 colifonn 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. ,r ❑ ® , 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 tie 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': f , r Yes. ..No ,. ❑ ❑' the system iswithin 400 feet of a surface•drinking water supply a . ❑ ❑ , 'the system is within 200 feet of;a tributary to,a surface drinking water supply, . z ❑ ❑ 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?W`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 syste'm 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. t5insp official document•03108 - Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 1 Commonwealth of Massachusetts U d Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-10-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® . ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® - ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of® this inspection? El ® Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments, ,M 923-925 Main St l 34�y ?,'� �``� Ca ` Property Address Cotuit Inn Condominiums Owner Owner's Name. information is required for every_ Cotuit _ MA 02635 8-10-10 . s page. City/Town State Zip Code Date of Inspection D. System Information , Residential Flow Conditions: Number of bedrooms (design): 20 Number-of bedrooms (actual): 20 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of_bedrooms): ` 2200 Number`of current residents: , _,� , ;E Varied Does residence have a garbage grinder? s>. ❑ Yes ® No Is laundry on a separate sewage systemZ[if yes separate inspection required]:, ❑ Yes ® No- Laundrysystemnspected? El Yes ® No Seasonal use? ,•:r ' ~t r, fi 'p El Yes ® No Water meter readings, if available(last 2yyears usage (gpd)): ; Sump pump? ❑ Yes ® No' Last date of occupancy: 8-10-10 Date Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): ,.Y Gallons per day(gpd) at 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:, Last date of occupancy/use: Date _<Other(describe): . t5insp official document•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Director--Pumped 7-2010 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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): Approximate age of all components, date installed (if known) and source of information: 1988 Were sewage odors detected when arriving at the'site? ` ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 923-925 Main St z "; Property Address wy ; Cotuit Inn Condominiums ' ^j,;, "!e ; J -Q Owner Owner's Name information is required for every Cotuit M :, : . MA 02635 _ 8-10-10 . page. Ctyfrown State Zip Code Date of Inspection D. System Information (cont.). ;, 7 Building Sewer(locate on site plan): t.'•' Depth below grade: , 62 feet Material of construction:' ` ❑ cast iron ® 40 PVC ❑other(explain); Distance from private water supplywell or suction.line: 1 feet . Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic'Tank(locate on site plan): 50' Depth below grade: ' w,. feet Material of construction- ® concrete ❑ metal ❑fiberglass ry. ❑ polyethylene, > ❑ other(explain) , If tank is metal, list age: years Is age confirmed'by a Certificate of Compliance? (attach a copy of certificate) . ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- r r Dimensions: 4000 Gal Sludge depth: r 0 ..,Distance from top of slud9eao bottom of outlet tee or baffle 56 Scum thickness Distance from..top;of.scum to top:of outlet tee or baffle- 20,, , Distance from bottom of scum.to bottom of outlet tee or baffle ` Tape How were dimensions determined? r - , t5insp official document•03/08 --,- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-10-10 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.): Tank is in good condition with baffles installed and no sign of leakage" Grease Trap,(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑'fibei•glass ❑ 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 0. , . Date of last pumping: Date 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): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection ,Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 923-925 Main St Property Address Cotuit Inn Condominiums ,,n, •„ -,s ', t. w Owner Owner's Name information is MA .02635 8 10-10 required for every COtUIt � - - page. City/Town state Zip Code Date of Inspection ' D. System Information (cont.) Tight or Holding Tank (cont.) r , Dimensions:, Capacity: gallons Design Flow:- - r gallons per day Alarm present: _ ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last.pumping: 3 Date 1. > . r• ,p.,+ ,, . . Commen _ts(condition of alarm-and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ." Good condition with water at working level and no sign of.back-up. _ 4 r , t Pump Chamber(locate on site plan):" " Pumps in working order: ❑ .Yes ❑ No'.. Alarms in working order:: ❑; Yes't ❑ No t5insp official document a 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wb 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: L k 3-8'x8' ® 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.): Field has 3 leach pits and at inspection 2 were empty at inspection with no sign of back-up. The other was holding 40"of water with no sign of back-up. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name , , information is required for every Cotuit MA 02635 8-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate,on site plan): Number.and configuration Depth —top of liquid to inlet invert c Depth of solids layer Depth of scum layer - Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No, 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.): - t5insp official document-03ro8. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments 923-925 Main St Property Address Cotuit Inn Condominiums Owner Owner's Name information is required for every Cotuit MA 02635 8-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. 1 fo r 9 .�- - �i �- SSA' Ut4 I A -H- t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a • S 923-925 Main St Property Address „ Cotuit Inn Condominiums Owner Owner's Name information is 10 10 MA 02635 8, - - , ' required for every Cotuit �° . ,- page. City/Town State Zip Code Date of Inspection . e D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar Shallow wells Estimated depth to high ground water: 20 feet x 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: USGS maps show groundwater at greater than 20'. t5ins official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal S stem•Page 15 of 15 P P 9 Po Y 9 Commonwealth ®f Massachusetts - • Title 5 Official -inspection For s Subsurface Sewage`Disposal System Form -Not for Voluntary Assessments a Cotuit Inn Condominiums }' " Property Address 923-925 Main St Owner Owner's Name information is 4 ' required for Cotuit . MA 02635 5 4-07 . every page. City/Town 4 >w' State Zip Code Date of inspectiori c Inspection results must be submitted on this form. Inspection forms may not be altered in any way- A. General Information . 1. Inspectors Shawn Mcelroy r Y Name of Inspector, Shawn Mcelroy Enterprises Company Name 29 Atwater Dr. a#i'L �j` �- Company Address E. Falmouth - ,if EVtA . k ;, 0253e ' City/Town State Zip Code 1-508-495-0905 Telephone Number License Number ra B. Certification 1 certify that I have personally inspected the sewage disposal systerri at this-addr and thalg he Z�;- information reported below is true,accurate and complete as of the time of the ins} ion. The inspRtion. was performed based on my training and ezperienc;e in the proper function and rrtai enance tsf on e sewage disposal systems. I am a DEP approved system inspecto€pursuant to S 'on ICJ40 d'Ft Title 5(310 CIVIR 16.000).The system: PasseSL. " ElConditionally'Passes - El Fails {; Se,. Needs Further Evaluation by the Local Approving.Authority Inspect Srsolnspect gnature 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 46d'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, t5insp•081116 # iltfe 5 OfrrcwJ Inspection Form.Subsurface Sewage Qisposai System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fong Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. Cotuit Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 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: ® 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: System and all components in good working order. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metai'or not) is structurally unsound, exhibits substantial infiltration or exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *.A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•OWN Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 , Commonwealth of Massachusetts Rj Title 5 Offidal Inspection For :. P Subsurface.Sewage Disposal SysteRn Form_Not for Voluntary Assessments Cotuit Inn Condominiums Property,Address 923-925 Main St Owner Owner's Name •r ,a . w information:is. Cotuit ,'a • 4 MA 02635: 5-4-07 !°"•� _ �] required for every page. City/Town ` = ;; ' ' i, f' State Zip.Corte Date of inspection B. Certification (coat:) 4. ' B) System Conditionally.Passes.(cant): •- ] `s�•s .s. r �_ t; disfribution tiox is leveled or replaced ND Explain: 1.r .`.` ,.�l. t � ' _{� «. '� �' ' ���*+„•,- 'a,p. F.S,r `ia'.l .rr.yAa;i 'a: x. ..�', _ �-r : sr ,'❑ .The system required pumping more than 4 times'a year due to broken or.obstructed pipe(s). The L ,f i , f. ;r • ,..;rsystem will pass inspection if(with approval of the Board of Health):' broken pipes)are:replaced ,� _'�*'•a E obstruction is removed - ND Explain: C) Further Evaluation is Required by the Board of Health: t El Conditions exist which require:further,evaluation by the Board'of Health in.order to determine if the system is failing to rotect ublc health;saf '` y 9 P P efij or the:environment. unless Board of Health determines in accordance with 310 CMR .--a- z,a systea11 is soot functioning in a manner which wiltprotect public health, e�#afar�nr!tlt.e�mmre><r"ereesaraemnl+ •- i� CF! cnnn! or nrnnr! grathlre sft feat of 2 clre fir a t+taSQr "^r •!''oFgne+e�€nr r�n,nr Ar aanisSrre ft�i�3�#nF p nn�r€or]nrT�aQ¢�7t��'nc€:arnts�,rti'�c�c�€r maErn -: ��• fib�.. ';17$'� -/ti +. s 1'} Y T nr .S `� ,. . ., •�. _ �Doan Health lasid'Public r�S€ippl r; .:: - -,..+n rsrsaw n.a..yw nl 4AMl,,.l.aaNnsM"a •aaw wltr�Ravaea-.ea ala.ral4MTf�r•lllaa!'-a�rweA.wie..♦`,tiw.Ma•M��I.►�r,.atlia + of ule" JE.+�t�.''� s yyaaaqfp tp ggyqm n it n, n .r. .N•. J6LSe 6�Ea t,l��lY:v3S o3�E,,',71�33-�4 a `� •+� .•i rfi..•1 ^ �I' L, 1. :-> _ .1. _1...... _....3�. - •3:=.c33?� i-,3.2 ::> 393 a3.1:�.�}].3°'. V:. }�t1 ..._. :Y IE.i:. _ - a]vr,a]Iar aaaa;3 y - Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Cotuit Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) . C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. t5insp-08/06 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 15 t Commonwealth of Massachusetts . Title 5 OfficialInspection for Subsurface Sewage Disposal,'System Form. Nat for.Voluntary Assessments Cotuit Inn Condominiums ,,,,t r .•. , Property Address - 923-92:5�/Iain,St. Owner Owners Name _ ins or;naton;is required for Cotuit. k ,; H MA 02635. 5-4-07 F. every page- Cityfrown State Zip Code Date of trispection B. Certification (coat.) t t.,D) System Failure.Criteria Applicable to All,Systems:(writ.): Yes No .Any portion of a cesspool or privy, is within a Zone 1 of 'a public well r Any portion of a cesspool or.privy is within 50 feet of a private water supply well. "' '�' 0" ® •f ''; Any,portion of'a cesspool or privy iss,less than 106 feet but greater than`50 feet f rm a petvate,Water supply wen"with no acceptable water quality,analysis. LThis system passes if the well water areal sis, performed at a DFp ce,tofae. ' A�61nr�4nrna fnrlr��`ar ra�l�Irnppr�'ba�r�4avoW c�� --a F� _- , ,of ammonia n en and nitrate nit_ •4°`w�3 rr�`wn is,tqual t6"3&less t4'6a5r,5 PrII`a65g ve _j`r zi it EG r«[!! +•1f`J� f+ -•" t J "t .,.-'>y� a3:a=? v> yV-'1 � } i}:t T}:U iivts3 }!--ert ai:}.•+t W.✓V tl."v } .t}Wt.✓„ - •+ r eriteria'emst taav dory;gore in 310 GM 1i5.303,therefore€he vystern Tails. I lie •'l y1� } . - . i,a Ra�'`T. 'i,'t- '6 �-�s .� ` '.. } � r+s#., ♦°.Rf=e....nr.e..� k.1 .m.=;. .: .,< -.::.,«- , tie esary to t oireck Erse a iu e. t. j:c 1r ., . t•i �'�'. '�';' i l• t. ,� a .3a r, •`y41 -.. , ..6E , * � yea`coa. .s'v�c tA.•rppa.�iv�crcv u sal c a"o'ai641.4as�"scJa'y°aacix r'G.rfs'gays'Rgg,` v`r's so a', . For large systems,,you must intricate either"yesP yr"no'to each of the foilowin'a',,in addition to the ' _ ! i'.' �{• r:;,i.• -"...Yes iY.•+C°ICo j.t,+*i.,v.Y _•i �(9✓ w t � ;x-� i� d'..,. } vtL,�..t c}�} - . z�.; • <'t the syste.rst,is within 400 feet'ofa surfate dtinkint`watersibpply r,o• 1e }e # f Illy 5y8Ier€t i5 rg Inin IOU feet of.a €nt;U41enry to;a S;itT��CEriniiirl€y�water supply + d • r—� &� ��� . a.,tr�'�4,. # �} #4. E3E��# s 13 "s3�` a :- v_<;._ ..�.<'L iE_,s i__i Li !9 _M°PA mm nnfif 7 n n P ii of ,n;7?1; .s-?tar ca;nnW R". li you nave answered "Fes" o any question ia:: a .°sn c Me systern IS t opiisidere d a sly-nifirarit[;`treat, -v�ta� -•'-r.�::-:�.v.r:,:i = a..,-ca£;n�-c�t. r^mot ax: a��.-.'C�:?errs . ? i_Q! ear.:i r�- IV n n sc.-.- - t. - Sy.atvtaa tivts.>avvavu v vaytaatavuttt tt aavut u:atvt.t vvutavat�.va sa�.e.#aLu taa.svvt vwavta v 5i9uir�i 'tuvv taiv - iv�ev ei •e 5'ev= f. _._v b. r- :s_.i. -- i r Commonwealth of Massachusetts u Ville 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Cotuit Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes" or"non 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)] t5insp•08/06 Idle 5Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 - 1 Commonwealth of Massachusetts j I _ Title 5 Official-Inspect ion Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y+M Cotuit Inn Condominiums. s c*•fig•'•-+•^ ►a: 41' +s: ':. Property Address 923-925 Main St , VIP, Owner r Owner's Name information is required for , i * :, .,~-•ry. Cotuit , . .. �' : ' r, MA: 02635 . 5-4-07 every page. City/Town'' t ,• , '.�u State Zip Code. Date of lnspection` D. System Information Residential Flow Conditions: Number of bedrooms(design): 20 Number:of bedrooms (actual) 20 2200 DESIGN flow basedori.310 CMR)5.203 (for example: 110 gp6x#of bedrooms):. • _ .. - Number of current residents: jf .r ':sold-,.- r~ le -f' •f Varied Does residence have a garbage gander? „ ,i r1;41 r- ❑ Yes ® No - Is laundry on a separate sewage system? ['d yes separate inspection required],: ❑ Yes E No Laundry system inspected? ❑ Yes ® No r . t-•. . ~:le• ; 4 ❑ Yes ® No Seasonal use? . � L it , Water meter readings,.if available past 2 years usage(gpd)):'j•- .' i' • Sump pump? El Yes ❑ No Last date of occupancy: : , �•�. a": � s ,- _ 5-4-07 Date Commercial/Industrial Flow Conditions: v+.` ► r` Type of,Establishment: v, 0;. 44,1 , _: =p; . t� 'Design'flow(based on 310 CMR 15 203): p, , n . tGallons per day(gpd) Basis of design flow.(seats/persons/sq.ft:,etc.): Grease trap present? ❑ Yes El No r Industrial waste holding tank present? ❑ Yes ❑ No Non-:sanitary waste discharged to the Title:5 system?. .z. t' r A .;x t:f:,.,: .❑ Yes ❑ No k . 4l a Water meter readings, if available: +� Last date of occupancy/use: Other(describe): t5insp•08/06 .;. a} Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15: Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µM Cotuit Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping,Records: Source of information: Director--Pumped last year Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: z Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy I . ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(f known)and source of information: 1988 Were sewage odors detected when arriving at the site? - ❑ Yes ® No t5insp•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form' : Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Cotuit Inn Condominiums ',"A-ad , -4, Property Address 923-925 Main St Owner Owner's Name information is n;; t required for COtUIt °-- ' :: MA 02635 5-4-07 every page. CityrTownj': Vr f � :fadlc"" State Zip Code x Date of Inspection �� ,•�� D. System Information (cunt.) t � , ,;: ;; J{,. . tl ;.; t ,f y: Building Sewer(locate on site plan) Depth below grade: 48" f 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.): J . ' Septic Tank(locate on site plan): .:, ; Will Depth below grade: feet Material of construction: 4:.u. ; ® concrete ❑ metal" ❑fiberglass ❑ polyethylener, 3❑ other(explain) If tank is metal, list age: z'_ ► _. , ,. �_ " years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate). ,X.El„Yes ❑ No ----------------- ---- ------------ ---- ---- --- ---- --- ---- ---------- � ',r y•, ;r7..1'..,. • _ 'f .i.',{.t.T.' `k='.. k, R � .. ��. �•.. 3 i•?.o l.r...j ',f Tl1 *f' Dimensions: 4000 Gal Sludge depth, 60 'rf 1. Distance from top of sludge to bottom`of.outlet tee or baffle,"' - 50 ' Scum thickness .if u 811 ' r Distance from top of scum to top of outlet tee or baffle J• - , f • ,. F: , + Distance from bottom of scum to bottom of outlet tee or baffle 19" • How were dimensions determined? Tape t5insp,08/06 Title 5 Of k3al tnspecbon Form:Subsurface Sewage Disposal System•Page 9 of 15 L Commonwealth of Massachusetts _ Tide 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Cotuit Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 every page. Cityfrown - State Zip Code Date of Inspection D. System Information (cunt.) 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): .r . 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 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): t5insp•08M Titter 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection F®em Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Cotuit Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is ~ required for. . Cotuit �; F• c"= ti t�` MA 02635 5-4-07 every page. City/Town' State Zip Code Date of Inspection D. System Information (cunt.) : .Tight:or-Holding Tank,(cont.)'.,, Dimensions: Capacity: , a, gallons Design-Flow: to p rd ... . - . gal ns a ay' Alarm present: .f❑,Yes ❑ No"-.. I Alarm level: R Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc): y"' *Attach copy of current pumping contract(required).-Is copy attached? v❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site-plan):, ' Depth of liquid level above outlet invert 0. Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage irito or out of box, etc.): - '=t 1'. 4,.... Good condition. - fit' +t 'tt�•�'`5t f' k: +� n : ' t am_ t w. ' .'Y-J 7 v i t Pump Chamber(locate' on site plan):' { n Pumps in working order: ❑ 4Yes ., ❑ No Alarms in working order: ❑ Yes ❑ No t5insp-,08106 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15'+ I Commonwealth of Massachusetts . Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM " Cotuit'Inn Condominiums Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r . Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): y Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: 3--6x6' 0 leaching chambers number. 0 leaching galleries number: r 0 leaching trenches number;length: ^^ 0 leaching fields number,dimensions: El overflow cesspool number: innovative/aRemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits in good working order with no sign of back-up or break-out. t5insp-08/06 Trde 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts ; Tide 5 Official Inspection `1 drm' +� Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments Cotuit Inn Condominiums Property Address 923-925 Main St Owner, Owner's Name information is' r required.for Cotuit ""`�°� +' i A,% MA 02635 5-4-07 J every page. City/Town State Zip Code Date of Inspection ,.'!rx D. System Information (coat.) Cesspools (cesspool-must be pumped as part of inspection) (locate on site plan): � �ri , ,: F'i,, ti � -^ '. ..r ,a?A ( .r. .. ., r,{•.n, �;���',�'+�t � .,'}:3, it. I Number and configuration '4 :„t. s.,! 1 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation, etc.): t Privy (locate on site plan):' -Materials oft construction: _ Dimensions Depth of solids - - Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): , t5insp-08/0641 q, „, =a s?> Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , Cotuit Inn Condominiums s Property Address 923-925 Main St Owner Owner's Name information is required for Cotuit MA 02635 5-4-07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.)Y ( Sketch Of Sewage Disposal System: Provide a sketch 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. 1 A O L op 17 A- A_ o_ t5insp•08/06 Title 5 official Inspection Forth:Subsutface Sewage Disposal System-Page 14 of 15 vvi imviiive2ili i vi i�ia��aCiuSc'�w Tifla A Official inspection For„ Subsurface Sewage Disposal System,Form-.Not for Voluntary Assessments Cotuit Inn Condominiums Properhf Address r 92-34,25,MAJ.n�St Owner Owner's Name required for COtuit MA 02635 5-4-07 every page. city!Town - State Zip Code Date,of Inspection , Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ` ❑ Shallow wells Estimated depth to ground water: 201 i feet • Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system,design:plans o n 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: USGS Maps show groundwater at greater than 2W. t9msp•UFf/Ilii i We.CJYhcM1:165pet.•Qan:F-amt:.SLCsurPace S[.wage Usposaf S}!stem•Page 1 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 d RECEIVED •. . JUN 1 7 2004ly TOWN OF BARNSTABLE TI' EALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 923-925 MAIN STREET COTUIT,MA 02635 0—G q. ' �n� CC?n�Q tYl C11w�1 S Owner's Name: AL ROLLAND Owner's Address: PO BOX 84 COTUIT,MA 02635 IVIAF y 3J Date of Inspection: 5/17/04 PARCE4 i 2: o(3 X Name of Inspector: (please print) JOHN GRACI,INC. LOB` Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 t-5.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally es _ Needs Furthei aluation by the Local Approving Authority Fails Inspector's Signature: Date: 5/17/04 The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti . If the system is a shared system or has a design flow of 10,000 gpd.or greater,the inspector and the system owner sha 1 submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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 perforni`in the future under the same or different conditions of use. T.41P S Ingnp.r. inn Fnrm 6/1 V?000 1 Page 2 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 Owner: AL ROLLAND Date of Inspection: 5/17/04 Inspection Summary: Check A,B,C,D'or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes:. _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. } Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a . n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced , _ obstruction is removed - _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _obstruction is removed ND explain: n/a { Page 3 of 11 , OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 Owner: AL ROLLAND Date of Inspection: 5/17/04 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)ythat 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 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 n/a **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to ihis form.. 3. Other: - n/a .. Page 4 of I 1 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 1 . Owner: AL.ROLLAND Date of Inspection: -5/17/04 y D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM HAS BEEN PUMPED EVERY YEAR PER nWNFR, _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.'The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply _ X the system.is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11. , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 923-925 MAIN STREET COTUIT,MX 02635 Owner: AL ROLLAND Date of Inspection: 5/17/04 Check if the following have been done. You'-must indicate"yes or"no"as to each of the following: . Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site.inspected for signs of break out?. X _ Were all system components,excluding the SAS, located on site'? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems _a The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health.. X _ 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(3)(b)] • 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 923-925 MAIN STREET COTUIT,MA 02635 Owner: AL ROLLAND , Date of Inspection: 5/17/04 -FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):20 Number of bedrooms(actual): 20 DESIGN flo w based on 310 CMR 15.203 for example: 110 d x#of bedrooms): 22( 00 p gP Number of current residents:6 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] - Laundry system inspected(yes or no):NO r, Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): NO t Last date of occupancy: n/a �� `� 1 ��� • COMMERCIALANDUSTRIAL r' Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO " Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a ` OTHER(describe): n/a GENERAL INFORMATION Pumping Records =. Source of information: SYSTEM HAS BEEN PUMPED EVERY YEAR PER OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a " TYPE OF SYSTEM X 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) _Tight tank Attach a'copy of the DEP approval Other(describe): n/a = Approximate age of all components,date installed(if known)and source of information: 1985 PER OWNER • r Were sewage:odors detected when arriving at the site(yes or no): NO Page 7 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 r Owner: AL ROLLAND Date of Inspection: 5/17/04 . BUILDING SEWER(locate on site plan) Depth below grade: 48" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc,): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 42" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 4000 GALLONS" Sludge depth.: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" - Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a . Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a a 7 Page 8 of I I . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 Owner: AL ROLLAND Date of Inspection: 5/17/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a - Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE ' Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D=BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and'appurtenances,etc.): n/a R Page 9 of 11 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 Owner: AL ROLLAND Date of Inspection: 5/17/04 SOIL ABSORPTION SYSTEM(SAS): X.(locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' 'leaching pits, number: 3 n/a leaching chambers, number: n/a n/a leaching galleries, number: ' n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: : n/a i n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PITS.THEY APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.RECOMMEND RAISING COVERS. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) t Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a r. Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a , q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN STREET COTUIT,MA 02635 Owner: AL ROLLAND Date of Inspection: 5/17/04 - SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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 build'ng. Y to FI ) pc _ a o • y �1 L AC EA Y �b uj a to Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN STREET COTUIT,-,1VIA 02635. Owner: AL ROLLAND Date of Inspection: 5/17/04 " SITE EXAM _ _Slope _Surface water _Check cellar " Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12 FT. , ' y r ` COMMONWEALTH OF MASSACHUSETTS . •\ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ` y TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 923-925 MAIN ST.COTUIT,MA 02635 0'J S--4.Z)1 P Owner's Name: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Owner's Address: BOX 84 COTUIT MA.02635 Date of Inspection: 4/4/01 RECEIVED i Name of Inspector: (Pleaseprint) JOHN GRACI APR 1 7 2001 Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 TOWN OF BARNSTA13LE HEALTH DEPT. Telephone Number: 508-564-6813 FAX 508-564-7270 3t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is 'E 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. 1 am a DEP approved system ;. inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: g X Passes "Ut Conditionally Passes _ Needs Fu er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4/4/01 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS a , ' TO PROLONG THE SYSTEM'S USEFULL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how4he system will perform in the future under the same or different conditions of use. is j" r f. Title G-Tncnartinn Fnrm 01 5 Eno Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER r.a Date of Inspection: 4/4/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 4 •�tf, i+ A. System Passes: X 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: }s, THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. '• B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, rt 1f upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. t ='. t s n/a 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 exfiltratiori Ror tank failure is imminent. System will pass inspection if the existing tank is replaced , with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is°available. ND explain: n/a f. n/a Observation of sewage backup o`r break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): = _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a G' n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced , _obstruction is removed of v11 ND explain: n/a Yf ye f! Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r Property Address: 923-925 MAIN ST.COTUIT,MA 02635 4 , Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 4/4/01 yr{ C. Further Evaluation is Required by the Board of Health: Conditions exist which requirel,f rther evaluation by the Board of Health in order to determine if the system is failing to r F protect public health,safety or the'environment. ry. 1. System will pass unless Board;of Health determines'in accordance with 310 CMR 15.303(1)(b)that the system is u' 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 b . _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 3 `. Y 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 t supply or tributary to a surface water supply. ' _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has 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�fo determine distance n/a ;'r • '; y "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and Yt volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is-'equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy E of the analysis must be attachA 'to this form. �,g s 3. Other: n/a z �r i3. F 1 \k:h Z Page 4 of 11 41 , s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS =.i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t, CERTIFICATION(continued). Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 4/4/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ~=' _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ; q pumping Y gg' P P ( ) X Requiredmore than 4 times in the last year NOT due to.clogged or obstructed i e s .Number of times pumped nLa. #. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. :',' , X Any portion of a cesspool.or privy is within a Zone 1 of a public well. 1 _ N X Any portion of a cesspool-or privy is within 50 feet of a private water supply well. r . X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with ` i no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that�facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 'r (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system,must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. ' You must indicate either"yes"or"no"to each of the following: fi (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply ,L.. _ X the system is within 200 feet of a tributary to a surface drinking water supply } X 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 " es" in Section D above the large s y stem has failed.The owner or operator of an large s stem considered a significant threat Y g Y,,,� p Y g Y !� 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. IS, a Page 5 of 11 _r:3•1 l rFa f . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM l; PART B CHECKLIST Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 4/4/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health s St'3 Wq X Were any of the system'components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? } X Have large volumes of water`been introduced to the system recently or as part of this inspection? a° i X Were as built plans of the system obtained and examined?(if they were not available note as N/A) 3 X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the 'a .. baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ 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: i. Yes no X Existing information.For example,a plan at the Board of Health. X _ 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(3)(b)] wi f fit_ .a Page 6 of 11 x' r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS y °s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ' Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 4/4/01 P fs`i's FLOW CONDITIONS RESIDENTIAL `:{ Number of bedrooms(design): 20, Number of bedrooms(actual): 20 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2200 Number of current residents:20 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no):NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no): NO y = Non-sanitary waste discharged to a Title 5 system(yes or no): NO Water meter readings,if available: )a .: Last date of occupancy/use: n/a OTHER(describe): n/a Y 'itGENERAL INFORMATION 3' Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--'How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system `r _Single cesspool 9 r3• 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) , _Tight tank Attach a copy of the DEP approval h� Other(describe): n/a ,. c s fi Approximate age of all components<date installed(if known)and source of information: , . APPROXIMATELY 15 YEARS OLD Were sewage odors detected when arriving at the site(yes or no): NO ' 17, t �. Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 4/4/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" ,w T :. Materials of construction:_cast iron X40 PVC_other(explain): n/a x` Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER ..4 SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age coi►'firmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions:4000 GALLON SEPTIC,TANK" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) 4�; r Depth below grade: n/a r Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a 4 Scum thickness: n/a ` Distance from top of scum to top oe6outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a l Page 8 of 11 � 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 4/4/01 o- S TIGHT or HOLDING TANK: (tank must be pumped at time of iuspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a x Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Y Date of last pumping: n/a Comments(condition of alarm and;float switches,etc.): _ n/a , DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into r + or out of box,etc.): DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):NO . Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i n/a is._. } @ j 3 i lit Page 9 of 11 h OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C } ;'SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER Date of Inspection: 414/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a is Type 1000 GAL 6' X 6' leaching pits, number: 3 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a s n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a +. n/a innovative/alternative system ;r# T e/name of technology:Type/name 9Y n/a Comments(note condition of soil,19igns of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO , Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Ff n/a , PRIVY: (locate on site plan) Materials of construction: n/a t ' Dimensions: n/a Depth of solids: n/a ., Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): t n/a s i } - a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER r' Date of Inspection: 4/4/01 n SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage dispo"sal 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. 1 Ia L18 ' age A6 ql . BA 3 ob LIj a e ,:r,w I tt. in Page 11 of 11 t t i i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923-925 MAIN ST.COTUIT,MA 02635 Owner: COTUIT INN CONDOMINIUMS C/O BEVERLY DONHEISER i Date of Inspection: 4/4/01 z SITE EXAM _Slope _Surface water Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS databaseexplain: n/a f You must describe how you established'the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET 1 •ue 1 R w, Af , oFIMEr Town of Barnstable s. Department of Health, Safety, and Environmental Services enxxsrast 9� MASS. �0r Public Health Division ArF1639- P.O.Box 534,Hyannis MA 02601 i Office: 508-862 4644 ! Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health } ' June 1, 1998 Al Wohlwend i # P.O. Box 76 Cotuit,MA r RE: Septic System Inspection Requirement/Cotuit Inn 923-925 Main Street, Cotuit } Dear Mr. Wohlwend: The Town of Barnstable Public Health Division has no records of any septic system inspections conducted within the past three years at the above referenced property. Please be advised that the State Environmental Code,Title V, Section 310 CMR 15.301 (3) states: "the condominium association shall be responsible for the inspection, maintenance, and upgrade of any system or systems serving the units,unless otherwise provided in the governing documents of the condominium association." This section further states: "... each system on the facility shall be inspected at least once every three years and all existing systems shall be inspected by December 1, 1996." Therefore,the Cotuit Inn Condominium Association has been in violation of this provision of the State Environmental Code for eighteen(18)months. Please make arrangements to hire a private septic system inspector and have the septic system located at 923-925 Main Street Cotuit inspected within thirty (30)days of your receipt of this letter. Sincerely yours, Thomas A. McKean 1 i :Tune, 22, 1984 Mrr `Richard B_ oy, `Chairman 'Zoning Board of Appeals Town- of Barnstable klyanniB,.. Ma: Dear Mr. , Boyi.: The 'Board-,of Health approved oneite sewage .place and issued a sewage permit t,p the-,Cotuit Inn.on Jaiiuery, 18 ' 1982,-'for'modification of the Ynn The_-plans approved,.were desighed. for. .eight units (with a total ,of -bedrooms.;wt th sn occupancy of: 30 persons This permit' ;expired',.January 18, .19W Since that date we .have not received nor approved any plans for any neWIproposals. Very Eruly yours, John M. Kelly Director of.,Public Health . JMK/mm December 8, 1986 , rs' 14r. Walter p. R'app s ; 722.1 Richmond avenue Darken, Illinois 6055 9 ,. . Dear l,,r.' Rapp: ; r' Your letter dated ,December 3,'.1.986,,,#W"ki Iing .the property formerly • known,as The Cotuit Inn, is ack`noxvledh�d. . ` The On-site Seiva�;e Disposal.$y§tem was approved 0'r this site 'because itet all`,bf• the regulations• optained. in 31 U c ?ilt 15.00, The i'State . Erkyirpnmental Code Title '5 Minimum Requirements For.The S ak�'ubsurf t; Disposal of Sanitary Sewage .and the Town of BAffistable 11ealth Regulations. :r Federal and State 'Standards for."Nitrogen - 114itrate. is 10 mg/l found.'in public or. private -;water supply wellb. ' This project was .not in a :Zane of 'Contribution to ahy Water supply wells, therefore; 'the nitiate ".level calculations are,I-not pertinent to th.i •sapproval of an -On=Site Sewage. Disposal-System. The Board. ' of. I-iealth adopted.-a "Nitrogen Nitrate,.4 ading_ .Health Regulation that applies to- 'Zones of Contributi©iis 1, 2 and 3., .Theme are the zones requiring, maxtrn4' protection accor'ding.. to. the grt fl water study performed by SEA Consultants., Thd,'-Cotuit Water Department. has"t.he :major responsibility Of protecting their•water supply, and they-d Id,not'object to this project. Please remit six (6) dollars and'.we with'furnish you a,copy of Title S of the State EiXvironmental Code and- all,'other Regulations pertaining to the installation' of: on-site sewage disposal systems and the protection of ground water. Very truly yours, ; John M. Kelly . erector BOARD OF 'HEALTH TOWN OF BARNSTABLE F, JMK/bs i i 7221 Richmond Ave. Darien, Illinois 60559 December 3, 1986 Town of Barnstable Board of Health Town Office Building Hyannis, Ma. , 02601 RE: 923 Main Street, Cotuit, Ma. Gentlemen: My house at 33 School St. , Cotuit, Ma. , abuts the above property of Cullen and Lentell (Cotuit Inn Partnership) recently granted a building permit #30022 for (10) dwelling units. The Board of Health (86.-981) ,,has approved septic plans which I question. The Inn property is less than one acre and abutters to the south have experienced problems from the Inn in the past. Federal and state nitrate standards of lOppm have been attested by water quality experts that they will" be exceeded with 10 housing units. I will appreciate your advising me' of what standards are in our code books and how approval was given for this construction. �Very truly yours, Walter P. Rapp s , Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection ,John GrAd One winter Street,Boston,Ma. 02108 DER Title v Septic Inspector P.O. Box 2119 r I'eaticket, MA 02536 (508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI (Ma U.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORPART A CERTIFICATION 1 1Property Address: 923-925 Main St.Cotuit Cotiut Inn Condominiums 10 units AddressofOwner: . ��A(If different) oDate of Inspection: 3126198 Floyd Sylvia:619 Main St.Centervill . Name of Inspector: John Graci I am a DEP approved system inspector pursuant to Section 15.340 of Title°k(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT below I certify that I have personally Inrsspected the They nspecage ltion was psposal erformedem at lbasedron my ess tahninghandf a perience reported.h proper ifunct on and rate and complete as of the time of inspection. maintenance of on-site sewage disposal systems. The system: This Inspection le based on criteria defined In Title V X Passes code 310 CMR 16.303.My findings are of how the system is _ ail performing at the time ofBu inspection.My Inspection does Condition y P sSes not Imply anywarrsnty or guarantee of the longevity of the _ Needs Further valuation By the Local Approving Authority septic system and any of its components useful lire. Fails Inspector's Signature: Date: 4114198 , leting The System Inspector shall submit a copy of this inspection report to the Approving Auy ithinspectthirty or and the(30)days of compowner shall submit is inspections. If the system is a shared system or has a design flow of 10,00 gp o greater, the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: 4 Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria' ` defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y,.N, or the owner or operator has provide basis of lon in all instances. if "not d the system nspector with a copy ofa„Certi explain icate of not. The septic tank is metal, unless -- ColYtpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or tial infiltration or exfiltrati the septic tank,whether or not metal,is cracked,structurally unsound,shows substan failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septticic tank tank as approved by the Board of Health. (revised 0427)97) k One Winter Street • Boston,Massachusetts 0210E • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 923-925 Main St.Cotuit Cotiutlnn Condominiums 10 units Owner: Floyd Sylvia:019 Main St.Centerville Ma.02632 Date of Inspection:3126199 _ Sewage backup or.breakout.or. hinh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. i) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A WANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other a D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due tp an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 0627)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 923-925 Main St.Cotult Cotlut Inn Condominiums 10 units Owner: Floyd Sylvia:610 Main St Centerville Ma.02632 Date of Inspection:3126199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day.flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary.to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 li of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 923-925 Main St.Cotult Codut Inn Condominiums 10 units Owner: Floyd"via:019 Main St.Centerville Ma.02632 Date of Inspection:3126198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. x — As built plans have been obtained and examined.' Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _X— — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. . x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge, depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revleed 04f27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION. Property Address: 923-925 Main St.Cotuit Cotiut Inn Condominiums 10 units Owner: Floyd"via:810 Main St Centerville Ma.02632. Date of Inspection:312819E FLOW CONDITIONS RESIDENTIAL: Design flow: 3100 g•p•d./bedroom for S.A.S. Number of bedrooms: 20 Number of current residents: 8 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:8 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nla Last date of occupancy: n1a OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION'- PUMPING RECORDS and source of information: rUa System pumped as part of inspection: (yes or no)..to_ If yes,volume pumped:8 gallons Reason for pumping: rVa TYPE OF SYSTEM : x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? _ Other: APPROXIMATE AGE of all components, date Installed(if.known)and source Information: �aet; Sewage odors detected when arriving at the site: (yes or no) No (revised 04127)87) s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 923-925 Main St.Cotuit Cotiutlnn Condominiums 10 units Owner: Floyd Sylvia:619 Main St.Centerville Ma.02632 Date of Inspection:3126198 x SEPTIC TANK: x (locate on site plan) Depth below grade: 3' Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: 4000 gallon septic tank Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness: Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: Measured 1 , Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally Bound and functioning property.Recommend pumping everyyear. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: We Date of last pumping;va Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) nia BUILDING SEWER: (Locate on site plan) Depth below grade: 3'6^ Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line?ovm Diameter. 4.,_ Qmments:(conditions of joints,venting,evidence of leakage, etc.) (rev19ed=7197) x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 923-925 Main St.Cotult Cotiut Inn Condominiums 10 units Owner: Floyd Sylvia:819 Main St Centerville Ma.02632 A. Date of Inspection:3126f98 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rya Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: We Capacity: nla gallons Design flow: rya gallons/day Alarm level:_wA Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rya (revised 04127)97i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 923.925 Main St.Cotult Cotiutinn Condominiums 10 units Owner: Floyd Sylvia:619 Main St Centerville Ma.02632 Date of Inspection:3126198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 3-1000 gallon leach pne leaching chambers,number:Na leaching galleries,number: nla leaching trenches,number,length: Na u leaching fields,number, dimensions:Na overflow cesspool,number:nle Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The teach pits appear to be functioning property. - CESSPOOLS: - (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na , (revised 04127197) r S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 923.925 Main St.Cotult Cotiut Inn Condominiums 10 units Floyd Sylvia:019 Main St.Centerville Ma.02632 3120198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) lti l n I C/ ' a ?ay ! o! 16 (revised 04fl71971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 923-925 Main St Cotult Cotlut Inn Condominiums 10 units Floyd Sylvia:019 Main St Centerville Ma.02632 3126198 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation'. Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Chwte (ravlaedWWJ97) page IO of 10 PJLL Alild'- �) Commonwealth of Massachusetts li Executive Office of Environmental.Affairs Dept. of Environmental Protection John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket,MA 02536 (508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI U.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 923-925 Main St.Cotuit Cotiut Inn Condominiums 10 units Address of Owner: (If different) Date of Inspection: 3126198 Floyd Sylvia:619 Main St.Centerville Ma.02632 Name of Inspector: John Graci I am a DEP apprtived:system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: This Inspection Is based on criteria dented In Title V X Passes code 310 CMR 16303.My findings are of how the system is _ Conditional) P SSeS performing atthetimeof the inspection.Myinspectiondoes _ Needs Fu er valuation By the Local Approving Authority septic not psystem a any nd any of its components usnty or nuarantse ofthe eful of the Fails r Date: 4114199 Inspector's Signature: the Approving is The System Inspector shall submit a copy of t is inspection report ptof 10.000 gpd oAgreat ty the inspector and the system within thi (30)days ofpowner leting shall submit Inspections. If the system is a shared system the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: x�I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. if "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoThpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127197) One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 923.925 Main St.Cotuit Cotiutinn Condominiums 10 units Owner: Floyd Sylvia:619 Main St Centerville Ma.02632 Date of Inspection:3126199 _ Sewa4e backup or.hreakout.or hiah.static water level observed.in.the distribution b.ox is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a,surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and is within 50 feet of.a private water supply Well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5'ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 007197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 923-925 Main SL cotuit Cotlut Inn Condominiums 10 units Owner: Floyd Sylvia:619 Main St Centerville Ma.02632 Date of Inspection:3126199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the.Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or.more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 0427W) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 923-925 Main SL Cotuit Cotlut Inn Condominiums 10 units Owner: Floyd Sylvia:019 Main St.Centerville Ma.02632 Date of Inspection:3126199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ _ Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. x — As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _X— The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)] (revised WNW) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 923-925 Main St Cotult Cotlut Inn Condominiums 10 wits Owner: Floyd Sylvia:819 Main St Centerville Ma.02632 Date of Inspection:3126199 FLOW CONDITIONS RESIDENTIAL: Design flow: 3100 U.p•d./bedroom for S.A.S. Number of bedrooms: 20 Number of current residents: 9 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rVa Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: We Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n1a Last date of occupancy: nla OTHER:(Describe) n!a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)Na If yes,volume pumped:0 gallons Reason for pumping: rya TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source Information: , 1986 Sewage odors detected when arriving at the site: (yes or no) No (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 923.925 Main St Cotuit Cotlut Inn Condominiums 10 units Owner: Floyd Sylvia:610 Main St Centerville Ma.02632 Date of Inspection:3/26199 SEPTIC TANK: x (locate on site plan) Depth below grade: 3' Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: 4000 gallon septic tank Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle:23" Scum thickness:"' Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:17" How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structuresy sound and functioning property.Recommend pumping every year. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain} Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle: Ma Date of last pumping;v„ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 3'6" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line" Diameter: 4 Qi!mments: (conditions of joints,venting,evidence of leakage,etc.) (revised 04127W) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 923.925 Main St Cotuit Codut inn Condominiums 10 units Owner: Floyd Sylvia:619 Main St.Centerville Ma.02632 Date of Inspection:3126199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: ria Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nia Capacity: n1a gallons Design flow: nra gallons/day Alarm level:_n<a Alarm in working order? Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Alarms in working order(yes or no)_yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rda (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 923-925 Main St.Cotult Cotiut Inn Condominiums 10 units Owner: Floyd"via:619 Main St.Centerville Ma.02632 Date of Inspection:3126199 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: 3-1000 gallon leach pits leaching chambers,number:We leaching galleries,number: n►a leaching trenches,number,length: rda leaching fields,number,dimensions:nk overflow cesspool,number:his Alternate system: nra Name of Technology:_rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The leach pits appear to be Nnctloning properly. CESSPOOLS: (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: rda Depth of solids layer: n1a Depth of scum layer: nla Dimensions of cesspool: nla Materials of construction: nia Indication of groundwater: ria inflow(cesspool must be pumped as part of inspection) nfa Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: his Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1a (revised 0027197) ♦ Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 923.925 Main St Cotult Codut Inn Condominiums 10 units Floyd Sylvia:619 Main St.Centerville Ma.02632 3126198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells Wthin.100'(Locate where public water supply comes into house) -1J O (revlaed0412T19n Pape 9 OL %0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 923-925 Main St Cotult Cotlut Inn Condominiums 10 units Floyd Sylvia:619 Main St Centerville Ma 02632 3126198 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revised 0427197) page of 10 y •iSni�:i G�.SESOSO^R!S MAP NO: -PFt ItlO.i � L��� "I s2,r+. .}.�nT ri f*���\#�•S'F �. No - Y ., Fgs ........,i .... THE COMMONWEALTH OF MAS4M5LHjJSPTZ6L,1J FLi;, - j,. BOAR® OF HEALTH f .... ..................OF.. .... U� 1N tis Apliratinn for Mipwial Workii T=34rnrtiun .ermft/ Application is hereby made for a Permit to Construct T;Pl- or Repair ( ) an Individual Sewage Disposal System at L Address cation-As or Lot fro. Owner Address �!/__._...... {!Y —`! ✓t1��.............. installer Addres ..._!1f�^ Type of Building / � �J Size Lot_- Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of ...................... No. of persons............................ Showers ( ) — Cafeteria ( ) Q' er fixtures _________ ___________ _ _ _ d --------------------------------------------------------------------•--••• W Design owZ.._..1ie1Ao _ lons per day. ,Total daily flow............................................gallons. 04 Septic Ta ga ength____/P�__,___-Width.... -------- Diameter_--_ Depth.. ___....... Disposal Trench—No. .................... Width___....__._._.___ Total Let gth._....__.__......... Total leaching area............._......sq. ft. Seepage Pit No------3----------- Diameter...IS..._....... Depth below inlet....a........... Total leaching area..................sq. ft. Z Other Distribution box (9) Dosing tank`( ). _ Percolation Test Results Performed b 4/V..,.: /� a Y /------------ Date --------------------- Test Pit No. 1.....62......minutes per inch Depth- of Test Pit--- .. Depth to ground waterer_L'.Z ........ (z, Test Pit No. 2.....'A`...... 'minutes per inch, Depth of Test Pit.12 ......... Depth to ground water_>_%2.':........ �/ .................................................. Description of Soil .. � Q - ,- --------------------------------•-.-•---- V ----------------------------------•-•--•-••----•---••------•----•-•-•-•---•-------....-•••••......---•...••-------•---•---•--......•---•----------•-----------------•----•---•----•----•----•-----•---- W VNature of Repairs or Alterations—Answer when applicable:..-------------_____-----------------------------------------------------------................ ----------------------------•-------------------------------------------------------............--------•------.....--.............................................................................. Agreement: - -The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of` i s E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Com ance issued by th and of health. si Application Approved B d'� PP PP Y-•---•. ----' --- Date Application Disapproved for the following re sons:-------•----------------------------------------------------•---•---------------•------•---•---•-----•......••-- ............------------- •••---.•..... • . - ------.. ........-----------.---...--------.--- ---- .................. Date Permit No. � .. y ..-......................... Issued-------------------------------------------------------- Date w No.... :....4. l Fiz$............................. - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ofl�l %.ACC-------. ... Appliratilan for. ispolM Work -, Tonstrartiun rrnttt , Application is hereby made for a Permit.to,Construct )'or Repair ( ) �an Individual Sewage Disposal System at: /, ..... _ Location-!id ress +: o Lot o. �?f tR.�z _. .....Owner' %�.�j...... .:...... i _.J/._...--- '�. !r_ :---.�,�.. ........ ._.. .. Owner ,� Address a (..................•._...----..----------- Installer�. Address Type of Building Size Lot____�� .-+-•,,� ,,?_ 's®__Sq. feet Dwelling—No. of Bedrooms........ ___ ..............Expansion Attic ( ) Garbage Grinder ( ) Other—Type ofBuildu .............. No. of persons............................ Showers ( ) — Cafeteria Q' er fixtures~�-__- d1• ---•------•----•- W Design low. _..../.;". I$._ Ion s per day. Total daily flow.___. _ •______________ Ions. W Septic Ta —Li ui p ga ength._.hO__...... Width-_-A.......__ Diamete 15epth_ ........ Disposal Trench—:�To. ..__._._ a x p Width.................... Total Length----------••--__---- Total leachlri@ area'._______=_.........sq. ft. YJ.I ' ; Seepage Pit No.___. ____ Diameter: ..__..__ Depth below inlet_.______________ Total leachin ;.area__ - " ------ ---- � -- P - ---------------sq. ft. z Other Distribution box Dosing tank ( ) '-' Percolation Test Results Performed b _.__. �/`t ! 3 1 ___ Date� `2� ___ a Y ��,� I' . Test Pit No. 1----G�.......minutes per inch Depth of Test Pit.. .Z____......_ Depth to ground...`vtt"a'ter,>,__�l______--. 44 Test Pit No. 2__..4R.......minutes per.inch :Depth of Test Pit.,✓2............ D�;N-o groundwater>4.�� � .. ax. -----•-•--•-•................••_--- �3 O_ �....._.._._-• - Description of Soil___�,1�/1l, _�� ............� -'W ...--•--•- (� •-----••____---•--------•-•--•' UW .............................. ................................ .................._._......__._..__...........:______...___n __...__..___._...._...._.... ! Nature.of Repairs or Alterations— Answer when applicable------------------------- __-_. . .!'1 . --•.••................................. ... .__ ..................................................... .................... The undersigned agrees to install the aforedescribed Individual Sewage-bisgnsal System in�iceo ee` itl �,;�- the provisions of 1�i j ." j of the State Sanitar Code— The undersigned ftt-agrees not to place the-system in OP eration until a Certificate of Com lane issued by the-bL and of health. o � _,`-j S" 41, ---- -•---- 'd Application Approved BY L.�• ' `' i `' � . Date Application Disapproved for the f ollowan re sons_______________________________________.................... ............................. .............................................................. _- te Permit No.....�1 l. Issud:_.. ....._...--- . e --••--...---•------..au...._. Date f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .� .'�... aF..................... . ............. (Err#ifiratr of Tuntplialta THIS IS. O CER Y,rThat the Individual Sewage Disposal System constructed ( ) or Repaired ( } by..................... - ........ u �..........._.. -•-•---------•------•-r•--------------•-----..........---...------:..-•-----•--------------------- at. �!l! `•-------•-----'�: !f -----------Install �7,71 _y; ------------- has =k Z 1 been installed in accordance with the.provisions of Ti TIE j gf e/State Sanitary Code as descri' in the application for Disposal Works Construction Permit No._...`r�'._�__ Tt_...._... dated_--. .:_: : ........ _ - :-I w� IS,YAtd-00 OE,THIS_CER' IFIC�TE SI�IAL..I�NOT BE C®�dSTRl1E®.AS A GflJARANTEE THAT rHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. .. -._ .7--------•-------•------------ Inspector--•-- ` a .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NA-In 1_.... 1 1:�...................0F..........0 ::�:�......� I'EE....._....`.............. Disposal orkn Tn p ian anti# Permissionis hereby granted................... . . -•=--•....-----__ ...-•- •----• __.-.__--•---------._--.-•------___-•-----••-------•---•••---•--- to Construct ( ) or Repair ( ) an I d dual ge Disposal System atNo..__ -t�_..__.._ t_-+.:,''1___. �.._.......__ ��_U_l t ..__._................................................................................................. Street �- 7 as shown on the application for Disposal Works Construction Permit N f6__1 b•_--____ Dated.. ._. r _-_bf. ........ r- ^= ' Board of Health DATE.•.................••.....•..••-••-••...._._...._•....•............••........... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No.- ... .. .d%5 FEs ....._-�..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH Appliration for IliopooFal Workri Tonitrur#ion ramit. 4 .a Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .C.v�.... .................................................... Address /h/ / / or Lot No. A&W. ..............•----••----........................... Owner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........../�........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures d -------------------•------•-----•-------•-••-----•---•--•---•------.. W Design Flow..... ................................gallons per person per day. Total daily flow.------ ...a�..r�C .................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.-..-3------------ Diameter...1,44........ Depth below inlet.....6.......... Total leaching area...j�./J&...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........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............................................................_'.................................................................... •--•••------•--- ODescription of Soil........................................................................................................................................................................ W ••-•--••--------------------•-----•---•-•-•-•-•--••-----------•-•...---•-••••--•--••--•---•-------------•---------------------•-------••----•---•-•-----...-•--........................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...................................................................................................................................................).....--........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code— The undersigned further-agrees not to place the system in operation until a Certificate of Compliance has 1 ar, issued by the board f health. C Signed a�� l� �ll� . ........ .2. f Date Application Approved By....................... Date Application Disapproved for the following reasons:................................................................................................................ ...............................................................:...............................................-•---•---•----•----•-•------••-------•------••-••--...................................... Date PermitNo......................................................... Issued------------•---------................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF.............. a........ ................................ kDatifirtt#r of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repair-,d ( ) by............' ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ nstaller has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the application.for Disposal Works Construction Permit No..-- ..,5............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................•-------•--•------------------------•------••-•-------....-•---- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH / t..z�..........OF....... ... ............................................ ................. No.. .�_�-..._.�� FEE. �to�oo�al ork� �ono#rion rrnti# Permission is hereby granted............................................................................................................................................. to Construct ( L�­6r Repair ( ) an Individual Sewage Disposal System atNo......................................71;; .........�--------! ------........... Street as shown on the application for Disposal Works Construction Permit No..................... Dated............................. ........................................................................................................ Board of Health DATE............-................................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .o THE,COMMONWEALTH OF MASSACHUSETTS:. . 'BOARD ® HEALTH ..... x-r►..............OF .. :. . --- Appliratioan for Klis`#os al Workii C onotru ion Prrmit Application is hereby made for a„Permit to Construct ( ) or Rep air- ( )`an Individual Sewage Disposal System at: - --....; ' .� ":....... �' ... 449..............................................................catlo -Address or Lot No. ... r ------------------------------------•........•_....--•--------------•------••---.•..•.•...------ Owner ---•---------------------------Address Installer Address Type of Building `` Size Lot............................Sq. feet Dwelling—No. of Bedrooms.........../..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other, xtures •--••----••------•.......=--•-- . W Design Flow.__... _: allons per person er da Total dail flow____._.. ............... Ions. g ----••---•••g P P P Y Y 9 Septic Tank—Liquid'cdlpacity.....__.....gallons Length................ Width................ Diameter................tDepth................ Disposal Trench—No. _...-., .............. Width.................... Total Length.......-_ ---- Total leaching area.. ..... sq. ft. Seepage Pit No. .. ---------- Diameter ,14V ..... Depth below inlet...... .... Total leaching area.,.-IV q. ft. z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-___-__.-_-__•_.----_--. GT,1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-__---_--__------_-. R� -----------------•-•---•----------•-•-------•--•-------------------•-------------------------...--..----------------- --••--•-•••••-------- ® Description of Soil..............................................................................................................---------------------•---•------------------•--•--•-.---•- x W ----------••----...-----•----•••---•--•-•---•••-•-•----------•-•-••---•------------------------•-•••------•-•-••---------•------•--•-••--=•-•---•----•---------•-•••-•---•-••--•--•--•----------•---•--- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..------•--•-------------------------------•--------------------------------------••---•-------••---•---•••---••----••---------------•--•---•----•-•----•---•••-•---•-•-•••---••--......._..._...-•--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T?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 haabsied by the oard healthSigned - x e�. _..._ " Date ApplicationApproved BY-----------------------------------------------•-----------.....---------........................ ........................................ Date Application Disapproved for the following reasons:................................................................................................................ -----------------•--........---------•--.......-•---•------.......---•---•-•-----......----•-••--•----- .-----•......---------••-------•--------••--•...--•--•---•----•-•••-•--•-•---------••--•-•------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ec�"7 *........O F...... ....t *�� z �, .............................. uprrtifiratr of TI-Intnliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) -----------------•-•-• ..... Y �,+ Astaller has been installed in accordance with the provisions of TITLE. 5 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 CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEALTH ..............{ .... .. ..OF........ ................................. FEE ,No.. .... . Dispoo al Works Totastrudion rermit Permission is hereby granted.............................................................................................................................................. to Construct ( L)-,6r' Repair ( ) an individual Sewa a Dis osal System atNo....................................... ........ ?" ...... ---- ------------ � ..... .. `; ................_....... Street as shown on the application for Disposal Works Construction Permit No..................... Dated................................................ -•---•-•-----•------•.................•------•-••------------------------•••---•-......_.......••--....._ Board of Health DATE............. ..............•---•--•---......----••-•--........--•--•.......•••. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS l �a� 4 r , , _ �. e t. r. , :, _ *T-'.'9r 5. t P : ..... ,n r a ,'," nti,,:.,. .,. _. „ ,w."x 1•'C /, .v., r - .. - e. , .:: T , t,.. : , ,, - .. .r .. :". < it , , ., - .. , .i., , ., t, .. - .. -e .. ... , ,x. :v .. !1 t. , ;. , . , „ t + - P a , :' , , ,, ,,, `: , 4 _xa, . , s I ,: , ' "! a<:r,, a ' , . 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V- a .. � 3 y �r/' -"'u^ntwir...•..wa•...w,wpF _ x i i t � �. .� g I ¢� \1 , I ,` V 1 i., • rd �/r r :r , r' 1 01' I____ V•(J••1Li\Vi,j.1VN i t C. IY V "r •' .:' �• a1.YYL1Wt11Ut'fl'V!'t t'�.:ItLVLlii1Vt � I �� � � ' `, i 5 t ,. t 'd V. h C, '�,. ,..a N0 y� t Z$ _ LOCATION , / n',V l9 . I o�.T ._ - ` DATE I- ® ,Z r 3 VILLAGE /i V j •.- ea1- EE. - — APPLICA T I -� � I __ ' ., (Non-refundable �• L TELEFSHONE NO. ADDRES S -- - 2'8 r7 �/ __ EPoe ac &/ i • TELEPI?QNE NO. 2�/�J//V� /� _� A ENGINEER _ DATE SCHEDULED �,L4L ' p' (Applicant s signature) .Z• . O 2 r ! .1 sr`�•r••rr•r•rr•r•ar•r•rr.• i ,�� — ..,_..% �.,,.. ..emu.....,..—.._.�-._��.«,.__.. I ' : ok _m _____-- _. -- , SOIL LOG •r- A/_ry , - ___ ,?r vcTo { , r, „"t /� , ,0.•k1 TIME /�: „ --- -- — I?ATE 1 . -- 1¢S ' � s� 3 0o W ,2b©• S/' CO/�li�p', G /YiA. 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