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HomeMy WebLinkAbout0035 MOORING DRIVE - Health A= 024- 129 - -- - _-- _ 1� r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,a 35 Mooring Drive Property Address Zachary Cheney ` Owner Owner's Name information is 'U required for every Cotuit l Ma 02635 1/25/2019 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. i Important:When A. Inspector Information 1353t filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do,not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority. 4. ❑ Fails 1/25/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 4 Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/M18 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 35 mooring Dr Cotuit is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 leach trenches. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. it *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of t Compliance indicating that the tank is less than 20 years old is available. .` ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ) Title 5 Official Inspection Form f' a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) . System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t� 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS.and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary(cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate yes or no for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ry W Title 5 Official Inspection Form ►� p �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring M e 9 Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available:. Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system repaired 2/23/2015 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): .5 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy,of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 611 Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5„ Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Y�} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments If 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2---32'x3'x2' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) , 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trench was video inspected through vent and was found dry with no sign of past saturation. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information i e required for every Cotuit Ma 02635 1/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately r q3: 73 ;yq,p t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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 15 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: Design plan dated 1/6/2015 indicates that no groundwater was encountered at 132"and system is designed to have 5'+seperation between adjusted high water elevation and bottom of s.a.s. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts r9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Zachary Cheney Owner Owner's Name information is required for every Cotuit Ma 02635 1/25/2019 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. / ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. I 6 0 — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYicatiou for -Disposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components f c., Locatio Add ess or Lot No.35 oorin b�I V e Owner's Name,Address,and Tel.No. C4fLlII—' n-tnniv Sc /-�c�® (77Y 72.2 -157 Assessor's Map/Parcel i 214 Pel iz M n r�lle 's N e,Address,and Tel.No. gner's Na Address',and Tel.No. 9 rXCQVf,F.fid�l �Og�`� Z7-I��S 3 `.Gl�K 3to Z grne�/c�1� Type of Building: Dwelling No.of Bedrooms'_3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �3 C/ gpd Design flow provided 34T gpd Plan Date j�(e I —Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of th vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f He th. Signed Date 11 -711 Application Approved by Date�—g—� Application Disapproved by Date for the following reasons r Permit No. 0 6 — Date Issued I .� • � - '��W�---mot• _- - - No. j _ Fee #0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplifation for Misposal *pstpm Construction Permit Application for a Permit to Construct Repair( ) Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Add ess or Lot No. Ow er's Name,Address,and Tel.No. Asses r s Map/Parcel y /rC�/ �1 ` nf°n 1 v SQr rf/a j0 (77Y)72 2 —/S 7 Installer's Name,Address,and Tel.No. esigner's Na Address,and Tel.No. �,XLaVaflt)n 77 -lJ S wn , Engr neei c nq sog)ti 3 Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ). Other Fixtures i Design Flow(min.required) 33_6 gpd Design flow provided gpd �,. Plan Date J ' L, Number of sheets Revision Date Al � Title Size of Septic Tank Type of S.A.S. x" Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board He th. Signed Date Application Approved by L Date Application Disapproved by Date for the following reasons , Permit No. 0 W a-- Date Issued c.--- r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS CPrtifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by 'f ���\/,-I at ' / has been constructed in accordance with the provisions of Title 5 and e for Disposal System Construction Permit No.a C 1 — pU'�— dated Installer Designer7po N4-1 G� n TI nt P4, i j #bedrooms t Approved desi ow gpd The issuance o his permit shall not be construed as a guarantee that the system wi 1/ n ion ,designed. Date I �� Inspector ---------------------------------------------------------------------------- -------- ---------------- ------------ ------ No. 1 60 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3pPrmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) M1- System located at , /�(fin( 1^4 o e. Cali) 1:7r 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit Date Approved by �� � FROM :down cape engineering inc FAX NO. , :15083629880 Feb. 24 2015 01:25PM P1 J INC - v VE Thomas F., (PcERcr,Diicctor ' 01 Pubtfu Healthy_T'lvip ma .k�� �b��bu`t!!'�°E?h�!t�'��lle2n➢��l�J.C�Q�,��Qd�,' i Ofane: Sibs-F,62.4644 sa s.-m-630 4 Date: a. r5 sewinga Pe.=iO c�015-- 00� A DAzP\Parerl a Ala ' , , - , - - � )I•���Il���� ---- - � C r eL r1 aa>tr�s�Llf�ii.. �� � � �v=�.� fin.....,.. —..._ was itN;us d a permit to iu.4611 a (date) finstr) 4 $3 tic-yStEiM..Ed � d®r l l r'1/e __baS'A on a design,clydvvn by fizl' T.certify tbat the septic sysftaa refc.7cn(,,Pd above was iamA tll.ed substanf-My accorr_?g to. tlae desigu,-Alob.rrzr include n-linor appro-tud_ changes „ rb. as 1_ rxai xF1c cstinn.ai`''In disttibudon box a,.o. lcta:seak tank. T, certi y that tki. septic 2ysteia rr uemccaft aLovr,was _iitalled-svii:L major. chuages (Lea, grc atc r.than 1.0' lata-ta.1 rclocati.aa of Vie SAS nx any e,adral rclnca-6,on of auy compone'llt of the segfi,system)but in accdrrr-tarlr(:with Sfzv,E 17,oud Rc:galatio:as, 'N=ro-vigion.o:r re,d acl a8-built by rlPST.g ar to:ollo,N. �qH OF 14Aq. DANiELA. '61 OJALA �IIfS'idllFr'Sigifil e} CIVIL No.46502 � F 9TSt � NAL i.gner's Si ait[urG) {1 �6.)chigacri'sStamp Heyo) 13ji LQj4)N. QkRT BICA.T.E_..OF �C.a�1 r a 96r: a._P7{3'A' .-r+ o. �a3 �ra�a�, ssa a��a �g FOW, ..: AR-BUILT,c a ARE T]E4'J :Rb 7[` + °ti�il�Ll' lL��]P�7 �,1ti .AFC➢'➢ IIDAV1810rl. TH.AA]k:YOU A-Upa.-W!Caitirfnmgi"..rCPvtifirafrmFnrm..1-2"4-dnC FROM :down cape engineering inc FAX NO. :150836298BO Feb. 24 2015 01:25PM P2 r��i.u117 / .07 f 1 } f.459'�� } o� Aro f S f / 1 / 734 ' / ra.uP f 44 /f 1;5 ■ ,.rR� LOT Ali 7.6E 20,063 Sq: Ft. opS=DIElLa B o' IL� 67.32 • 44 _ P4DECK 57,67 Ass rsi. 4 U.M. 66. 12' i�.rU .ri 7.73 .19 N67.19 BEDICli MAN—CORNER OF • CMIC.BLUREAD. EL-68.7 l O ti 66 t� ci9 OAK f 67.09 SEPTIC AS-BUILT. PREPARED EXCLUSNELY FOR THE HEALTH DEFT. NOT FOR ANY OTHER USE LOCATION : 35 MOORING DRIVE, COTUIT SCALE : 1" = 30' DATE : 2/24/15 PREPARED FOR: REFERENCE MAP 24 PARCEL 129 B&B EX TTa / 01 N down cape �ngirreering inc. 4AND SURlEYORS DATE REG. LAND SURVEYOR S 9 Mato Street — Y'ARMOLIMPORr. MASS TOWN OF BARNSTABLE LOCATION 3 S I�(�D/`,rK �¢'�y� SEWAGE#_PO/S_ O® VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. !:5J ��Ce.�•c��on ���fJloS� SEPTIC TANK CAPACITY lCoo 6c/ � s LEACHING FACILITY. (type) (size) �u2 3,;Z i x .X�;t NO.OF BEDROOMS OWNERh '� PERMIT DATE: 6' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY P TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE �©e G�•�' /ASSESSOR'S MAP&PARCEL ©a ��s� rya rs INS NAME&PHONE SEPTIC TANK CAPACITY 1 S%Y-D Cz,,\43"\5 a LEACHING FACILITY:(t)pe) Lr br- , i (size) i 00Q NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > $ Feet Private Water Supply Well and Leaching Facility(If any wells exist on . site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BYC1� V O oq I r � O ® 0 o �d � TOWN OF BARNSTABLE Lq�CATION SEWAGE# 1;P VILLAGE ut�` ASSESSOR'S MAP&PARCEL 'S NAME&PHONE NO5 r.' k Gdowu rI 177 SEPTIC TANK CAPACITY /6W LEACHING FACILITY:(type) t'g" (size) /000 g� NO.OF BEDROOMS 3 OWNER Sqc ne fYloan PERMIT DATE: C ATE:=n5 49 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY 56 39 , , 50 3 4 24 \ \ \ 1 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ! f r f r f ! f ! r J f ! f J f f r J J r f ! f r f r r x Mate Servi Mooring Drive m .. m a F m Postage $ C3 Certified Fee dPostmark+,J" Return Receipt Fee ,:Here ' O (Endorsement Required) N C3 Restricted Delivery Fee O (Endorsement Required) P O �! rl! Total Postage&Fees 0 r-3 C3 Mr. & Mrs. Antonio Santiago, 111 '_________________ E 35 Mooring Drive ------------------ Cotuit, MA 02635 4 Certified Mail Provides: t' o A mailing receipt k>✓ 's�' a A unique identifier for your mailpiece 0 A record of delivery kept by the Postal Service for two years Important Reminders: `. a Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. to For an additional fee,a Return Receipt may be requested to provide proof of: delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the'Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. ' IMPORTANT:Save this receipt and present it when making'in ini uir*y. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 ' • Complete items 1,2,and 3.Also com lete - X' item 4 if Restricted Delivery is desired. \I ❑Agent o Print your name and address on the reverse '! ❑Addressee so that we can return the card to you. B. Receiv y(Printed Name) C./Ze of D ive ® Attach this card to the back of the mailpiece, / or on the front if space permits. tz 1. Article Addressed to: D. is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No Mr. &Mrs. Antonio Santiago, III I 35 I�'.00_ring Drive 3. Service Type CotuA# I A 02635 ❑Certified Mail® ❑Priority Mail Express'" ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery I 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (rransferfrom service tabeq =-7 4"' 12 0 b 6 01 0 3 5 8 0 3 3 8 �j PS Form 3811,July 2013 Domestic Return Receipt k UNITED STATESVC 'AL�EFZVICE First-Class Mail ` t !1 ( Postage&Fees Paid USPS .a. Permit No.G-10 • Sender: Please print your name,address, and ZIP+4®in this box* Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 I i ,i Town of Barnstable •�° Barnstable 0—to THE Tp� r� y�PM &1I°� Regulatory Services Department jmcacft • BARNS-TABLE. 9� MAS& 04Public Health Division m ATE°"hA�a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0338 January 19, 2015 Mr. &Mrs. Antonio Santiago, III 35 Mooring Drive. Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 35 Mooring Drive, Cotuit MA was last inspected on 12/04/2014, by Patrick T. Sullivan, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) dueto the following: • SAS shows signs of hydraulic failure/with heavy staining at the top of the chambers • Tank was not opened due to it being under the brick walkway; tank must be made accessible. • Distribution box showed signs of back up and solid carry over You are ordered to repair the septic system within sixty (60) days from the date you receive this notification by either(a)replacing the rear cesspool with a TITLE 5 compliant system or(b) hiring a licensed plumber to reconfigure plumbing to front Title 5 septic system. A permit must be pulled to properly abandon the single cesspool. Failure to repair the septic system within the deadline'period will result in future enforcement action. PER ORDER OF HE BOARD OF HEALTH Th as McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\35 Mooring Dr Cot Jan 2015.doc kV9) 1N snnopuiM : uaajsnS eui}eaado luunjj : aweu aasn Jf668H11d3H auaeu jajnauaoo Wd°'IZI4)al600 (ieaaal a�aeda ,,gda5saaaaall)I1d351a1! aaea5 ! , r ib 4 lm uohand�suo3 r a G r uoileoo� oijdoS'se0'aajeM slignd sa!i!pn i Paned" peon IaAa1 dydea6odol E 3� E �O10 P496N �� �a'6uiuoZ 10-1OW uae�ai6u!Sk asn �_ Wo saaoy PIT 01 009z0a diz aae;s llloo AID zaaaaas ... ._a0 JNIa00W 5€ Paeals ^ !o mo III OINOlNV'OJVI1NVS aaumo au 0 ;tt _ n Mull M _ �t b THO A t — 4,4 deW an.l�eaawI I�fi;�tiCl I y :ueoS a!ldaS ll!nQsb .. OU06,I saPu 0 ,ssaappe siglle slslxa AaMas uMol 4 IPeo N a 1If110O�aou�sia aaij ll(1100 a6epi� a6e�uoa�oag peon oas . .. L tiZ61.a6ewoa j iad jAIaO ONIa00W 9E''uoi�e)ol II1101 ao�aedo�ana4 6Z6"1rZ0 4I1111ed u e - � ��z � �z , •Lam � �. l��J'�u����� . cXdse' a'),IF�dr`pjppnoA Yuej�!IZIbssi TZ z. X lieaap laed ^ CD TV 3 E d o , o . L------------- iQ Commonwealth of Massachusetts 92) Title 5 Official Inspection Formo � a� a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' 35 Mooring Drive Property Address Fawna Santiago _ Owner Owner's Name information is MA 02635 December 4, 2014 required for every COtUIt _ _ 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. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: key to move your p cursor-do not _Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating Company Name P.O. Box 89 Company Address Forestdale _ _ _ MA City/Town State Zip Code 508-888-6055 _ S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority I December 5, 2014 _ -- 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. j 1 &/11/1 y tSins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive _ Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA _ 02635 December 4, 2014 page. CityrFown 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: 7z-- 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. �/ i ' 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 ❑ N '(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 'uM 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit _MA 02635 December 4, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more tha�4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with app oval 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 isjRequired by the Board of Health: ❑ Conditions exist whi h require further evaluation by the Board of Health in order to determine if the system is failing o protect public health, safety or the environment. 1. System will p ss unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 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 SA 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 S�AS 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 pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ilure 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 '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 _ _— — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the syste/question n 4 0 feet of a surface drinking water supply ❑ ❑ the syste200 feet of a tributary to a surface drinking water supply ❑ ❑ the systeed in a nitrogen sensitive area (Interim Wellhead Protection Area— IWmapped Zone II of a public water supply well If you have answered "yes" to ion in Section E the system is considered a significant threat, or answered "yes" in Section De large system has failed. The owner or operator of any large system considered a significa�nnder Section E or failed under Section D shall upgrade the system in accordance with 3/10 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 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,.4 •'°c 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. City/Town State Zip Code Date of inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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 GPD t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013= 129 GPD g ( y g (gp )) 2014= 112 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): � Gallons per day(gpd) Basis of design flow(seats/le: Grease trap present? ❑ Yes ❑ No Industrial waste holding tan ❑ Yes ❑ No Non-sanitary waste dischastem? ❑ Yes ❑ No Water meter readings, if av t5ins•3I13 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 °.� 35 Mooring Drive Property Address -- Fawna Santiago r Owner Owners Name information is required for every Cotuit MA 02635 December 4, 2014 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: Owners records: Pumped Feb. 2011 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: M 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name -- information is required for every Cotuit _ MA 02635 December 4, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: Septic tank and leach pit installed 11/13/1980. D-Box replaced Feb. 2011. Certificates of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'3" feet Material of construction: ❑ cast iron ❑ 40 PVC ABS ® other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 4"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1 V X 4.5'X 5' 1500 Gal. _ Sludge depth: 4 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 35 Mooring Drive Property Address Fawna Santiago _ Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 4" at inlet 2" at outlet Distance from top of scum to top of outlet tee or baffle $ Distance from bottom of scum to bottom of outlet tee or baffle 10" — How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee and concrete outlet baffle in place.Liquid level at outlet invert. Inspection ports over inlet and outlet access. Tank is showing signs of corrosion. Recommend replacement with new SAS. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal/outlet lass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to tffle - — Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive _ Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: � ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working 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•3/13 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 35 Mooring Drive Property Address Fawna Santiago _ Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 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 11 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.): One inlet, one outlet. New with riser within 4"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments note condition of um chamber, con um s and a urtenances etc. : ( P P , pumps appurtenances, ) 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•3113 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 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 ___ page. City/Town State Zip Code Date of inspection D. System Information (cont.) Type: ® leaching pits number: 1-6' X 6'w/ stone. ❑ leaching chambers number: - ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level 1" below invert at time of inspection. Light high water staining at inlet invert. No visible holes in sidewall. No available storage in leach pit. System is in failure and needs to be replaced. 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 j Indication of groundwater inflo / ❑ Yes ❑ No t5ins•3/13 ! Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Mooring Drive _ Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ondin condition of vegetation,P etc.): 9 Privy (locate on site plan): f Materials of construction: Dimensions Depth of solids — Comments (note condition of 7so', 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Moo_rind Drive Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately f i .AJI -% I I I I I + I I e OX t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive _ Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 —_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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. 1980 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous Title 5 Inspection 2011. ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole at#80 Mariner Circle in 2011 found no ground water at 12'. Base of SAS 8' below grade. Accessed local ground water contours and topo mapping. Adjusted ground water at 35'+-. Property elevation is at 68'+-. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 35 Mooring Drive _ I Property Address Fawna Santiago Owner Owner's Name information is required for every Cotuit MA 02635 December 4, 2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 — 3UW Tom of Barnstable . P# y' IDeparti naaut of Regulatory.Services n > ��� Public Health Division Date l( r aa3A. 200 Main Street,Hyannis MA 02601 Date Scheduled e� ` ✓ Time �!•oQV , . �����. Do av Soil Suitability Assessm' entfor S IS ' Performed•By:_V�h -e I 17G � t(�E Witnessed By: / ORMT Location Address �� ,6 6 ✓� Owner's Name "moo Address Assessor's Map/Parcel: Z� !Z Engineer's Name J Q V__ NEW CON S T RUCTION REPAIR Telephone# Vd Land Use: W� � Slopes(%) 0 Surface Stoues �r�✓1 Distances from: Open Water Body ft Possible Wet•Area�O�. $ prinking Water Well I tVo ft Drainage Way �t ft Property Ling (� ft Other ft SIC ETCH.,(Street name,dimensions of lot,exact locations of test holes&pore tests,locate wetlands•tn proximity to boles) -m - \, N O %� ® Ul Z Parent material(geologic) ` l� � � Depth to Bedmck Depth to Groundwater. Standing Water in Hole: !V/ - Weoping from Pit Eaca. ( / Estimated Seasonal High Groundwater /yr DIETERIMNAUON FOR SEASONAL HIGH r i Method Used: Depth Observed standing in obs.hole: In, Dnptli to-soll"mottlt s:. In, Depth to weeping from side of obs,hole: In, Groundwater Adjustment ft. �I{ Index Well# Reading Date: index Well lcvol __ Ad(,Actor- Adj.Growidwater Level, s RER.COLA.TION T +'ST Date._.,,T_,.., Time___�__t Observation Hole# Tlma at 9" Depth of Pere. Time at G" Start Pre-soak Timm @ Time(9"-0) End Presoak ,fin 4 Rate Min.fluch /'� Site S�uitablll�Assess �t;--Site Passed- _.. ___.�— Siti7 Fulled: /~ Additional Tes[ini Needed(Y/N) Original.- Public Health Division Observation Hole Data To Be Completed on Back---=---- • ; ***I£percolation toast is to be conducted witbin 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(A)week prior to beginning. Q:\S l?PTIC\PBRCFORM_D O C DREP.OBSER'VATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture .Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure, Stones;Boulders, o i tcn;y�96'Cravcll 0 - 0 10 z s l - 13z (0 4? -------------- LL�GP'•013SER`V.ATION'HOLE LO.G• Depth frorn Soil Horizon Soil Texture Soil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis en 35 rave lh t -5;L OYA 2� Y � DEEP OPSERV'ATYON HOLE LOG Hole k Depth from Soil Horizon Soil Texture Soil Color Soil Other' Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. conFiLtmu,Iro 0 e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sall Color 5oll Other Surface(in.) (USDA) (Munsell) Mattling (Structure,Stones,Boulders, Co si ten 6 ' • v y Flood Insurance'Rate Map: Above 500 year;flood boundary No� Yes 'Within 500 year boundary No Yes ' Within 100 year flood boundary No-Z 'Yes. Depth of NaturaHy Occurring Pervious Material Does at least four feet of naturally occurring pervious mtiterial exist in all areas observed throughout the area proposed for the soil absorptibn system? yZ S If not,what is the depth of naturally occurring pervious material? ce ti iication I certify that on_�X//12— (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 requited training,expertise and experience described in�10 CMR 15.017. Signature ' Q:1S,Bl''I'lC1T'L�1tCPORM.nOC • No. �Z �.I t ` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Migoaf 6pgtem Comaruction 30ermtt Application for a Permit to Construct( ) Repair 6/` Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �ti�� C.0�Vd vv,, s— ,I7Y_oPS_` ?5 Installer's Name,Address,and Tel.No.' -- '(, Designer's Name,Address and Tel.No. 3 7( Sit-tea-6e�S� Type of Building: Dwelling No.of Bedrooms 3 Lot Size L46 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed � Date a I05acw I Application Approved by (Q/��.�� Date T' � Application Disapproved by: Date for the following reasons Permit No.ab 1( — Q L4 Date Issued W No. g-D I l/`t a . r Fee _�-�- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Wiration for ig o5aY *pgtent Congtruction Permit Application for a Permit to Construct O Repair(vf Upgrade O Abandon O ❑Complete System [: f Individual Components Location Address or Lot No. 3S w1 `^ �w�' —' „`I Owner's Name,Address,and Tel.No. t'�gw�a SVJv���wQ +� — Assessor's Map/Parcel Yvl� QD rj 9<-I— Installer's Name,Address,and Tel.No.`F�=� Designer's Name,Address and Tel.No. p,o. 3Z��j- 1 W !a— ram-6v sS" Type of Building: Dwelling No.of Bedrooms 3 Lot Size eL-(6 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health.. Signed Date Date Application Approved by {�1 �(jl/LZl Date Application Disapproved by: Date for the following reasons `I Permit No. a 1( 0 u Date Issued THE COMMONWEALTH OF MASSACHUSETTS a BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired<(� Upgraded ( ) Abandoned( )by �,o at 3 5- Y"/\an..r-"••.� ^1 �,�` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 a l I - t�1/ a .4 dated .2 _4 $= m Installer n ' Designer #bedrooms t,V ,A Approved design flow AJ A— gpd The issuance of thi�hall not be construed as a guarantee that the system will fu ction as designed. Date �a Inspectors rtN. r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS x1i9po5al *p.5tem Corr,5truction permit Permission is hereby granted to Construct ( ) Repair (✓ ) Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date Do I I — (h L4 Approved by YY'L vy-\ t j t tom- • t lu 12,0001 Imp . tV. 4 A' r . - • •' � '• r ' � a or 'Y `�s n�4a(- 4$ �.tf*}.1` 1. ,�s '�' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Li Cory y 35 Mooring Drive, Property Address Fawna Santiago , Owner Owner's Name information is required for Cotuit MA 02635 February24, 2011 every page. City/Town State Zip Code Date oflnspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the (�onlycomp the tab key uter,use 1. InSpectOr: to move your Patrick T. Sullivan cursor-do not Name use the return of Inspector key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich MA 02563 Cityfrown State Zip Code 508-888-6055 8112843 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 Q Title 5(310 CMR 15.000).The system: - C Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - •-,,I c?o �--�� February 28, 2011 � c�a inspectors 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 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pag�1 J `Yf 1 I Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'f 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for ry Cotuit MA 02635 February 24, 2011 every page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yesn, "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•09/08 il Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 4 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p� 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name y information is required for Cotuit MA 02635 February24, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box is cracked and leaking. System "Passes"once D-Box is replaced and inspected by the Barnstabled Board of Health. Certificate of Compliance from permit will be issued upon replacement of D-Box. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which requir/dHe valuation b the Board of Health in order to determine if the system is failing to protecalth, saf y or the environment. 1. System will pass unless Hea determines in accordance with 310 CMR 15.303(1)(b)that the system ning in a manner which will protect public health, safety and the environment ❑ Cesspool or privy is et of a surface water Cesspool or privy is et of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z 35 Mooring Drive Property Address -Fawna Santiago Owner Owner's Name information is . Cotuit MA 02635 February 24, 2011 required for ry every 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 so' absorption system (SAS)and the SAS is within 100 feet of a surface water supply r tributary to a surface water supply. ❑ The system has"a septic tank an SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tan nd SAS and the SAS_ is within 50 feet of a private water supply well. ❑ The system has aseptic tank and AS and the SAS is less than 100 feet but 50 feet or more from a private water suppl well". Method used to determine di nee: "*This system passes if the II water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided at 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is Cotuit required for MA 02635 February 24,2011 every page. Cityrrown state Zip Code .Date of Inspection B. Certification (cunt.) ' Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified • laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in.310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to.15,000 gpd. For large systems, you must indicate either"yes" o no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 0 feet of a surface drinking water supply ❑ ❑ the system is wit n 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is I sated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWP or a mapped Zone II of a public water supply well If you have answered "yes"to y question in Section'E the system is considered a significant threat, or answered"yes"in Section above the large system has failed. The owner or operator of any large system considered a signifi nt threat under Section E or failed under Section D shall upgrade the system in accordance wit 310 CMR 15.304. The system owner should contact the appropriate regional office of the D artment. t5ins•09= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 5 r Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �l 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist , Check if the following have been done.You.must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 'Was the facility or dwelling inspected for.signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El 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: 110 330 GPD ( p gpd x#of bedrooms): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 every page. CitylTovvn state Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: , Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2009= 77 GPD g ( y g (gPd))' 2010= 197 GPD Detail:. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the itle 5 system? ❑ Yes ❑ No Water meter readings, if availabl . t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February24, 2011 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: Owners records: Pumped 2009 Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,_volume pumped: gallons How was quantity pumped determined?- Reason for pumping: Type of System: ® _ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 every page. Cityfrown. state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: System installed 1 111 3/1 9110. Date of Compliance on file at Board of Health (as-built). • Were sewage odors detected when arriving at the site? ❑ Yes ® No ` Building Sewer.(locate on site plan): 1w3" Depth below grade: feet Material of construction: ❑cast iron ❑ 40 PVC ® other(explain): ABS Plastic Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate'on site plan): 4„ Depth below grade: feet Material of construction: ® concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑, Yes ❑ No Dimensions: 1 V X 5'X 4.5' 1500 gallons Sludge depth: 3e t5ins•09/08 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 35 Mooring Drive Property Address Fawna Santiago. Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 381 Scum thickness 1/2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet ABS tee and outlet concrete baffle in place. Liquid level at outlet invert. Inlet and outlet access covers are inspection ports. Grease Trap (locate on site plan): Depth below grade: e feet Material of construction: ❑ concrete ❑ metal ❑/rglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scu /of e or baffle Distance from bottom of outlet tee or baffle Date of last pumping: Date t5ins•09= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago d Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 _ every 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 ❑ metal ❑/erglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: ` gallons Design Flow: gallons per day. Alarm present: ❑ Yes ❑. No Alarm level: t Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February24, 2011 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): D-Box is not structurally sound and showing signs of leakage. D-Box need to be replaced. Very little solids carryover. No sign of high water staining over outlet invert. Pump Chamber(locate on site plan): Pumps in working order:. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump/amber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Me 5Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Mooring Drive Property Address , Fawna Santiago Owner Owner's Name information is required for Cotuit MA _ 02635 February24, 2011 every page. City/Town state Zip Code hate of Inspection D. System Information (cont.) Type: leaching pits number: 1-6'X 6'w/ stone. ❑ leaching chambers number: ❑ ." leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology-. Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Liquid level in leach pit 11"below invert at time of inspection. High water staining 10"below invert. Two course of holes w/clean stone visible with mirror. Hand probing around leach pit found 2.5'of dry stone. No sign of past hydraulic failure. Riser brings cover within 6"of grade. 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 a Indication of groundwater inflow ❑ Yes ❑ No t5ins•09= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 every page. city1rown 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,si ns of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rt 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for , Cotuit MA 02635 February 24, 2011 rua every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) 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 � i pt•:�c��'�i I e i . f c z L) ON t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 35 Mooring Drive Property Address Fawna Santiago Owner Owner's Name information is required for Cotuit MA 02635 February 24, 2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked . ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r No. t�' U a Fee ` .�- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Miopo$al &pgtem CongtrUction Permit Permission is hereby granted to Construct ( ) Repair (� Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. (J P,5 Date Approved by THE COMMONWEALTH OF.MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (Z Upgraded ( ) Abandoned( )by at W\ao J-'tr� ,;� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a a i! U �- dated 2— Installer Designer #bedrooms AAA- Approved design flow gpd The issuance of thi perm shall not be construed as a guarantee that the system nNiao designDate �} �/ Inspector � Commonwealth of Massachusetts ' u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 35 Mooring Drive Property Address Benjamin Stateman Owner Owner's Name information is Cotuit MA 02635 January 27 2009 required for ry every page. Cityrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way tr►,portllin filling ng out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name f 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority January 27, 2009 Ins ector'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. 09-10 Slateman.doc•08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 35 Mooring Drive Property Address Benjamin Stateman Owner Owner's Name information is Cotuit MA 02635 January 27, 2009 required for Y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of.Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pit had never been more than 2/3 full. B) System Conditionally Passes: ❑. One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup.or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced, ❑ obstruction is removed 09-10 Stateman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''~ 35 Mooring'Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit MA 02635 January 27, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont) B) System Conditionally Passes (cont.): distribution box.is leveled or replaced ND Explain: ❑ The system required pumping more than 4 tim es a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced . obstruction is removed ND Explain: C) further Evaluation is Required by the Board of Health: • ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within.50 feet of a bordering vegetated wetland or a salt marsh 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. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ` 09.10 Stateman.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts F Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit MA 02635 January 27, 2009 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ®, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09.10 Stateman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is COtUIt required for MA 02635 January 27, 2009 every page. 'City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] :❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 101000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no' to each of the following, in addition to the questions in'Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system.in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09-10 Stateman.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,,a,••''• 35 Mooring Drive Property Address . Benjamin Stateman Owner Owners Name information is required for Cotuit MA 02635 January 27, 2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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)] 09-10 Stateman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit ' MA 02635 January 27, 2009 every page. Cityrrown State Zip Code Date of Inspection 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 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? El Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 12/26/08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): -- 09-10 Slaleman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is CotUlt required for MA 02635 January 27, 2009 every page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 4/23/08 and every two years prior. 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) ❑ Tight tank. Attach a copy of.the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 11/13/80 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09.10 Stateman.doc-08106 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit MA 02635 January 27, 2009 every page. Cltyrrown State Zip Code Date of Inspection D. System Information'(cont.) Building Sewer(locate on site,plan): 1 . Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC^ ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): -Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a.Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 09-10 Staleman.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °�M •'" 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is COtUIt required for MA 02635 January 27, 2009 every page. Citylrown 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.): Baffles intact and clear, liquid level found at bottom of outlet invert Tank is not in need of pumping Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑.concrete ❑ metal ❑ fiberglass ❑'polyethylene ❑ other(explain): 09-10 Stateman.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit MA. 02635. January 27, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level:' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): g , No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-10 Stateman.doc.•08I06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit MA .02635 January 27, 2009 every page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of,pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: El leaching trenches number, length: ❑ leaching fields number, dimensions: El 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.): Leaching pit had 12-14"of standing water at time of inspection, root infilration indicates pit had not been more than 2/3 full. 09-10 Stateman.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Di- g Disposal System Form Not for Voluntary p Y u tary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is COtUIt , required for MA 02635 January 27, 2009 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)` 09-10 Slaleman.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Mooring Drive Property Address --- _ -------------- ---- --- - — Benjamin Stateman _ Owner Owner's Name information is Cotuit _ MA. 02635 January 27, 2009 required for ry every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 56 39 50 3 ,.A. 4 24 / ; / / Water Service Mooring Drive t 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Mooring Drive Property Address Benjamin Stateman Owner Owners Name information is required for Cotuit MA 02635 January 27, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: pate 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: USGS topo map and town GIS. You must describe how yob established the high ground water elevation: Town groundwater contour map shows water at el. 30 and topo map shows property at el. 60. 09-10 Staleman.doc•06/06. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 L OC A T ION ''• SEWAGE PERMIT NO. // �-e. Zo - 3,:5-0 _ V I i L A G E I N S T A LLER'S NAME i ADDRESS ALDER OR OWN ER �- DATE PERMIT ISSUED -7 15_kt� DATE COMPLIANCE ISSUED �� ram, � �� � � S d0 � W � W � V-� .. fi d _� �. �� �ri , ,�? ,,. No...... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD H;7MT .............0F..... ................................................... Appliration for Dispnoal Vurkti Towitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syslem,at* - I ......... -0`00000��...................................................................... Locat* dress r Lot No. ........... .. ........................... . ............................. OW6 . ,e.r n 0. ........ .. ----------- -------- ►Wa Installer Address Type of Building Size Lot.410,.6k2.....Sq. feet U 3.......................Expansion Dwelling—No. of Bedrooms--- Attic Garbage Grinder 1­ No. of persons..........(P.............. Showers Cafeteria Other—Type of Building A4 i Otherfixtures ............................ ;**---------------------------­"-------------------------*---------­------- -------------­----------- Design Flow.............63 ............ ----gallons per person per day. Total daily flow.........3:3.0................_._....gallons. WSeptic Tank—Liquid capacity. Length-_- Width..'Y_Ik�p.... Diameter................ Depth................ Disposal Trench—No. .................... Width ....... Total Length..._................ Total leaching area....................sq. ft. Seepage Pit No............/...... meter. .... Depth below inlet_,25....... Total leaching area..,.:02-�-....sq. ft. Diameter..' .... X4.Other Distribution box (j Dosing lank 1.4 �_ ..........Percolation Test Results Performed b ......... .............. .. Date......_..........._..........._......... Test Pit No. I................minutes per inch Depth of Test Pit.__.__............._ Depth to ground water.._. -------------- - y...- 44 Test Pit No. 2................minutes per inch Depth of Test Pit..____......._..___. Depth to ground ............ P4 ............ ......... . .... .. ........................................................................................................................ 0 Description of Soil..O.-.k.... ......................................................................................................................... U ................................&_:�:30.............. ....... - ----------------------*.......*---------------------------------------------------------------------------- ---­--------------------3°7,/k4r.......... ... ... ..... .........................................................:-----------------------*-----------*,*,-*--------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAI'= - 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,iAued by the_b --of h Ith. a�te S' .......................... ............. .. ............................ . ........ ...... .... ....... Application Approved By...... AVd . Date Application Disapproved for the following reasons:................................................................................................................ .........................................................................................................I............................................................................................... Date Permit No....r__ Issued.- ................... D e ............... THE COMMONWEALTH OF MASSACHUSETTS o BOARD OF HEALTH ,t Appliratiun for 11iupuuttl Works Tuntrurtiun Frrutit Application is hereby made for a Permit to Construct (><) or Repair ( ) an Individual Sewage Disposal System at• f ..... ........ - ..... .... ... --••--•. f / /� Location yAildress or Lot No. W ......................_.. ....................: ............. Tj •- ......--............................. J Y a - ................................ .......................................... •---------...----._____.........----•----•-•------•-•--•--J-....__-•--•--_�.................. / Installer Address Type of Building Size ......Sq. feet U Dwelling—No. of Bedrooms...........:..:.. ........... Expansion Attic ( ) Garbage Grinder ( ) -----•-- pa, Other—Type of Building Zk ..... No. of persons.........4.v.............. Showers ( ) — Cafeteria ( ) Q' Other fixtures .......................-•.............................................................. W Design Flow..................5�.....................gallons per person per day. Total daily flow......... .x_�.......................gallons. W Septic Tank—Liquid ca.pacity/�'c .gallons Length..` y -`j--_1 ..... Width. 6....... Diameter................ Depth................ x Disposal Trench—No..................... Width.............. Total Length............... Total leaching area........._....sq. ft. Seepage-Pit No.-_---__._1_...... Diameter....... .......... Depth below inlet..'2..3........ Total leaching area._:5.6: sq. ft. Z Other Distribution box (l ) Dosing tank (f ) q �"� .E! l ....* J dYrr. '.. Percolation Test Results Performed by....................... .... . .__.........__.__...___...._:..__. Date........................................ ,aa Test Pit No. I................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.. ___......__......._.. Descriptionof Soil_..:::- = .............."...."•"""•-""-"-••--"-"---•-......"--"-.....--"--------"""""""--""•---""-""--"-"""""-""-"-...."""•-""""--• U 1 ----------•---••--•.... f` ` U Nature of Repairs or Alterations—Answer when applicable.___ _.. ....."................................................................. ..--"---"""-"-......""-"---"---""""................."-"""-""--"-"-""....------•....._...__----._..........................-• ••--..._._....-----•.......--•-•••_...•-•--.....................-•--...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of�iTLE y g - g p y 5 of the State'Sanitar Code,—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. .----- --�,-----------------------------------—• /G ate Application Approved BY = ... ...........:....................... --.. !!:.j..................... Date Application Disapproved for the following reasons:-----"-•------""-"--"""---•••---""--""-:-""-"""-----•-""-----""-"--"--"-""-":"-•--= } Date PermitNo........................................................... Issued........................................................ Date - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' w. Jc . t .. Trrtif iratr of Tout Rana THIS IS TO CERTIFY-,That the Individual Sewage Disposal System constructed (%/I or Repaired ( ) by VV C..................f/_,.......r . r t ..-.vf`. ...."""-"•-""""-"--"--"-" ". ................-- "--._....--------""............ =••_!........................... ................................... .iez- --�""""" J ........................................................... Fig- � � .1.� •r. has been installed in accordance/with the provisions of T j off The State Sanitary Code asdescri ed in the application for Disposal Works Construction Permit No. ...... ............. dated__:. `'./.$__!r: ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...--""--- . /..3�eO....... ..........-"-•---"--•--"---------. Inspector_..!&------ /VZ.................................................. THE COMMONWEALTH OF MASSACHUSETTS �// --- BOARD /OF HEALTH € OF...........}......c............... .......................'r`.. No........ :;-:: .: FEES .............. Y Disposal Worki5ATunutrnr#uan famit Permission is.hereby.granted......L✓ l............. /'"1/ice / "-----:""...............•----•-•"-" to Construct (,, ) 'or'Repair ( ) .an Individual Sewage Disposal, Syst�r at Nod_.�.._"-- " ±... t t '" �. .�/ / /z •-•---....... r _ r �•--•-• :.. , �l t -- i '\. Street ............. YC" livv z° C R` ' as shown on the application for Disp�al Works Construction Per No....._ .:_ ated.....�-._� `' � ` ............;;... ��'" .................. Board of Health ��� DATE....>" .Is._:_... .............................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �" �. . x' ^�•_ 1 F.FL. ELEV.=�1Xc) FINISH GRADE _ �X`� FINISH GRADE FINISH GRADE TOP OF FOUND., OVER TANK = (�,-lX,7) OVER PIT �Xv ELEV. _ .%'X.'� • CHIMNEY BLOCK BACKFIL`l\` 3' PEAS TONE 4" C.I. - \ WHERE NEEDED DWELLING - 4 V.C. 4"V.CJ ., . . I U:---z I ­ o O O O o ' o v 0�,, 61x , , . •_a • •° '�• �, `. ,° � O O Q O o � ° � 3/4" TO I-i/2�� �= GALLON -- r' CELLAR FLOOR ��- b 9 0 ELEV. = oe-'x� REINFORCED GONG. p o O O O o . J ,� p� CRUSHED STONE b v o 0 O O o � �! • • FIST. BOX o O o �+ -- � � o . a o o O o o ° �►- (TO BE LEVEL v o O Q O o v BOTTOM OF PIT SEPTIC TANK -r ° a 9 ' AND STABLES /� 0 O O O o • ° � 4 �� ELEV. SYSTEM PROFILE 8 ( NOT'TO SCALE) LEACHING PIT DESIGN CRITERIA NUMBER OF BEDROOMS = GALLONS PER DAY I � .. Ja GARBAGE GRINDER = ✓U /� TOTAL DAILY FLOW = -' `� 'LDTi/�+ SD' �i/ �J 06 i. LEACHING AREA PROVIDED = IN tV PP SOILS LOG hLP " I ��y I�'�T b r 0" ELEV. = f I .n? ♦'�Nk '� I I ---- -7,a 7 ,-- �a��//,1 Al PROPOSED SEWAGE DISPOSAL SYSTEM • �� PROPOSED DWELLING INSPECTED BY: . DATE MASS � - PERCOLATION RATE MIN./INCH SCALE AS NOTED „ DATE /I/ OWNED BY 7J, IS -+ NORMAN GROSSMAN PE., R.L.S. 226 HOLLY POINT ROAD CENTERVILLE, MASS. l NOTES SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR 1. DATUM IS APPROX. NGVD (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 2, MUNICIPAL WATER IS EXISTING o ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 67.6' 67.2f' 4. DESIGN LOADING FOR ALL PROPOSED PRECAST MINIMUM .75 OF COVER OVER PRECAST 2% SLOPE REQUIRE OVER SYSTEM UNITS TO BE AASHO H-M o R� c5 PRECAST H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT. o �n�tie Go R2S�ERS TYP. 4"9sSCH40 PVC o 6°b v 2" PEASTONE OR GEOTEXTILE 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE PIPES LEVEL 1ST 2' o FILTER FABRICI EVER STONE WITH 310 CMR 15.000 (TITLE 5.) 64.2 10" EXISTING 14" :y 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND �„ ' y ` EXIST* TEE 1000 GAL H-10 TEE 65.62f' s~ MIN. SUMP , o00000000000000000000000000 00 0000 SEPTIC TANK** °°°°°°°°°°°°°°°°°°°°°°°°°°°°°° ° °O°°°°°°°°°°°°°° °°°°°°°°°°°°° NOT TO BE USED FOR LOT LINE STAKING OR ANY 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00001010090900090,0 0°o°0°ogogoo 12" MIN. INT. DIM. 63,7 000000000000000000000000 �_ 0 0 0 0 ° o °o°o°o°o°o°°°o°o°°°o°o°o°0°0°0 0 00 oo°o°0°o00°0 °o°o°o°o°o°o°o , OTHER PURPOSE. '-oo�a?�°�°- °oo0°0°000°0°0°0°00000°00000°0 0 0°0°0°0°00000°0 °00000°0°0°00o r LOCUS ADD GAS BAFFLE: o00000000000000 00000000000000 61 .54 4' LIQ. LEVEL (ACME OR EQUAL) Cb 8. PI FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 63.91 63.78' 4" PVC SET AT 00"�'/' SLOPE E C S J� P ' ,,,.r•. • �ON 2' DOUBLE WASHED 3/4" - 1 1/2" STONE J 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF 5.34' HEALTH AND PERMISSION OBTAINED FROM BOARD 6" CRUSHED STONE OR MECHANICAL OF HEALTH. COMPACTION. (15.221 (2)) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND ( 5.4% SLOPE) ( 1 % SLOPE) VERIFYING THE LOCATION OF ALL UNDERGROUND & LOCUS ��� BOTTOM TH 1 ELEV. 56.2' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF FOUNDATION EXIST. SEPTIC TANK 31 D' BOX 10' LEACHING WORK. FACILITY NOT TO SCALE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE* AT SHALL BE REMOVED 5' BENEATH AND AROUND THE UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE PROPOSED LEACHING FACILITY. ASSESSORS MAP 24 PARCEL 129 I PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE 12. EXISTING LEACHING FACILITY SHALL BE PUMPED CONDITIONS IF NOT SUITABLE AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND 67.07 SAND. / 07 99 - / EXISTING CONTOUR X 99.1 EXIST. SPOT ELEV. / -[99]- PROPOSED CONTOUR /6. a O� 1 198.41 PROPOSED SPOT EL / I TH1 ,x 6.43 � TEST HOLE , �►` // 6 I m YYY pp / SYSTEM DESIGN: 2i% SLOPE OF GROUND / 21 O O � n GARBAGE DISPOSER IS NOT ALLOWED c� UTILITY POLE T N FLOW: 3 BEDROOMS 0 110 GPD = 330 GPD / 67.84 DESIGN FIRE HYDRANT NOTE: NOT ALL SYMBOLS MAY APPEAR IN oRAwINc -__ / `� 8.02 6 2 USE A 330 GPD DESIGN FLOW X .6' 44 SEPTIC TANK: 330 GPD (2) = 660 35 TEST HOLE LOGS N � �5 g 60 RE-USE EXISTING 1000 GAL. SEPTIC TANK ** X 5 6 LOT 111 6 . 7.86 LEACHING: ENGINEER: DANIEL E. GONSALVES, SE #13587 Yo 20,063 Sq. Ft. EXISTING DUELLING TOP OF FNDN. `10), 12'�F 4 SIDES: 2[2 (32 + 3) 2 (.74)] = 207 GPD _ EL. 69.24 BOTTOM 2[32 x 3 (.74)] = 142 GPD WITNESS: DONNA MIORANDI, RS �RyEAo 6 .35 A 67.32 DATE: 12/31/14 1�S. -7.8QECK 67.62 6 , " OAKS _ < 2 MIN/INCH � TOTAL: 472 S.F. 349 GPD PERC. RATE - .39 �7.0 / TH1 CO USE (2) 32' LONG x 3' WIDE x 2' DEEP CLASS I SOILS P# 14610 6g. 4 67.56 LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE i 68.6 12" A 18" OAK ELEV. ELEV. 67.60 6 .62 67.73 % 0» 4 67.2' O" 4 67.2' ®6 6 ®.58 X 6 7.19 � 7 � A q Lu 10 0 LS LS AKS BENCH MARK - CORNER OF ' % _ MA 10YR 3/2 10YR 3/2 CONC. BULKHEAD. EL. = 68.7 / 0 QV 6 12" OAK APPROVED DATE BOARD OF HEALTH 1 off12 s� A �7. B B = `-- ' 6p X61L�'v X 66.92 TITLE 5 SITE PLAN LS LS \ 3 0 �6, 4 OAK OF � 10YR 6/6 10YR 6/6 � � � SHED 24„ 65.2 25 65.1 ��. 35 MOORING DRIVE C, C, COTUIT, MA SiL SiL PREPARED FOR 1 OYR 5/4 1 OYR 5/4 x 67.09 35„ 64.3 36 64.2 B&B EXCAVATION/SANTIAGO O �`L<� PERC DATE: JANUARY 6, 2015' / / AS 1 �tH OF Mq S off 508-362-4541 M CS M CS sgcy �ya`� 9cy fax 508-362-9880 2.5Y 6 4 2.5Y 6 4 ��� DANIEL A. GC m �o DANIEL L�m� I downcape.com / / o OJALA - � A• CIVIL OJALA down cope endineering inc. 132" 56.2' 132" 56.2' �No.465020 No.40980 1f „ , °'6, /STE��,��'.y °cFSS���QQ civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 �_Zc0\5 sS10NAL ENG gNDSURJ land surveyors 939 Main Street ( Rte 6A) c' 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 DCE # > 4-3u 6 14-366 B&B-SANTIAGO.DWG 1