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HomeMy WebLinkAbout0025 MASHPEE ROAD - Health 25 MASHPEE ROAD, COTUIT l /, A= 007 039 _ T W1~t O B ... T LE 1.00Aw'lI�t7N,.. I V�LLAt`e1E a' A 55ES6mR'S' I45TALL.B 'S 513�'I'XC �CA1Wk 'CAP ACTTY )BUILDER C� T� IItMMii'T'DI4�N.._ w, : . :,... ._..�..:»�Cy1t1aYF� .Ia 0A. ... ..... S��t�ratiotl�1t,PttClr,��3l:twC�tl one' i .: NlnXilnum lid'jsWd Gr0.Dilwatei Feet Pllv�Bo roJ'Jt�ti�t JldI3I2ty�`�4�1'fk11G$Y+CO1C�liCE��c�CHlle�► ex+i4.'lly$V4:IIs cx(sa (rzp�9, , rin sate as.vylthin: (lq:feet of lethitt rifit},� . .r..,...r.., �..- -.,. . . Iasi "cy 1N t4a�r9 elld I �Ac�ttli�r clli¢y(ICk ally aJellaltci4.aist sec i91�i�Zlt1_�Q{ItCt .I ICAC�1Irls�Zft`'..rY1 P urriiahcd 6y 7-7 t� r, TOWN 01F BARNSTA.BL,E ,OCAI`SON , J�'c 5� e fS SEWAGE # L l%I I,AGE �o T�' A,SSESSOR'S MAP&LOT NSTA.L ER'S NAME&PHONE NO. ;EMC TANK CAPACITY I b EACU NG FACIILM: (type) y' .(size) r0.OFUDROOMS-3 MILDER OR OWNEId.............. --.,,.�.k... -._..._.._..-.—,_,._.._......_—_.....�...._. a.. IERMI'I.'DATE: - - _-_COWL,IANCE DATE: --- laparation distance Between the; Aminium Adjusted Groundwater Table to the Bottom of Leaching Facility ... - _Feet �ravtate Water Supply Well and Leaching Facility '(Yf zany wells exist on site or within 200 feet of leaching facility) eet idge of Wedand and Leaching Facility(I£any weilands exist within 300 feet of aching fuciliip) r _._...o� I eet Burnished byGw'� /��`�!�'�� . f T� IN � a Q! QCN U o � Q G o � � n Q � rr) 'o • TOWN OF BpARNSTABLE I LOCATION I���� ���G SEWAGE # VI?:,LAGE f��/� /���r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 LEACHING FACILITY: (type)' (size) NO. OF BEDROOMS co BUILDER OR OWNER PERMITDATE: 110'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) I Feet Edge of Wetland and Lea ng Facility (If any etland exist within 300 t le ty) Feet Furnished b S a r W N .W n TOWN OF BARNSTABLE LOCATION � � SEWAGE # VILLAGE , �� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY I'D60 LEACHING FACILITY:(type) A size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No A44 cOk cSjA L& 45 `1 °'� - 0 s J,� / / _ � �g Re` `� /� T�`� � T. �\ •/ \ 9 � j� i Commonwealth of Massachusetts 0D��03� Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd z Property Address W Timothy Watroba Owner Owner's Name information is ,• x . s • . „ required for every Cotuit - MA 02635 6-8-16 r 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. A. General Information �77 1.1` Inspector: }Shawn Mcelroy ` Name of Inspector Upper Cape Septic Services l• Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town 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 ;. • ❑ Conditionally Passes ❑ Fails INC ❑ Needs Further Evaluation y the Local Approving Authority t ` - 6-8-146 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 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-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 1 of 17 �rAV` 1pfS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address�y , ;. Timothy Watroba Owner Owner's Name requir atifor a Cotuit MA 02635 6-8-16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure-criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System 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 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name - information is required for every Cotuit ^ •> MA 02635 6-8-16 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. ' A Ile B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced `❑ Y, ❑ N> . ❑, ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N.' ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑tN ❑ ND (Explain below): i ❑ 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): ❑ brokenpipe(s) are re laced Y N ND (Explain below): P ❑ ❑ ❑ ( P ) ❑ 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 borciering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is required for every Cotuit MA 02635 6-8-16 page. Cityrrown 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 El ® 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''/2 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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name ; information is Cotuit t MA 02635 6-8-16" required for every IL page. City/Town• State Zip Code Date of Inspection B. Certification (cont.) .'Yes f No f El ® Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped: 5 r ` ❑ ®'1 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. `* ❑-wo ® i f - Any portion of a cesspool or privy is within a Zone 1 of a public well. A El -® r. An' 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 . ' a '` • system passes if the well water analysis,performed at a DEP certified laboratory,forJecal coliform bacteria indicates absent and the presence S .- 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 F•_ ;�,� . ,rf -and chain of custody must be attached to this form.] ' ts,. ❑ h ® , t 7hesystem,is a,cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. . ., The system fails.) have,determined that one or more of the above failure ❑ r '® r.. criteria exist as described in 310 CMR 15.303,therefore the system fails.The -'� ar .:'< 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. Fordarge systems, you must indicate either!)yes"or"no'�-to each of the following, in addition to the , questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to'a surface drinking water supply the system is located in a nitrogen sensitive area,(Interim Wellhead Protection 4 ❑ ❑ ` Area— IWPA)or a mapped Zone 114 a public water supply well If:you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins"3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is required for every Cotuit MA 02635 6-8-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate"yes"or"no" as to each of the following: Y 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 ofrbreak 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 ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has w been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® , ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable).[310 CMR 15.302(5)] D. System Information , Residential Flow Conditions:. Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example:,110 gpd x#of bedrooms): 330 t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name +r information is Cotuit MA 02635 6-8-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? - ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? + . s ,:- ;* +f r; ❑ Yes ® No Water meter readings, if available (last 2 years•usage (gpd)): Detail: Sump pump? ' ❑ Yes ® No Last date of occupancy: 6-2016 Date Commercial/Industrial Flow Conditions: _ t • ' Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq:ft., etc.): r, r Grease'trap present? ". ❑ Yes ❑ No Industrial waste holding tank present?- ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ' =• ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 1 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is Cotuit MA 02635 6-8-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ` Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 e Commonwealth of Massachusetts v Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is �. . - required for every Co -. MA 02635 6-8-16 1 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed (if known) and source•of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: f 18" feet Material of construction: i'•. ` E cast iron i ® 40 PVC ❑ other(ezplain):� I Distance from private water supply well or suction line: feet R Comments (on condition of joints, venting, evidence of leakage, etc:): Good condition. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene , ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is r Cotuit MA 02635 6-8-16 required for every ry 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 20" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 61# Distance from bottom of scum to bottom of outlet tee or baffle 15" 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 ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Timothy Watroba - Owner Owner's Name , information is required for every Cotuit { ' - . MA 02635 6-8-16 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.): „ . t 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.): f "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is Cotuit MA 02635 6-8-16 required for every - ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): , Depth of liquid level above outlet invert 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 pit. 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 i Commonwealth of Massachusetts - Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is Cotuit '- • ' MA 02635 6-8-16 required for every • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ® leaching pits number: 1-1000 gal ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields I 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.): Good working order with water level and stain line at 24" below inlet invert. 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 Forth:Subsurface Sewage Disposal System•Page 13 of 17 ' I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is required for every Cotuit MA 02635 6-8-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd M , Property Address Timothy Watroba Owner Owner's Name information is required for every Cotuit �'-` MA 02635 6-8-16 r ', page. 4City/Town ` ° State Zip Code Date of Inspection t D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal,system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r s . . I � , ! ,liE Loic- A". t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is Cotuit MA 02635 6-8-16 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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 no groundwater at 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Timothy Watroba Owner Owner's Name information is required for every Cotuit MA 02635 6-8-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r 'o � o All, NOIStli 4 6 ?f ,i'a f i . s lei 1 • ur yy `�11��� S iT9e a.r• +` s 1 � '3 t•.�`•i��"y3r`� ,r?a"b"ems 1 t 8 c 'J i i i J i l t P ' y. _.�-n..tom.�.}�_.... • +r♦ • •- t-..W...P i )j [ 5•.f i . Z _ Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 Mashpee Rd Property Address Jeff Barnes s Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 . page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information C 1. Inspector: I Shawn Mcelrey Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr t . .. Company Address E. Falmouth MA 02536 City(rown 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 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs.Furthe'r Evaluation.by the.Local Approving Authority - 3-7-12 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I V t5ins•11110 Title 5 Official Inspection F tSur1face Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts #' W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. Cityfrown 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): 1 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 25 Mashpee Rd , Property Address - r. Jeff Barnes Owner Owner's Name # information is required for every Cotuit MA 02635 3-7-12 page. City/Town State Zip Code . Date of Inspection B. Certification (cont.) _ B) .-.System Conditionally Passes (cont.): ;« ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' '' ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ _obstruction is'removed - ❑ Y ❑ N d ❑ ND (Explain below): distribution box is leveled or replaced -0 Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further,Evaluation is Required bythe 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'MR 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is Cotuit MA 02635 3-7-12 required for every ' 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 '/day flow t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage.DisposalSystem Form -Not for Voluntary Assessments , 25.Mashpee Rd Property Address Jeff Barnes Owner Owner's Name, . information is required for every Cotuit MA 02635 3-7-12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes ,No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑'` 1 z '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. ❑," rZ s 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. f� `` ❑ ` ® ` '''Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence .of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- r " 10,000gpd. ` ` The system fails: I have determined'that one or more of the above failure ® criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure., E) Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd. For large systems, you must indicate either,",yes" or-"no"to each of the following, in addition to the questions in Section D. , Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El El Area'-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, ,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 ,,, _ Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. City(rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official -Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Jeff Barnes ,Owner Owner's Name information is "required for every Cotuit MA 02635 3-7-12 ; ' page. ,CityfTown State Zip Code Date of Inspection D. System Information , k Description: . Number of current residents: 0 Does residence have,a garbage grinder?. ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection'required] ❑ Yes ® No Laundry system inspected? , C• El Yes ® No Seasonal use? - ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: r Sump pump?.'. . , . e ❑ Yes ® No 3-2012 Last date of occupancy: Date - Date Commercial/Industrial Flow Conditions: Type of Establishment: Design,flow(based on 310 CMR 15:203): Gallons per day(gpd) . e 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? ~r r: ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: I 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) (f 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 DER approval. ❑ Other(describe): t5ins-11/10 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, ,M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit r MA 02635 _ 3-7-12 page. City/Town State Zip Code Date of Inspection D. System-Information (cont:) Approximate age of all components, date installed (f known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan):, „ Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC "-K ❑ other(explain): ' . .r% . Distance from private water supply well or suction line: feet ' Comments (on condition of joints,venting, evidence of leakage, etc.): . Good condtion. Septic Tank(locate on site plan)' Depth below grade: "' ,. "`' 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: - - 1000 gal Sludge depth: 12" t5ins•11110. _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary a Y Assessments ^M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20° Scum thickness 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 15" 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 ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ti Commonwealth of Massachusetts Title 5 Official Inspection Fora _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 25 Mashpee Rd Property Address 4 Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. Cityrrown 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 El metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions:. Capacity: gallons Design Flow: f: gallons per day f Alarm present:. ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25 Mashpee Rd Property Address Jeff Barnes • :r 5. Owner. _ Owner's Name information is Cotuit - MA 02635 required for every page. Cityfrown J State Zip Code Date of Inspection D. System Information (cont.)' } Type; a d, ® leaching pits number: 1-1000 gal ❑ leaching chambers number:''. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:. ❑ innovative/alternative system Type/name of technology: s Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of Vegetation, etc.)` Leach pit in good condition and empty at inspection with stain line at 30" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts _ W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level'of ponding, condition of vegetation, etc.): i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 25 Mashpee Rd. r Property Address Jeff Barnes Owner Owner's Name information is Cotuit - MA 02635 3-7-12 " required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) f ` 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 C1D 'O� t5ins•11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Mashpee Rd Property Address Jeff Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water t ❑ Check cellar ❑ Shallow wells Estimated depth to high gr ound 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•11/10 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 25 Mashpee Rd Property Address , Jeff-Barnes Owner Owner's Name information is required for every Cotuit MA 02635 3-7-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z. System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 _ Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable P# 13 -5 ('0 IKE Department of Regulatory Services BARNSTABIE, : PublicMealth Division Date M 0 � 200 Main,Street,Hyannis MA 02601 i Date Scheduled H,2 e-�n (o 2 U 2- Time f 1'�t) iv if Fee Pd. •O a Soil Suitability Assessment for Sewage Disposal Performed By: xG Cat uC� �,-VA w t E l I� GS A Witnessed By: Dbtnul to 'D-SmCkrCLC% t(Z.s LOCATION& GENERAL INFORIVIAT_ION Location Address nas�(Jce �aGG� Owner's Name �or�ata �, Ktnteci�c Cv4ust µA 02&3.5_ Address G5naskeee t2oacl Co1vt4, K� 0 2(,3.5 Assessor's Map/Parcel: 7 / 3(o Engineer's Name IC,L'—%U)eer<,r.S , r- C. NEW CONSTRUCTION REPAIR X Telephone# 5 0 21 3-0 7 7 Land Use S 05i e nmil a"Akc!�% Slopes(%) 2-5 Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line 7 t U ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) s ee_ ct tkikV,-S 1� 1 Parent material(geologic) OUkwu5lri Depth to Bedrock Depth to Groundwater: Standing Water in Hole: .. Weeping from Pit Face Estimated Seasonal High Groundwater -7 DETERMINATION FOR SEASONAL HIGH.WATER TABLE Method Used: Du o k o to seru 4 Fi0n Depth Observed standing in obs.hole:, >12(0 in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: — in. Groundwater Adjustment+ ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level= :PERCOLATION i ION TEST Datc 3 2 :Terre Observation Hole# Time at 9" Depth of Perc y e Time at 6" Start Pre-soak Time @ p:2t A)f Time(9"-6") End Pre-soak �I 26 A Rate Min./Inch Z Site Suitability Assessment: Site Passed Yes Site Failed: Additional Testing Needed(YM) � Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC a,> DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel u--y _ "I 2 A/C L5 it)i r 3/1 12-3'0 LS l0 it S�8 30 ^(2(o G N S 2,5 /tO DEEP OBSERVATION.HOLE LOG... Hole#, Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. -----. Consistency,%Graven p. DEEP OBSERVATION HOLE LOG 001e# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel DEEP OBSERVATION HOLE LOG Hote# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No ✓ Yes Within 100 year flood boundary No '� Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes If not,what is the depth of naturally occurring pervious material? Certification I certify that on /0'27-9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the:required training,expertise and a perience described in 310 CMR 15.017. Signature Date 3-12-f L Q:\SEPTIC\PERCFORM.DOC s DATE: 1 /4/01----- PROPERTY ADDRESS:_25_Mashpee Road 1.7-_ ---- � -a9 Cotuit,Mass. --------------- 02635 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. 3 . 1 -6 'X4 ' precast leaching pit. ( 3 ' of stone. ) Based on my Inspection, I certify the following conditions: 4 . This is a ,title:_five._septic system._ ( 78.-Code .) 5. The septic system is in proper working order ;at the present time. __ __ 6 . 'Waste water is 42" below the invert pipe of the pit. 7. Pumped septic-tank at time of inspection. Heavy scum & . solids. layers were present. SIGNATURE: J. Name:_,L,_F __M_acomber jr­,______ Company: Jose.ph_P__Macomber & Son , Inc .' Address: Box_66------------- ��® •vi a 32-0066 4 L®OZ Center lle , M _ 026 � JAN `� 1 qi�-ABLE Phone:___508_775_3338 UvaH �Lj�DEPT• ------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • Oro JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfleids Pumped & Installed Town Sewer Connections P.0. Box 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: 25 Mashpee Road Cotuit,Mass_ Owner's Name:WarnPr ' .TAMPR Owner's Address: .1 21 Oxford Drive Date of Inspection _ /A /n� Name of Inspector: (please,print) J.P. Macomber. Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P.O- Box 66 Sant-Prx i l l A Ma 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that 1 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. 1 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 Authoriry . Fa'Is Inspector's Signature:- /Z/ Date; /t' �,e—QA Jr The system inspector shall bmit 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 "••Thif r rt epo only describes conditions at the time of inspection and under the conditions of use at that _ aime. 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 Paee 2 of l l , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: 25 'Mashpee Roadf Cotuit,Mass. Owner: Warner James Date of Inspection: 1 4 01 - Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of.Section D' ;A. �st.emPasses,' r` N. have not found any in format io hick indicates that any of the failuie 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 time,, - B. System Conditionally Passes: One or more system components as described-in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined,(Y,N,ND) in the for the following statements. If"not determined"please explain. r Ad 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: Observation of e backup _Q or break out or hi static water w 'le el ,g p high to the distribution box due to broken or obstructedpipe(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: 4 The system required pumping morethan 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): y broken pipe(s)are replaced , obstruction is removed ND explain: - 2 Page 3 of 1 1 t 1 r x OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Mashpee Road cotuit,mass. Owner: Warner James Date of Inspection: C. Further Evaluation is Required by the Board of Health: ND 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(l)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Ak 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 safe tyand environment:ronment: 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. 4J2 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. a The system has a septic tank and SAS and the SAS is less than 100 feet but 50 l5cet 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 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. 3. Other: y 3 Pagey4 of 1 I ` OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,CERTIFICATION (continued) Property Address: 25 Mashpee Road Cotuit,Mass. Owner: Warner James - - Date of Inspection: 1 4 01 D. System Failure Criteria applicable to all systems: You must indicate 'yes"or"no" to each of the following for all inspections: Yes No ' ackup'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 Staiic liquid level in the disq'bution box above outlet,invert due to an overloaded,or clogged SAS or cesspool le<f P isrA., i' Liquid'depth in cosfpeal is less than 6"below invert or available volume is less than h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped . y portion of the SAS, cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within IOO feet,of a surface water supply or tributary to a surface ater supply. y portion of a cesspool or privy:is within a Zone 1 of a public well. y 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 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 thisform.] //)'(YesfNo)The system fails. 1 have determined that one or more+0f the above failure criteria exist as described in 310 CMR 15.363.therefore the system fails. The system owner should contact the Board of A 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 io,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 _ the's stem is within 400 feet of a surface drinking water supply — Y g v 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 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. 4 j Page 5 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Mashpee Road Cotuit,Mass Owner: 1 /4/0 2 Date of Inspection:Warner James Check if the followine have been done. You must indicate"yes"or"no"as to each of the following: ' Yes No 2Pumping information was provided by the owner,.occupant, or Board of Health Were anv of the system components pumped out in the previous two weeks-? Has the system received normal flows in the previous two week period ? 4/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,4&luding 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: Yes no ; kl Existing information. For example, a plan at the Board of Health. y 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)) q 5 Page 6 of.l 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Mashpee Road i o ui , ass, Owner: Warner James Date of Inspection: 1 4 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): J DESI w DESIGN flow based on 310 CMR 15.203 for example: 110 d # T x of be( drooms Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system ( es or no):,Gb [if yes separate inspection required] Laundry system inspected(yes or no): iy Seasonal use: (yes or no): .(0 .. Water meter readings, if available(last 2 years usage'(gpd)): Sump pump(yes or no): •(�© - Last date of occupancy: - Q!�2�i9 � COMMERCIAL/INDUSTRIAL ` Type of establishment: _ -Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present (yes or.no):Ag Non-sanitary waste discharged to the Title 5 system (yes or no):/L[�' Water meter readings, if available:. Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION " Pumping Records • Source of information: . Was system pumped as part of the inspection(yes or no): If yes, volume pumped- 4�G0P, gallon9s,r-- How-w`(a/Ys ua�n�� uym ed determined'.) / . frReason for pumping: c�X.3oyrl � s�0 s 04 wee p TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy 1_6 Shared system(yes or no)(if yes,attach previous inspection records, if any) ,fff�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): Approxi/m to age of all cco ponen date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): -10 ,. 6 t Page 7 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mashpee Road Cotuit,Mass, Owner: Warmer James Date of lnspection:1 /402 BUILDING SEWER (locate on site plan) " Depth below grade:�_ _//Materials of construction: cast iron We)40 PVC t/other(explain):�i f/�' S� /•'�G� Distance from private water supply well orsuction line: 12A Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.Noevidence of leakage-The system is vented through the house vents. SEPTIC TANK: zoocate'on site plan) Depth below grade: Material of construction: oncrete,�metal,dO fiberglass 4V polyethylene �other(explain) w® If tank is metal list age:,&&l Is age confurned by a/Certificate of Compliance (yes or no):,W(attach a copy of cenificate) Dimensions: t! 1Pi '1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: d Scum thickness: 4:51 Distance from top of scum to !op of outlet tee-or baffle: d Distance from bonom of scum to bonom of outlet tee or baffle How were dimensions determined:. Comments(on pumping.reccmmendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related-to outlet-inven-evidence of-Ieakage,.ete.):_____ ump the spptir tank empry 2-1 ears, Inlet & outlet tees are in place.The tank is structtrally" sound and shows no evidence of leakage. GREASE TRAPIOL/ oocatc on site plan) Depth below grade:1!94 Material of construction:.tJ concrete metal. ,4 fiberglass�olyethylene,�.Vother (explain): ,U/Q Dimensions: AfIle Scum thickness: Distance from top of scum to top of outlet tee or baffle: illy_ Distance from bosom of scum to bosom of outlet tee or baffle: Date of last pumping: 4J Comments (on pumping recormer,:d2tions, inlet and outlet tee or baffle condition, smictwal integrity, liquid IeveLs as related to outlet invert, evidence of leakage, etc.): Crease trap is not present 7 Page 8 of 1 I- OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued)_ Property Address: 25, Mashpee Road Cotuit,Mass. Owner.'Na rn r 'Jam G Date of Inspection: 1 1 4/()2 TIGHT or HOLDING TANI<t"(tank must be'pumped at time of in pection)(locate on site plan) Depth below grade: Material of construction: concrete�metal,&o fiberglass,!,*Polyethylene,M other(explain): Dimensions: - Capacity: .1/ gallons , Design Flow: gallons/day Alarm present(yes or no)': 'Alarm level: .40 Alarm in working order.(yes or no): J� ' Date of last RJ pumping: R Comments(condition of alarm and float switches, etc.): Tight .-or h'oldirig tanks are not present`. + DISTRIBUTION,BOX:Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakaee into or out of box, etc.): I Distribution box has one lateral No evidence of solids carry over-Nn e,vidRore of leakage into or out of the box PUMP CHAMBER(locate on site plan) a ; Pumps in'working order(yes or no): .rfd Alarms in working (Y or no)order es : r ' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): .Pump chamber is not present. 8 r Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Mash ee Ro otuit,Mass. Owner: Warner. James. Date of Inspection: SOIL ABSORPTION SYSTEM{SAS): (locate on site plan,excavation not required) 1 -4 ' 1 ' 1f SAS not located explain why: Located; See Page Type . ' / leaching pits,number: — leaching chambers,number: } &i) leaching galleries,number: d,?j leaching trenches,number, length: d' leaching fields,number,dimensions: L� 4 overflow cesspool,number: - i+ �—r ?,F innovative/altemative system Type/name of technology://�' �/1�° Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,conditton of vegetation, etc.): No signs of h dr LoamSan fa 1 012 f s r is inc e below the invert pipe. 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: i 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.): Cess , PRIv Yy/&&e (locate on site plan) Materials of construction: Dimensions: 40 Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Pr 9 Page 10 of I I t. 4 A OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properry,Addr,essi25 Mashpee Road cotuit,mass. ; Owner:Warner James r -Date of Inspectioo: 1 4 02 -SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to�at'teast two permanent reference landmarks or benchmarks. Locatc all wells within 100 feet. Locate where public water supply enters the building. f r v 4 ... { L.5 vv( 6S\f,pce_ A i3 A `►- I�` r; I 5 , ~ of 3 52, 3- �ri 10 APage 1 1 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: . 25 Mashpee Road Cotuit,Mass. , Owner: Warner James Date of Inspection: 1 /4/0 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: bt ' lans on record If checked, date of design plan reviewed: bserved site(abuttin property bservation hole within 150 feet of SAS) , r c ed wt ocal Boar o ea t -explain: _C cked with local excavators, installers- (attach documentation) ccessed USGS database-explain: You must describe how you established the high ground water elevation: Used; Gahrety &Miller Model12/16/94 Ground .water above sea level . USGS; Observation Well Data june 1992 USGS; Annual range of ground water_92-000,1 P1atPfi 2 Tup of r un Leaching Pit i :eet ' t " Groundwater/ Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method ,I Therefore,the vertical separation distance between the bottom J/ i Of the leachirig,pit and the adjusted groundwater table is 7/0 feet. ' 11 _ •rmr+r.-nlr�*—.r-ern:=mr•nTenrs-nrt rnxmrrn+•++�.rr�+r*�*n+n nrrxZ n��a+sn ws .r�-rT•r- r—n--. - ... TOWN OF Barnstable BOARD OF HEALTH { SUIISUIIFACF 9EWA(;E DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••T••..7••.••.: ��.IIT.�.�TT.TT.1.1'R•T►ITR}pTIf TTT.i1'.t—!.'I r11R1'\7'R1.TTTRRAf NTTwAA•'A7R7 ATIf ..�I'T'T•1. �. . -TYPE OR PRINT CI.EARL)'- P110PERTY INSPECTED - STREET ADDRESS.^ 25 'Mashpee Road Cotuit,Mass. ASSESSORS- MAP , BLOCK ANU PARCEL #. 007-039 t , OWNER' s NAME Warner Jantes PART D - CERTIFICATION NAME OF 'INSPECTOR Joseph P. Macomber Jr. - COMPANY NAME - Joseph P., Macomber & Son Inc -COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or City State IIP COMPANY TELEPHONE (508 . ) 775 - 3338 FAX ( 790 ' ) 1 578- 508 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa41 system at ®rlecoinmet)datioris , i,egardiiig his address and that the information ' reported is true , accurate , and omplete as of- the . time of inspection , The inspection Was performed and any upgrade , maintenance , and repair are consistent .with my training and .experien.ce in- the proper • function and maintenance of on- site sewage disposal systems , • Check one System PASSED � I Th.e inspection which I have conducterd has not found any information which indicates that the• system fails to adequately protect public health or the envi rot)merlt as defined in -310 CMR 16 - 303 . Any failure criteria not evaluated are as stated, in the FAILURE CRITERIA section of this' form .-. System FAILED* The inspection which I have con 'noted .hats found that the system fails to Protect the • ptibl,ic health and the environment in accordance with Title 5 , 310 CMR 15 .,303 , and as specifically noted on PART C - FAILURE CRITERIA of this- ,inspection orm . y � Inspector Signature / Date copy of this c t.ification must be provided to the OWNER, the BUYER One where applicable.) ;,and the 130ARD OF HEAL'I'1(, * If the inspection FAILED , ,the owner orop orator shall u p pgrado ' the system within one - year of the date of the . inspec;tion , ,,unless allowed or required otherwise provided in 3.10 CMR 15 . 305 , r - partd . doc v . ..,._...:.,-..W_.._,....,,:.t.-,-.R,•,.,;..;:� PF:.. ,;.... a..,�+. ` -ram.,:±.r �-... -.-..r--. D AT E:, jj.L41.2 PROPERTY ADDRESS:_ 25 MashpeeLRoad ....... Cotuit _ AP ,tea,.-,.._, .-, ,.e...v .t+•. w�w." 'f:?".`:m -' -s: }.r^'Y.v;...;�,� Mass 02635 HEALTH DEPT, -------------------- -- ?OWN OF @ARN6MM On the above date, I inspected the septic system at the above address. This system consists of the following: A. 1 1000 gallon tank ,,..-z.,.,Yt.A5 a...«:,,,.., :.,......». ,...... ..,G,.s:. B. 1 -distribution box. C. 1 -600 gallon leach pit packed in stone. Based on my Inspection, I certify the, following conditions: A. This is a title five septic system. ( 78 code ) B. The. septic system is in proper wotking order at 'the present time;. Ix. (,• SIGNATURE: Name: Company J v Macomhg� �, 4oa-Inc Address:__Rox_66 _ -- Centervillej_Mass_ 02632 Phone:_—' + 508-775_3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY mom rine'rowip.AMA & SON, INC Tanks=Cesspools-Leachfiefds' Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 s 775-3338 775-6.412 1 RONALD J. CADILLAC, PLS, RS Land Surveyor & Sanitarian page Box 258, W. Yarmouth, MA 02673 (508) 775-9700 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 25 11)2,4S111'6;57 /2 Owner's name (and/or resident) J A N t]—; )Zg--46 A tij Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Heald ►/ �novse SkAg a P l None of the system components have been pumped for at least 3 Y P p p 0 days and the o CGu P PL" system has been receiving normal flow rates during that period. Large volumes '" r.1e-e' w�"of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained. �S ���-T- Cam►-r�. -(ti-�,,� �,�, Y1'1 AGotiw ber- The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. V All 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. V 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. i page 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms 0 number of current residents No garbage grinder, yes or no 10 laundry connected to system, yes or no Iffs seasonal use, yes or no If nonresidential, calculated floe: Water meter readings, if available: 7 3 2 000 ra A L,5 - 94 C 0 Last date of occupancy SU Y'" �-- GENERAL INFORMATION -.nping records and source of information: 6w N�—rz J A-t,s hol 12 U m, P� 1'61 Ce D� )01 Igo System pumped as an of inspection, yes or no _ Y P P P if yes, volume pumped 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 Jcomponents. Date installed, if known. Source of information: -I q&3 N Gco/'GUr'si OW NIi/L LQ Sewage odors detected when arriving at the site, yes or no page 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORAZATION continued SEPTIC TANK: YES (locate on site plan) i depth below grade: material of construction: concrete _metal _FRP _other(explain) dimensions: /60o G,�f � 5 ' S 3 y sludge depth Z 7�'.distance from top of sludge to bottom of outlet tee or baffle scum thickness 6 distance from top of scum to top of outlet tee or baffle 1,Lt 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, evidence of leakage, recommendations for repairs, etc.) DISTRIBUTION BOX: YES (locate on site plan)' l�lv depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) 1 page 4 PUMP CHAMBER: /'D ate on site plan) pumps in workin order, yes or no Comments: (note condition of pum chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SOIL ABSORPTION SYSTEM (SAS): S (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 1 — 644�o le Ao 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 repairs,etcL.) 0c4e Per 1�ry iasm, �-1 �v�vfT T L��r Page 5 �l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued CESSPOOLS: /7 aw ,�:-7 (locate on site plan) number and configuration depth-top of liquid to inlet in ert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be puryped as part of inspection) Comments: (note condition of soil, signs.of by raulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: Y)OnJ� (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of by aulic failure, level of ponding, condition of vegetation, recommendations - maintenance or repairs,etc.) page 6 SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks ln4 Sxi pce [.?Cj locate all wells within 100' 7, 5 1pC / 8 Drive � ? to Coa(, N S, P1T DEPTH TO GROUNDWATER 4' depth to groundwater method of determination or approximation: E LEV&;n o�J 6 p,, U S 6 S ►vl (�-tp b 1S a e .� �e-c�e,t . i S L7 Pr T`iTtL S S� CT-1rr►n — 1 cl 8 3 b v ►L: Ca J1ecJ -t"or- �. • page 7 SUBSURFACE SE«'AGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) o Backup of sewage into facility? Y IVo Discharge or ponding of effluent to the surface of the ground or surface waters? NO Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6 below invert or available volume< 1/2 day flow? IVo Pumped 4 times or more in the last year? number of times pumped D Ao Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: do below the high groundwater elevation? PiT �rJ within 50 feet of a surface water? A within 100 feet of a surface water supply or tributary to a surface water supply? Nv within a Zone I of a public well? Vo within 50 feet of a bordering vegetated wetland or salt marsh? AO within 50 feet of a private water supply well? No 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. 1' 7 page 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of/Inspector Ronald J. Cadillac Inspector Number Registered Sanitarian No. 1060 Company Name Ronald J. Cadillac, PLS, RS Company Address Box 258, W. Yarmouth, MA 02673 (508) 775-9700 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. Check one: 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. _ I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature , Wj Date Z� �l.s Original to system owner ✓ACE EA 4A/ Copies to: Buycr (if applicable) proving authority No..7N -C:N,? ................. ...... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... OF.... ......... ....4Y......... -—------------------ unkrurtion Plitt �410 Application is hereby made for a Permit to Construct X) or Repair an Individual Sewage Disposal S tem W. ....... .. C................W041; / : . . . .. . ..... . ,pon-A(Ldqp or Lot No. . .. .... ... e......... 6.. ..... --_------------- �res-s........................................... ---- ------------- own...........et..0. .........19 ................ .......................................................................0!�t nstaller Address 'lie, Type of Building Size feet U s.......2..............................Expansion Attic 00) Dwelling—No. of Bedroom Garbage Grinder ( PL4 Other—Type of Building ............................ No. of persons....._.4................ Showers Cafeteria ( 04 Other fixWres ...................................................................................................................................................... Design Flow.........0.**)...........................gallons per personpe ay. Total daily flow--------J.3. .. .................gallons/ W - 1:4 Septic Tank—Liquid capacitv,/ZrO.Ogallons Lengthff.?:..�� W ....... Width*r:.A?.. Diameten!"o Depth....*0.7... Disposal Trench—No. ........ Width.._.&le*.... Total Length-.&It4,..... Total leaching area...?!!yA;eq. ft. Seepage Pit No--------/.......... Diameter....../.O�..... Depth below inlet......... ....... Total leaching area......;W- sq. ft. Z Other Distribution box Dosing tat* Percolation Test Results Performed by. 4V ......X!! Test Pit No. 1.2---lt.15!.minutes per inch Depth of Test Pit.................... Depth to ground water.---.................... Test Pit No. 2................minutes per inch Depth of Test Pit.-----......--...... Depth to ground water.--...--............---. ............ -------- ---------------------------------------------------- 0 Description of Soil-------- -e..................................................... W -----------*--------------------------------0 In .......................................................- ------- On .5........ --- ----------_ ------------------------------------------------A-* ..................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable---.......................................................................................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e rovisi us of'LI`I`IZ4 of the State Sanitary Code The unders' ed further agrees not to place the system in The ro'is* undersigned'Is 0 'I s e,P c'I agrees Werther c'poatio rti e of Compliance h C;� e n�ii by the boar h t riedl�l'• "A....... --------_---------- e p ov .. 7.,( p ca o Approved By........ -P Wn ....................... ...........) / -- ----------- Date p pli tion is prov for lication Disapproved for the following reasons:............................................................................................................. .......................I.................................................................................................................................... ........................................... Date Permit No.........94-:774+9................ Issued.......... ate ............. — ------ -------------------------- t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ..............................OF...................................... Appliration for Disposal Works Tonstrurtion "umit V Application is hereby made for a Permit to Construct O or Repair an Individual Sewage Disposal System at,:'S), ......... ............................................. .................................................. ------ Location-Address 5 or Lot No. ........................................ ................................................................................................ Owner" — / ' —Address X ----------- ....................;1..................nlw................ ...... ........................................................ Installer Address !I,, Type of Building Size Lot-, ..............Sq. feet U Dwelling—No. of Bedrooms___________________________________________Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons....... ................. Showers Cafeteria Other fix ....... tures ................. ............................................................................................................................. Design Flow_._...... '...................................gallons per person per day. Total daily flow---- .....................gallons. Li GO J,,Length A Width;51'_._/ . Diameter'._..__. "___-/ — "P 9 Septic Tank quid capacity.6�L.�'­gallons ...!�. --- Depth............... Disposal.Trench'-No.............1......... Width..-2 Z•'!..... Total Length.Z. Z !..... Total leaching area..!! r?.....sq. ft. Seepage Pit N'6........ ..... Diameter.._...Z�'_...... Depth below inlet.......... ....... Total leaching area.......` .sq. ft. Z Other Distribution box Dosing tank Percolation Test Result's Performed by...;°f................................................................Date__A.......Z. 1-4 Test-Pit No. 1.:.............minutes per inch Depth of Test Pit..._.___...._...._._ Depth to ground water.......______.__...____. Test Pit No. 2................niin,utes per inch Depth of Test Pit.._......_....____.. Depth to ground water........................ ........................................................................................................ ...................................................... 0 Description of Soil......... ............................................................. ............................................................................... r. ........................................................ ........�L........... ..... J......................................................................................................... .......................... ................................................. .......................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable------------------------ ..................................................................... ........................................................................................................................................................................................................ Agreement: The"undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with O,is' ns of.TITIE h of the State Sanitary Code— The under `gped further agrees not to place the system in d t__b`e�n issue4 ati ert e of Compliance ha's )y the boar of healt Signed........1. _C. ............. . ...................... ......... ................. ....... ,,),,Date.� .................................................................. ........................I............... 0 Approved By'.'­7­-'Z::N1..1:� Date pplication-Disapp roved.for the following reasons:............................................................................................................... ........................................................................................................................................................--- ------... ........ ...................... - Date Permit No._.....*4--------41W. ------------------- Issued....... . ..................... 4 Date THE COMMONWEALTH OF MASSACHUSETTS, .4, 1 BOARD bF HEALTH *TO.........................................07 ... ................................................. Trrti rati-i"d Tompliaurr THISJS TO CERTIFY, That the Individual'Sewage Disposal System constructed (t�C or Re'paire&_( by-- ...............0�......... ..........................................................................................................................................I................. Installer at-.........Ln.:( ------------ ............................................................................................. ..................... .has been installed in accordance with the provisions of TITLE 5 of The State.Sanitary - . Cod asescri e in- e.... application for Disposal Works Construction Permit No_q. .95.j�5� �. .......I I.... date( -------........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CINST ED AS A GUARANTEE THAT THE SYSTEM WILL F I CT ON SATISFACTORY. DATE............. ... .............. Inspector .. ...... ........................... .......................... - --------------.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................OF................................................................................................ V L -t.- E....!S FF ............ Disposal Works( Tonstrmtion Vprrmit Permissionis hereby granted....................... ...................................................................................................... to Construct orNRepair an Individual Sewage Disposal System at No.... ...... Street as shown on the application for-Disposal Works Construction Permit No.!R!.—'�'l L& Dated.._. ................... ....................................................................................................... DATE_.... .2......01 ............................. ........... Board of Health 7 FORM 1255 A. M. SULKIN, INC.. E30STON .*ems r _ / A 1, YAVEM�� Q i - 3 - ! i I. 4 r '' .� ..I(U 2 - 3 z r _ n l _ ! A9 r 1 aC(C /.SG� _ ! f RD I'lr. SCT'/3AC/< S +Ndl r /} Una J)D t j 4 � J 57�•i r Tyr--', a-, C ?v U.f /tv3 c. ! LP7 �f r ,7 9oA Z 5, 0 00 c f. t-,--`ems . A �3 ` rAA•' AORSE �� o — 6n` LAI t No.10951 O r R()f3ERTFFSS10NM-��` .LEGEND 13RU..� 1 I.STIN® SPOT ELEVATION on® a tLc)rzLUur --- -AX6.�'I'II� CONTOUR CERTIFIED PLOT PLAN H.E0- SPOT ELEVATION � t � As T / 2.I ® � -� v y• $0T .The location of any-. existing undert�iouind sewerage, - :welas, ;o-r othex utilities shown on this plan is appxox- I . 3male .only as determined from records and/or verbal 41 information. The contractor is responsible for the. '2 � � �' ' � 'werrfacation of the existing Locations in, the field. DATE <, �. ED E� '� '�`R��f� �� IN �LIENT�/� 1 CERTIFY THAT THE PROPOSED .i 'TARE RE®ISTF.RED Jog No. 8� I tlIL®IN® SHOWN ON THIS PLAN CIVIL LAND r,, CONFORMS TO THE ZONIN �LAW � E ® ER RV OF ARNSTABLE , PNAS3 712 MAIN. STREET CH BY, 13E ' HYANN I % MA'3S.. Z -z� SHEET,.. 'F A E ""REG. LAND SIJP°VF YOR ` ® � C . � Z e ° Q� ,y {l��y T94 a cQ N Jot �;0N 0 os �, Ada �� Wy ` 01 AA tz do 41P 14 It Nil ®� 1� t�--�• ,1 r@7 s � r u A. f.o MO.1'e.tcd b - ,----, If I.GH GROUND-WAl ER LC:VE E GOMPUT:AT I Otd: S r t e h o c a t i onL=`Jag7 Lot No. Owr,er _ �re c.—V Address: Contractor: Address: -—-- -- - : Notes dE �z - - -- -- - t STEP;. 1- Measure depth .to water -table to nearest 1/.10 f . . . l/4/63 ------ ----- ---- — — - ___-- date _ .. STEP 2 - Us.ing Water-Level- Range Zone ' and Index Well -Map locate life and determine: A). .Appropriat'e index well 8) Water=level range zone _ . . �' STEP ,3 Using monthly reFiort"Current Water. Resource's .fond i t i ons10 -- -� determine current depth to Q,Z� :water level for index well' . /�3 - 5� - -- mo y r — /wL'7,J a ` STEP' .:'4` Using Table of .Water-level Adjustments -for index well :curr.ent depth to water- level for index well f (STEP 3) , and water-level -----t zone; ,STEP 2B) determine N naQ ? water-level adjustment . . . . . . . . . . . . . . . . . . . . . ST 'P 5 Estivate depth to high water by %Ljbt Tact i fig the wat er- level adjustment (STEP 4) from. measured depth to water :,lr'vel at site (STEP 1 ) . . . . . . .. . . . . . . . . JJ