HomeMy WebLinkAbout0045 MARINER CIRCLE - Health r'r4!5
Mariner Circle
oti,t 'I�II�-'"Yt ,"° '
A,,,,023 - 044
DATE : _? 11102-_ _
� �^ DC AT V t✓r]RESS ------- 1
_45 Mariner-Circle - _ - _ _ - -
Cotuit, Ma. 02635 F1P
l�yo�Qs� �pp�
On the above date, I Inspected the septic system at the above addr
This system consists of the following;
1 . 1-1000 gallon septic tank .
2 . 1-Distribution box .
3 . 1-1000 gallon precast leaching pit . ( VX101 ).
�r
Based on my Inspectlon, 1 certify the following condltlo�r,Ar.EL —.,4C� ¢4
4 . This is a title five septic system . ( 78 Code
5 . The septic system is in proper working cider :)T
at the present time .
6 . Waste water is 66" below the invert pipe of the
leaching pit . (0c
SIGNATURE :.,.
meMacgz, ler— r
J- J--.-.__ /^1
1.
�ompany : Jcseph P _ -Macorober _& Son Inc
. ccress Box 66
• Cer. terv_ ? _ e , Ma_._ 02632-0066
,n0ne : 508_775_ 3338
THIS CERTIFICATION (DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P"0 aox 66 Centerville. MA 02632-0066
775,3338 775.6412
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL, INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 45 Mariner Circle
Cotuit, Ma_ 02635
Owner's Name: John Talma
Owner's Address: Same
Date of Inspection: 7111 1 /0 2
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: Joseph P_ Macomber & Son, Inc.
Mailing Address: Box 66
Centerville Ma 02632-0066
Telephone Number: 508-775-3 38
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 15.340 of Title 5(310 CMR 15.000). The system:
��Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F ils }
Inspector's Signature- Date:
The system inspector sha 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Paee 2 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 Mariner Circle
Cotuit, Ma. 02635
Owner: John Talma
Date of Inspection: 711 1 /n 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. stem Passes:
AD have not found any informatio hich 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:
The septic system is in proper working order
at the present me .
B. System Conditionally Passes:
W, 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 metal or not) is structurally '
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
exisFing 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
distribution box is leveled or replaced
ND explain:
/0 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:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Pro ern• Address: 45 Mariner Circle
Cotuit, Ma. 02635
Owner: Tnn TA 1 mA
Date of Inspection: 711 1 102
C. Further Evaluation is Required by the Board of Health:
4Ae Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. S*sstem 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
�I
Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh
2. SNstem 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 rributary to a surface water supply.
/1J0 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple
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 ee but 5 feet or more from a
private eater supple well Method used to deter-nine distance /
"This s'siem 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 facilir} 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 artached to this form.
3. Other:
I
3
Page . of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 Mariner Circle
C"'cst rd t r ma -009615
Owoler. Jrhn Taiwa
Date of lospecticn: a—/_1/42
D Svstem Failure Criteria applicable to all systems:
You must indicate "ryes" or "no" to each of the following for all inspections:
Yes Is
ackvp�of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or pondrtg of effluent to the surface of the g7ound or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the dissribution box above outlet inven due to an overloaded or clogged SAS or
� cesspool W o(JXl-0
j/Liquid depth if�a+is Icss than 6" below invcn or available volume is less than 'A day now
Requ=red pumping more than 4 times in the last year NOT due to clogged or obstructed pipc(s). Number
(times pumped �.
_ y ponion of the SAS, cesspool or privy is below hiound water elevation.
� gh gr
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
atel supply.
y ponion of a cesspool or privy is within a Zone I of a public well.
y ponion of a cesspool or privy is within 50 feet of a private water supply well.
ponion of a cesspool or privy is less than 100 feet but g7eater than 50 feet.from a private water
supply well with no acceptable water quality analysis. ITbis system passes If the well water analysis,
perfarmed at a DEP ceniftcd 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 aoalysis trust be attached to this form.)
/ O(Yes'No) The system fails. I have determined that one or more of the above failure criteria exist as
Ocscribed in 310 CMR 15 303. therefore the system fails. The system owner should contact the 3o:!^
Health to determine what µall be necessary to correct the failure
E Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.
You must indicate cither—yes" or "no" to each of the following:
The following criteria apply to large systems in addition to the criteria above)
es no
4/the system is within 400 feet of a surface drinking water supply
L Lh 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 — I WPA)or a mappee
Zone it of a public water supply well
!!yoc rave answered "yes" to any question in Section E the system is considered a significant threat, or answered
es" in Section D above the large system has failed. The owner or operator of any large system considered a
s e.n.:!",cznt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
;0- The s)sten•; pwner should contact the appropriate regional oMce of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 45 Mariner Circle
Cotuit, Ma. 02635
Owner; John Talma
Date of Inspection: 7111102
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes NoXPumping
! information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous rwo weeks
—/_ Has the system received normal flows in the previous two week period ?
ZHave 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)
YWas the facility or dwelling inspected for signs of sewage back up?
4z— Was the site inspected for signs of break out ?
JZ/_ Were all system components,:A")cluding 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 ?
z_ 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:
Yes no /
— / 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(3)(b))
I
5
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 45 Mariner Circle
Cotuit, Ma. 0,2635
Owner: John Talma
Date of Inspection: 711 1 /02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms (actual):
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms); A(?4j-1r0��'P
Number of current residents: A _
Does residence have a garbage grinder(yes or no):y4
Is laundry on a separate sewage systemX
s or no): (if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no): &6 Water meter readings, if available (last 2 years usage (gpd)):
Sump pump(yes or no): j
Last date of occupancy-. /
COMM ERCIAULNDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design now(seats/persons/sgft,etc.):
Grease trap present (yes or no):A,�
Indusrrial waste holding tank present (yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):.f V
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe): V-4
GENERAL INFORMATION
Pumping Records
Source of information: 4,J11Al2 62
Was system pumped as pan of the inspection (yes or no):
If,yes, volume pumped: gallons -- How was quantity pumped determined? 4f4
Reason for pumping: WO
T2eOF SYSTEM
Septic tank, distribution box, soil absorption system
,�J6Single cesspool
UDOverflow cesspool
Privy
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 syste owner)
Y LA
Tight nk ta Attach a copy of the DEP approval
/4JU Other(describe):
Appr, imate aye of 11 omponents, date installed (if known) and source of information:
/
Were sewage odors detected when arriving at the site (yes or no)�-Je
6
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OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property, Address: 45 Mariner Circle
.ot ui , Ma_ 02635
Owner: John Talma
Date of Inspection: 7/1 1 /0 2
BUILDING SEWER (locate on site plan)
I/
Depth below grade: /V
Materials of construction: A/6cast iron __j/40 PVC 4,4other(explain): 140
Distance from private water supply well or suction line:/,
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appear tight . No evidence of leakage . The system is
vented through the house vents ..
SEPTIC TANK: (locate on site plan) /-4W, &�.s
Depth below grade:
Material of construction: concrete�etalWfiberglass,pf polyethylene
NOother(explain) �tJh
If tank is metal list age: 6 is age confirmed by a Certificate of Compliance (yes or no):,42 (attach a copy of
certificate) .
Dimensions: �jJ y/�� p�i or- 7
Sludge depth:
Distance from top of sl dge to bottom of outlet tee or baffle%l(_
Scum thickness: -<
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tep or baffle:
How were dimensions determined: �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.):
Pump the septic tank every 2-3. years . Inlet & outlet tees are
in place . The tank is structurally sound and shows no
evidence of leakage ,
GREASE TRAIK"locate on site plan)
Depth below grade:
Material of construction:,kconcrete&metal 4/,4fiberglass Jr polyethylene24other
(explain): iIJA
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 bale:
Date of last pumping:
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 is not present .
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
'E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propert} Address:45 Mariner Circle
Cotuit, Ma. 02635
Owner: Tnhn Talma
Date of Inspection: 7111102
TIGHT or HOLDING TANK4&01(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: .04
Material of construction: AM concrete,&Y_metal fiberglass Polyethylene XM other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no): 2K
Alarm level: A)L4. Alarm in working order(yes or no): A,��
Date of last pumping: _AA
Comments(condition of alarm and float switches, etc.):
light or noldin .
DISTRIBUTION BOX: Z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: X&
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.):
Distribution box has one lateral .No evidence of solids
carry over . No evidence ot led- age i
.box .
PUMP CHAMBER4&&,4.`locate on site plan)
Pumps in working order(yes or no): u#
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present .
8
Pape 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 45 Mariner Circle
Cotuit, Ma. 02635
Owner: jr)hn malma
Date of Inspection: 2111 I n 2
SOIL ABSORPTION SYSTEM (SAS): Z(locate on site plan, excavation not required)
1-1000 gallon precast leaching pit . (6 ' X10 ' )
If SAS not located explain why:
Located ; See page 10
Type
leaching pits, number:ZI V'r
Bleaching chambers, number: 0
"leaching galleries, number: O
/VOleaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
A)D 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.):
Loamy sand to sand . No signs of hydraulic failure
_ or ponding , of s are ry , ege a ion is
CESSPOOLS/e,(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 laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not presen .
PRIVYA"ocate 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.):
Privy is not present
9
Pw IO of I I
OFFICLAI INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FOR/r1
PART C
SYSTEM iNFOR-tYAT10N (con(,nvcd)
P'oocrT� ^cofc,,, 45 Mariner Circle
Oxocr:
_—_r_t I]; t - M a 2635
0„c of
S)CrTCH OF SCWACF DISPOSAL SYSTEM
Pro.ioc c ,xc,ch of the ,cwtic di,polil IMM inclvd(ng tict to 11 Ic"I two permcncm rcrcrcncc Isn(vnux, o,
OcntNnuk, LOCI[( ,II wcll, whin 100 ( Loc�,c whcrr pvbiic wiccr tvpply cnlcrt the bviloin�.
O
Cr
p
u
10
f
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 45 Mariner Circle
rntuii- , Ma-0-2
635
Owner: 7-h n___T-& ma
Date of Inspection: 7 /1 1 /n 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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
YES Observed site(abutting property/observation hole within 150 feet of SAS)
N Checked with local Board of Health-explain:N A
y F�s Checked with local excavators, installers- (attach documentation)
y p,q Accessed USGS database-explain:h t t p town , barns table . ma , us .
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model . 12/16/94 Ground water elevation above
sea level .
Used ; USGS ; Observation well data Tune 1992
Used ; USGS : Technical bull in 92-000-1 PIat-P #2 Annnal rangpc nf
r un
ground water elevations .
Leaching
Pit �:eet
VT
Ground wateAFeet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
11
DATE; 6/19/,95
----------- i
PROPERTY ADDRESS:
_45_Mariner Circle
Cotuit,Mass
__—_--- _----_ 4
02635
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
A. 1 -T&Go—gallon septic tank.
B. 1 -distribution box. �•
C. 1 -1000:gallon leach pit . i
. i
Based on my inspection, I certify the following conditions:
A. 'This is a title -five septic system ( 78 Code )
B. The septic sysceth is ii? fJI.Op i WUrkIlly ui'Clei- at tile:
I
. present time.
i
i
S! G �!ATURE 1�., � � , /
-.., .. 211
r. 4- o.l
Name:_J_P_Macomber_Jr.
Company:
J.P.Macomber & Son Inc .
i
-------------------
Address: Box 66_______
Centerville,Mass . 02632
Phone: 508=775_3338
i
i
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR `.1ARRANTY
V UN eC
♦1 /
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I
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•Pcrnpoc; 8: ins+.al;cd � S � ,
n.(_l. :B:D bb h.nrtn-,.:I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 4!5 VIAC . k Paz C_i►zr_Lk
Owner ' s name Doris Nicholaides
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility ;or dwelling was inspected for signs of sewage back-up.
v The site was inspected for signs of breakout.
iAll system components, excluding the SAS, have been located on the
site.
✓ The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
CC,C�'U-t vtil (l) C7J�r j�� 4�
1 • h'�lDr'� iZI SZ C `TD S E P 71 C L:E -+ l 1'
L.1 PE d gr S-i 5 T >�
. B
SUBSURFACE SEWAGE DI€1POSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
2 number of bedrooms
T- number of current residents
garbage grinder, yes or no
` laundry connected to system, yes or no
seasonal use,. yes or no
If nonresidential, calculated flow:
Water meter readings, if available: ko/0 C
Y2 '�"��-`� Last date of occu Occupancy
y
GENERAL INFORMATION
Pumping records and source of information:
�U �J
System pumped as part of inspection,if yes, volume pumped yes or no
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)
Other (explain)
Approximate age of all components. Date installed, if known.
information: Source of
O
C.0 .
d Sewage odors detected when arriving at the site, yes or no
i
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade : ^ t2
material of construction: concrete metal FRP other(explain)
dimensions•Z1"
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evi ence ofr�1 akage, recommendations for repairs, etc. )
'T l rb Lelia,
4---,,- - o0-rC
DISTRIBUTION BOX: l�s
(locate on site plan)
1U1 depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
ev dence of leakage into oriout of box recommendation for repairs, etc. )
PUMP CHAMBER:_ AC)Q�
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number — (off
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or re airs et
L t(S?v t 0 L rO d0�'1�w� to CE C
CESSPOOLS (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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level •of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) '
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent refe
rences erences landmarks or benchmarks
locate all wells within 100 '
yo p S
O
4�
DEPTH TO GROUNDWATER
depth to groundwater
method -of determ ' - tron .or---a pzoxiionc C 4-
JN
el �G
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND
determination in all instances. If "not determined" , explain
basis of
explain why not)
Backup of sewage into facility?
Discharge or pond'ing of effluent to the surface of the ground or
surface waters?
Static liquid level el in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available
e volume< 1/2 day
...� Required pumping 4 time
s or more in the last year?
number of times pumped
Septic tank is metal? cracked? st
ructurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
Y` within . 100 feet of asurface water supply or tributary
PP y to a surface
water supply?
within a Zone I of a public well?
wit _._..__.
hin 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet
of a private water supply well?
1� 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 grganic compounds, ammonia nitrogen j
and nitrate nitrogen.
TOWN OF BOARD OF HEALTH
SUBSURFACE SEWAGE' DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS '�1 ,? A IQ I Me, C-let.69 C -nj,
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Doris Nicholaides
PART D - CERTIFICATION
NAME OF INSPECTOR 7�T-EC_GULL_ V kt"
COMPANY NAME �oNS�C�T1� `T ` iL>1 "N:l cc)m"BL= C,
COMPANY ADDRESS Box 66 Centerville Mass 0 632
Street Town or City State ZIP
COMPANY TELEPHONE—( 508 ) 775 - 3338 FAX ( 790 1 h - 78
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
complete as. of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined ',,'CN.R 15 . 303 . Any failure
criteria not evaluated are as state i10 URE CRITERIA section of
this form. nr
AcTI'R
System FAILED SULLJVAlY* �'�
NO. 29733
The inspection which I have conduct F.
T ,. R hat the system fails to
protect the public health and the en ' ' e accordance with Title
5 , 310 CMR 15 . 303 , and as specifically t.� d bn PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature V1V� 1S
Date S�
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
13�`
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART D
CERTIFICATION
Inspector : Peter Sullivan PE
Location :45 Mariner Circle Cotuit
Date :June 15,1995
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address
and that the information reported is true, accurate and complete as of the time of
inspection. The inspection was performed and any recommendations regarding
upgrade, maintenance and repair are consistent with my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
Please note the summary of recommendations as presented in this form.
Lastly please note 310CMR:15.302 Criteria for Inspection(1) "The inspection is not
designed to provide information to demonstrate that the system will adequately serve
the use to be placed upon it by the new owner. "
ve ly yours
Of4114
6A0PETER
Pe r Sul ivan PE SUUIVA ,
ado. 29733
s
Distribution: �lsss�' !J
A9.
Original to system owner
Buyer
Board of Heath
S
LOCATION �J_ SEWAGE PERMIT N0.
Ae��
V I LLAGE
INSTA LLER'S NAME i ADDRESS
a U L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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TCGVr + v BARNSTABLE
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LOCATION G� � SEWAGE #
VILLAGE P ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 1'��C�.at/�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �iF (size)
NO. OF BEDROOMS _
BUILDER OR OWNER ���
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching F cility (If y wetlands exist
within 300 feet c f ility/) Fee[
Furnishe y
r -
0
!s
CIA.
TOW RARNSTABLE
LOCATION 'S_ J SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OFBEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of l9aching facility) Feet
Furnished by ,` 2i� •` /� !efiiGf� G�f�s—
r
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4'
ti
yS` SAX T&ex
LEGEND
CONCRETE BOUND (FND) ■
CATCH BASIN
/ MANHOLE
® UTILITY POLE
® I
1
D 400 Fear'
LOT 39
�o� \ LOCUS MAP
PLAN REF: TUBE 167 �
DEED REF: 15380/212
ASSESSOR'S MAP: 23-44
ZONING: RF
\" ►�. SETBACKS: 30-15-15
FLOOD ZONE:
- - - - PANEL NUMBER: 250001 0021 D
„ ,,,,,,,,,,,,,,,,,,,,,
DATED: 07/02/1992
"'�.
,,,,,,, ,,,,,,,,,,
/� OVERLAY DISTRICTS: WP, RPOD, ZONE II
#45;;;;;;;;� \\ o�� N- \ MASS ESTUARIES
G {�
.iiiiiiiiiiiiiiiiiiii PROPOSED �51A®OA
PLOT PLAN OF LAND
BUILDING o ►
, LOCATED AT:
s u oov 45 MARINER CIRCLE
COTUIT MA
a y
�'- LOT 38 '>�4
20000.0 SQ. FT. -04-1-L-
0.5 ACRES PREPARED FOR:
0o O o
oo• �.Z� �,o RANDY HARNOIS
ti �
N PERCENTAGE OF LOT COVERAGE MAY 151 2012
LOT AREA 20000f S.F.
EXISTING STRUCTURES 10.6%
EXISTING PAVEMENT 2.1% REV: JU N E 1 , 2012
LOT 37 TOTAL STRUCTURES 14.8% REV:
TOTAL PAVEMENT 2.1%
TOTAL COVERAGE 16.9% REV:
YANKEE LAND SURVEY CO, INC.
119 ROUTE 149 j
GRAPHIC SCALE MARSTONS MILLS, MA
60
TEL: (508)428-0055 FAX: (508)420-5553
yankeesurvey®comcast.net www.yankeesurvey.net
1 inch = 30 ft. FSHEET 1 OF 1 JOB#: 54822 SH
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