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0061 MOORING DRIVE - Health
SMEAD KEEPING YOU ORGANIZED No. 10330 153L Tor M"PIYMQD POSTOMMM UMMUSA GET ORGANIZED AT SMEAD.COM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w ,M 61 Mooring Dr Property Address -C Andrea Gualtieri Owner Owner's Name information is ay required for every Cotuit ✓ -' MA 02635 4-29-16 page. , rt City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any m way. Please see completeness checklist at the end of the.form. A. General Information + 1.• Inspector: . • ;� .. 'it`. y,_ h., t 7 R Shawn Mcelroy Name of Inspector Upper Cape Septic Services - Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 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..)am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes; +, ❑ ,Conditionally Passes, ❑,Fails • E Needs Further Evaluation the Local Approving Authority ,t , *. t, L 4-29-16 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 e the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 . M r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 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: System is in good working order with no sign of failure. Recommend pumping tank and pit every 2 years for maintenance and to prolong life. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. ' . The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments ' �M 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is Co '`' MA 02635 4-29-16 n" i, r required for every 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 k pass inspection if(with approval of Board of Health): v }�,, r - _ ❑ 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 t ❑ 1 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 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:, 'k Tr , i } ' �❑ Cesspool'or privy is'within"50 feet of a+surface water ❑ Cesspool or p'dvy is within 50 feet EofDa bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ ® r clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to'the surface of the ground or surface waters due to an overloaded or clogged'SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6° below invert or available volume is less �' ® than 1/Z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts `•' - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments - ,M 61 Mooring Dr i Property Address Andrea Gualtieri .� Owner Owner's Name information is Cotuit ; - MA 02635 4-29-16 t' required for every •' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: t '� ❑ Ze • Any portion of the SAS, cesspool or privy is below high,g'round water elevation. ❑ .® , , Any-por'tion 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. .e 'a yam• , a,+. .�, � _. .- �f ' ..+• ",a r a. � �. .. ❑ ® 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 fi `•" " ' system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence 4 T . 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- f . E ® 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., i• E) 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 D.- Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply' ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑, ❑ Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question'in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system.owner should contact the appropriate regional office of the Department. t5ins•3/13 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 61 Mooring Dr 4M Property Address Andrea Gualtieri Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 page. City/Town State Zip Code Date of Inspection C. Checklist t 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? ® ElWere all system components, the SAS located on site. Ystem P onents� excluding . r . ® ❑ 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �qM 61 Mooring Dr Property Address Andrea Gualtieri 1 Owner Owner's Name t .• ?' information is required for every Cotuit i MA 02635 4-29-16 .• , page. City/Town State Zip Code Date of Inspection D. System Information a Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) R Laundry system inspected? ❑ Yes ® No Seasonal use? ...• El Yes ® No Water meter readings, if available(last 2 years usage (gpd)):•�, ,1 Detail: t Sump pump? r El Yes ® No Last date of occupancy: , 4-2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap"present? - _ . ❑ Yes ❑ No Industrial waste holding tank present?. _;.. ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?:. ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection : Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr f Property Address Andrea Gualtieri �: �. `• Owner Owner's Name information is y, required for every Cotuit g .�s `'.�' MA 02635 4-29-16 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: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan)-;, Depth below grade: .fr. :.. . ' 16"feet Material of construction: ® casf 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.): Good condition. Septic Tank(locate on site plan):Depth below grade: 8" 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: .r. * 1000 gal ' -Sludge depth:, 12" t5ins-3/13 !7 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form, e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: - feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 61 Mooring Dr ' Property Address + Andrea Gualtieri �} ►. I' ' Owner Owner's Name information is ' Cotuit°'' �- =�' �' MA 02635 4-29-16. r ' required for every • t-• page. CdytTown State Zip Code Date of Inspection +� D. System Information (cont.) t Comments(on,pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, liquid levels as related to outlet invert,•evidence of leakage, etc.)` U - 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: c 4 Capacity: gallons Design Flow` „r . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): r�. s *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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' M 61 Mooring Dr Property Address Andrea Gualtieri +- Owner Owner's Name information is required for every Cotuit • ' 'F # , MA 02635 4-29-16 page._ City/Town State Zip Code Date of Inspection c D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number' } ❑ innovative/alternative system „ Type/name of technology: -,Comments (note'condition of soil, signs of hydraulic failure,,level'of ponding;damp soil, condition of vegetation, etc.): Leach pit in good condition with water level and stain line at 18" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool ,i Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 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 61 Mooring Dr Property Address Andrea Gualtied , Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 61 Mooring Dr Property Address Andrea Gualtieri ' Owner Owner's Name information is Cotuit .3 ,., MA 02635 4-29-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) .11 : f*' , s t 4; . . *- 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 �CL 13 .31 50 ,Z, , , �+•. y , . I r V ' t k - t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 rr Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Andrea Gualtied Owner Owner's Name information is required for every Cotuit MA 02635 4-29-16 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 r t5ins•W13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts (,, . -Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,., 61 Mooring Dr _ Property Address• R Bank Owned (Contact David Holt @-Today Real Estate 1-800-966-2448) Owner Owner's Name I I I , information is ( Cotuit. MA . 02635 7-27-12 required for every page. - City/Town State Zip Code• Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Generallnformation 1. I I nspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr f Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification , • I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as'of the time of the inspection.The inspection 3 was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a,DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000).The system: ° 4® 'Passes ❑ Conditionally Passes. ❑ Fails El Needs Further Evaluation by the Local Approving Authority 7-27-1.2 ' Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 OfficiWonbsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. Y B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. , Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address x; Bank Owned (Contact David Holt @,Today_Real Estate 17-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27=12: page. City/Town State Zip Code Date of Inspection B. Certification (conf) 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 + g 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): t. ,r .r The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken-pipe(s) are replaced ' ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): :C) Further Evaluation is Required:bythe Board of Health:.•' , .. El 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. Systeni'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 El Cesspool,or privy is within 50 feet of'a:bordering vegetated wetland or a salt marsh t5ins•11/10 r 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 ay' 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) I� 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 _` .. Commonwealth of Massachusetts f _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today,Real Estate 1-800=966-2448),' F Owner Owner's Name information is COtuit • MA `r 02635 , required for every. - 7-27-12 page. , City/Town State Zip Code Date oflnspection • B. Certification (coat.) r Yes No: , t• s X El'" '® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: t -❑„ ® 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 orlprvy 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 toor less than 5 ppm, provided that no other failure criteria are triggered.A copy-of the analysis < ► and chain of custodymust be attached to this form:] The system is a cesspool serving a facility with a design flow of 2000gpd- .� The system fails.I have determined that one or more of the above failure Eli, ® ' criteria exist as described in 310 CMR 15.303,therefore the system fails. The _ r , • system owner should contact the Board of Health to determine what will be necessary to correct the failure:• ' t is ,e.a� .•' ..,,.. _ a h. , , - . 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. r - 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- - R❑ ❑ the system is within 200 feet,ofr a tributary.to a"surface.drinking water supply El ' ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection, ` Area= IWPA) or'a mapped Zone II of a public water supply well If you have answered"yes".to any question in Section E the.`system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate -regional office of the Department. t5ins-11/10 * h .& r, i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts Fy, �.,. Title 5 Official ,l nspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27-12 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 El ® 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? 4: ® ❑ 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 . Y Residential Flow Conditions: Number of bedrooms (design): 2, Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts - <• - . f" F Title 5 Official Inspection Form m a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address v Bank Owned (Contact David Holt @ Today-Real,Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit' : r MA 02635' •7-27-12 , page. City/Town State Zip Code Date of Inspection D. System Information _# • a' Description: Number of current'residents: Y - Does residence have-a garbage grinder?, ❑ Yes ® No .1 Is laundry on a separate sewage system? [if yes separate inspection-required]. ❑ Yes ® No .Laundry system inspected? El Yes ® . No r Seasonal use? r: ti ❑ Yes ® No ' Water meter readings, if available (last 2,years usage (gpd)): Detail: Sump pump? _ e. ❑ Yes ® No x Last date of occupancy: ,_ 6-2012 Date Commercial/Industrial Flow Conditions: Type of Establishment: + Design flow(based on 310 6MR.15.203): va gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.- etc.): Grease trap present? -ik 'a . ;tA ❑ Yes ❑ No Industrial waste holding.tank present? N 4. ❑ Yes ❑ No Non-sanitary'waste discharged to the Title 5'systerri?*- .,- F' ❑ Yes ❑ No k r` Water meter readings, if available: t5ins•11110• „ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth & Massachusetts Title 5 Official Inspection Form �. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M, ,•a°' 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit AMA 02635 7-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: �. N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 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 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP,approval. - Other(describe): t5ins•11/10 } Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 e Commonwealth of Massachusetts - Title 5 Official Inspection Form Ii~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 61 Mooring Dr Property Address Bank Owned (Contact-David.Holt @(Today Real Esfate 1-800-966-2448) ' - Owner Owner's Name information is required for every Cotuit°.. MA 02635 7-27-12 page. City/Town State Zip Code Date of Inspection D. System thformation (con`t.) Approximate age of all components;date installed (if known) and source of information: 1980 , r Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): v ° . e Depth below grade: { - 24" feet Material of construction: ; n t Elcast 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.): Good condition. Septic Tank(locate on site plan): x Depth below grade: 4:' j 1611 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: 1000 gal a 12" Sludge depth: t5ins-11/10'. . - Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 w Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41Ai 61 Mooring Dr Property Address Bank Owned (Contact David Holt @'Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) <: Septic Tank (cont.) r Distance from top of sludge to bottom of outlet tee or baffle 2011 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good codition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ' ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t Commonwealth of Massachusetts - • . . - 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr I Property Address +.- Bank Owned (Contact David Holt Today.Real Estate 1,-800-966-2448) Owner Owner's Name information is requiredfor every Cotuit. MA 02635 7-27-12 page. City/Town ''" x 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 ofiinspection) (iocate on site plan): Depth below grade: Material of,construction: .0 concrete ❑ metal - ❑ fiberglass. ❑ polyethylene, ❑ other(explain): Dimensions: Capacity: . gallons Design Flow:• •,. a : gallons per day Alarm present: ❑ Yes- ❑ No W Alarm level: Alarm in working order: `0 Yes ❑ No Date of last pumping: F Date Comments (condition of alarm and.float switches;etc.j: *Attach copy of current pumping,contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11l10 -Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection , Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Cotuit - MA 02635 7-27-12, required for every State Zip Code Date of Inspection Page. City/Tov✓n , ' { P P D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site,plan): ' Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes El No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located;explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i -Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address , Bank Owned (Contact:David Holt @Today Real,Estate 1-800=966-2448) Owner Owner's Name information is required for every, Cotuit ,; MA' 02635 7-27-12 . page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) Type ; y. ® leaching pits F number: 1-1000 gal ® leaching chambers number: ❑, leaching galleries number: El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:- ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of vegetation, etc.): Leach pit in good.condition and empty at inspection with stain line at 36" below inlet invert. y i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top,of liquid to inlet invert Depth of solids layer ' Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts a I= W Title 5 Official Inspection Form _ gSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 61 Mooring Dr. I Property Address Bank Owned (Contact.David Holt @.Today,Real Estate 1-800-966-2448) , Owner Owner's Name information is re q uired for every Cotuit MA 02635 7-27-12 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_ E drawing attached separately E '' ,6 A -D- c2(o 6-,0- 38" 31 ' } - r- 3Y, . . B-F- s©� 5 t • .4 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 x Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Mooring Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 7-27-12 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-'(attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: w groundwater at greater than 20'. USGS and town maps show g d Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 { Commonwealth of Massachusetts Title 5 Official Inspection Form !m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r I 61 Mooring Dr I Property Address 4 Bank Owned (Contact David Holt @ Today.Real Estate 1-800-966-2448) Owner Owner's Name information is Cotuit . MA .02635' 7-27-12., y required for every page. City/Town State Zip Code . Date of Inspection . E. Report Completeness Checklist = ®4 Inspection Summary:A, B, C, D or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information Estimated depth sto,high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r. t t5ins 11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION' Property Address: 61 MoorinQ Drive C otuit MA 02635 Owner's Name: Toni Murray Owners Address: j n Date of Inspection: January 22, 20.07 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville:.MA 02655-0049 i Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that.I have personally inspected the sewage disposal system at this address and that the information reported below,is true,accurate and complete as of the time of the:inspection. The inspection-was perf6f6led based n my,-; training and experience in the proper function and maintenance of on site sewage disposal systeins. I am a DEP: approved system inspector pursuant to Section 15.340:of Title 5.(310 CMR 15.000). The system: ca :ram . Passes CD Conditionally Passes Needs Arther Evaluation by the Local Approving A thority Fails Inspector's Signature: Date: January 30, 2007 The system inspector shall submit opy.of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes,conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page.l Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Mooring Drive Cotuit, MA Owner: Tom Murray Date of Inspection: _ January 22 2607 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments:, B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired...The`system,upon.completion of the replacement or repair,as approved by the Board of Health,will pass. 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(§)or due to a broken,settled or uneven distribution box., System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Mooring Drive Cotuit, MA Owner: Torn Murray Date of Inspection: January 22, 2007 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 orprivy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that,protects..the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a.surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than.100 feet but 50 feet.or more from a private water supply well**. Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of anunonia 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 . - 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Mooring Drive Cotuit, MA Owner: Tan Murray Date of Inspection: January 22, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"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'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ 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 watersupply 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility-and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above). Yes No _ 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. 4 Page 5 of 11 { OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ,61 Mooring Drive Cotuit, MA Owner: Tom Murray Date of Inspection: January 22, 2007 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 breakout? 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: Yes No ✓ Existing information. For example;a plan at the Board of Health. , ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.:302(3)(b)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:. 61 Moorin,Q Drive a Cotuit, MA Owner: Toni Murray Date of Inspection: January 22, 2007 FLOW CONDITI.ONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 2 DESIGN flow-based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a.garbage grinder(yes or no) No Is laundry on a separate sewage system(yes or no) n/a [if yes separate.inspection"required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available.(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last.date of occupancy: ' Weekend use .: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ' gpd ' Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) ; Non-sanitary waste.discharged to the Title 5 system(yes or no); Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION " Pumping Records Source of infonnation: Unavailable Was system pumped as part of the inspection(yes or no): 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: Installed on 10/17180-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Mooring Drive Cotuit, MA Owner: Toni Murray Date of Inspection: January 22, 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _east iron _40 PVC other(explain): Distance from private water supply well or suction liner . Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK ✓ (locate on site plan) Depth below grade: 12 Material of construction: ✓ concrete metal ._fiberglass polyethylene _other(explain) If tank is metal.list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth`. 2„ Distance from top of sludge to bottom of outlet tee or.baffle: 30" Scum thickness: 1" 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: 10" How were dimensions determined Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any insof leakage. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Moorine Drive. Cotuit, MA Owner: Toni Murray . Date of Inspection: Januarv.2Z 2007 TIGHT or HOLDING TANK: None .(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: eallons Design Flow: gallons/day . Alar ,present(yes or no): Alarm level: Alann in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Connnents(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.): The D-box was normal. No solids were&e'sent. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber;condition of.pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Mooring Drive Cotuit, Am Owner: Tom Murray Date of Inspection: January 22,-2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 -6'x 6'(1000 QaIJ w/2'stone-per design plans leaching chambers,number; leaching galleries,number: leaching trenches,.number,length:: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The leach pit had 6"of liquid on the bottom The scum line was approximately 1'up from the bottom. There did not appear to be any Sign o�failure The cover was 1 S"below grade The bottom to grade was 8' CESSPOOLS: None (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 or no): . Continents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Mooring Drive. Cotuit, MA Owner: ' Toni Murray Date of Inspection: January 2Z 2007 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. ,nck01 C3, a 3 (3 y ► a3 3y` . 3 31 yl 10 Page 11 of l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION (continued) Property Address: 61 Mooring Drive Cotuit, MA Owner: Tom Murray Date of Inspection: January 22, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water. 45 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS.database-explain: You must describe how'you established the high groundwater elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 45'+/-to groundwater at this site. gill , This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future.. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been_located and inspected. . 11 .. 1 TOVM A _ STOLE LQCA'1TQI�I'. [J. SEWAGE# VII:14GFt �D`T� ASSESS£}It'$lk :o"t€.QT 7hTS'FAi.LER'S r3AW PRONE NO) SEP IZG TANK CAPACITX LE�C�IING:FACILt'D (tyZr} . �, {sue) ^�QU,O 1Y0.4�FBFDROOMS BUIf€DER aR��."OV 4ERIo RERI�£E)A1�. C©R rp..L NCE t?t M $epgga40n 3?istance Bcrx.en fie. Maximum Adjusted Crroundwater Tatil�to the Botta�r of ,ea hmg Fac�lZty Pnvate dater Supp{j►Nell dud Leacbiaa l� ty auy urells exisi of site orWnthiie;2tfl ftf_a€leluscg frc'lexy} i Edge o£Wetland and Leaching lYaa' ty(If any wetlands exist withsn 3{3t1 feet ;f teactucg f7 S��w Feet Furnished a W � n r ' TOWN OF BARNSTABLE LOCATION 1''toor , n� U•: SEWAGE # VILLAOE - c:_o��� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY O O 'lei "LEACfHENG FACILITY: (type) ' (size) 1�� No.OF'BEDROOMS t ILOER OR OWNER PERMITDATE: COMPLIANCE DATE; Separation Distance Between ft.' Maximum Adjuster!Groundwater Table to the Bottom of Leaching Facility Feet Private Dater Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leashing f cility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of ping facility) Feet Furnished by QUA✓✓+ ��`��� ' i a * b �d 3y 3:9 F=- 341 ' 11 ,T R—F- 50 ' i TOWN OF BARNSTABLE L.�CATION CPI MVOrlAr r, _ SEWAGE# VILLAGE C�Vf ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY /M LEACHING FACILITY:(type) JP,7- Go G (size) 10VO NO.OF BEDROOMS a' 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 BY to S, r c or� �laZl07 J. a J. r3A4 , a 3 a y ► a3 3Y` a� 3s 3 31 yl y 31 . 0 LOCATION SEWAGE PERMIT NO. V I L L Co E /�o o n n� `pi'( ye l- ZL11 I %Sj A LLER'S NAME i ADDRESS 'd 0UILDEIII OR OWNER /��o Sdel^6 hd {^ i �iS DA T E P ERMIT ISSU E D _/s-_ d DATE COMPLIANCE ISSUED ,rf J O y J Y ..._....ZV .................. . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH � .....................0F....& ......-....... ............................................ Appliration for Bispoii al Works Tnnitrnrtion ramit Application is hereby made for a Permit to Construct Kl or Repair ( ) an Individual Sewage Disposal �J S st _ P ..y ........ ... .. . ,. .. ............... ...........---•-• .ocation es Lot No. ...................»».. - • ......•..••••...... .•........... •. ................... Ow ......rAddress W '- .............. r-a Installer Address UType of Building ``�� Size Lot.. .. :.................Sq. feet Dwelling—No. of Bedrooms------------�.,?-_-_------------------Expansion Attic ( ) Garbage Grinder ( ) `PL4-4 Other—T e of Building No. of persons_....._6................. Showers — Cafeteria Q' Other fixture WDesign Flow.............J ......................_gallons per person p(r day. Total daily flow__-_-_---3, 3 ..................gallons. WSeptic Tank—Liquid capacity-.! .gallons Length. ._f.tr... Width_y._. ..... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching 'area............ q. ft. Seepage Pit No...........1--------- Diameter........$........ Depth below inlet....!�....... Total leaching area--- ...sq. ft. Z Other Distribution box ( r ) Dosing to ( ) '� Percolation Test Results. Performed by-._._.._ Lg ... ............................... Date...... Y/o ............ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---. r 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R; --------- 0 Description of Soil....e.'7�?______ _ x 46..�...� -• . ------ U ----------------- ---------- UNature of Repairs or Alterations—Answer when applicable............................................................................................ -----•----•-----------------•--••---•---•------------...-------•-•-•-•-•-------------......._...----•---•------------•--------------....--------------------------------•------------....••••--••..•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L ITS 5 of the State Sanitary Code— The undersi ed further agrees not to place the system in operation until a Certificate of Compliance has been " ued b the d of h lth. Signe ---------- -•-- . ;� 1 .��. ... te Application Approved By..... ..... .. .... ........................... ------7-��... ---------••- Date Application Disapproved for the following reasons:............................................................................................................... -•-------...-•-•.................•-••-------•-----•------•-------------......------------.....--------------•---•----•------------•-----•-•-------•-----------------------------...------------......._. ~ �-•p-...... .--.---Date Permit No......................................................... Issued...��..:.. _.__"__ ' Date N(P)..jg.. ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... .......................OF..... ........................................................................ Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct (><) or Repair an Individual Sewage Disposal System at: ................................. ............ ........................................................................................ L or Lot No. Al, ,oi�,,Own r Address ....................................................... .................................................................................................. 7 Installer Address Type of Building Size Lot.__X/). �-----Sq. feet Dwelling—No. of Bedrooms.............3-----------__---------Expansion Attic Garbage�Grinder aOther—Type of Building ............................ No. of persons__....__6................. Showers Cafeteria Otherfixturgs ........................................................................................ ............................................................. Design Flow.............�r�....................gallons per person per day. Total daily flow______...._3.31�2..................gallons. W I If 9 Septic Tank—Liquid capacity.YM.gallons Lengthl..l..... Width..4/.'_C.... Diameter________________ Depth____.._._.___._. W Disposal Trench—No_.................... Width__..__.__.._._._._._ Total Length_.___`_._..__r:.__ Total leaching area....................sq. ft. Seepage Pit No...___.__._ ---------- Diameter.._..__7.1....... Depth below inlet___. Total leaching area...... __5�__s . ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.... X... ........ Date......I�Th� 1��__..__...__. .... ..... . .. ... .................. ........ ,4 Test Pit No. I.........____s�>nIinutes per inch Depth of Test Pit___.__.._.____.____. Depth to ground water_.__tu-c.............. fZq Test Pit No. 2................minutes per inch Depth of Test Pit_...._._________._.. Depth to ground water__ ` ....`__.___.___. P4 ........ ]z--------------------- 0 Description of Soil___ ----T...... ----------------- --------------"...........*-----------*---------------------- Z�.—h.... . ...Th/./ L,............................................................................................................... x .7...... ... ................................................................................................. ----------*-------------------- ............................................................................................. ------------- ...... 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 TITL7, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the b,'o�ard of health. Signed V -------------------------- . .... to Approved By.. .....C. ... .. .*.. .................. ......7sn4 Application Date .,Application Disapproved for the following`reasons:............................................................................................................. . .................................................. ................ ...........................................................•............................................................ Date PermitNo......................................................... Issued ---------------------------------------- 4 i,, Date 1. THE COMMONWEALTH OF MASSACHUSETTS., BOARD -OF HEALTH OF.......................... ..................................................... &rfifiratt.,Rf Toutpliatta THIS IS TO OkkVIFY, That the Individual Sew'a"g-e,,Disposal System,constructed O or Repaired by.....��t/..........> ............................................................................................................................................................................ at.._...._ ' /........./................. --------------------------**-------------------- - ---------------T---------------------------------------------------------------------------- has been installed in accordaae with the provisions of T of, e State Sanitary C9de as descrLieSVn the application for Disposal Works Construction Permit N e........... dated------7.--/....... ............ THE ISSUANCE OF THIS CERTIFICATE SHA NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W FUNCTIONS CTORY. ./L FUNCTION S A DATE_. .....al ----- Insoector...................................... .......................................... "s- t E9 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF........ •.............................. ............................. ...... ......... ..... .............................. FEE........................ Permission is hereby granted__._. --- ....................................................................................................................................... to Construct (V) or Repair an Individual Sewage Disposal System fl�at ......I......................................... as shown-`on the applicatiorr'for Disposal Works ConstructionPe ...... Dated...7 ............. ............ ... . ... ard of-Health . ................................ DATE,---�.'. -Z$........................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS F.FL. ELEV.= ---- FINISH GRADE = FINISH GRADE �J FINISH GRADE TOP OF FOUND. OVER TANK = 1i)(5- OVER PIT = 7LXO E LEV. „ ( CHIMNEY BLOCK 4 C.I. _ \ W.ezHERE NEEDED BACKFILL 3 PEASTONE DWELLING -- 4 V.C. _ 4 V.CJ/ .° . —-- ti�X l:92- o D v 0 0 0 0 1 ° c o D CELLAR FLOOR �O?��' GALLON x • '• ° t °° , o O o O O 3/4° TO 1-1/2" ELEV. _ S7C5 REINFORCED GONG. p b. o 0 o O 0 q" � CRUSHED STONE 0 0 o O v a ° a_- -----�-�- o e o' o • . D I S T. BOX • O o o O O tl 0 v o o O o T (TO BE LEVEL /`/Ec' Q O o t � y� `' BOTTOM OF PIT IV SEPTIC TANK ' - AND STABLE) a , o O o o Q `, ELEv. _ �'� � SYSTEM PROFILE7 8 �o NOT TO SCALE) LEACHING PIT DESIGN CRITERIA hLLMBER OF BEDROOMS GALLONS PER DAY 125•0� ..� GARBAGE GRINDER `1 LaTI,61 c TOTAL DAILY FLOW Z<�, OCXi S.F. LEACHING AREA PROVIDED= SO' ��L' 4 77- r Sd '1 x,g '/x4,.� l t •�� � F,F. 7�X-, N :ZO SOILS LOG '7Z I 'r 3 7 D$6px IZ'=� 0° ELE\I- = _ 7E37P/7 kj --- ' XTr A, ` , SEITrC p• / 161 rANKw�.S. r i ADD API kJ 6 SCALE- _/f- SUS i PROPOSED SEWAGE DISPOSAL SYSTEM INSPECTED B PROPOSED DWELLING_ `f� ''•'� 4 _ DATE �- ----- .fAKr Aj a5� MASS. PERCOLATION RATE NIN./INCH _ SCALE AS NOTED DATE : /4VA,e M°- _ OINVED BY ! r NORMAN GROSSMAN PE, R.L.S. 226 HOLLY POINT ROAD CENTERVILLE, MASS.