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HomeMy WebLinkAbout0029 NICKERSON ROAD - Health (29 Nickerson Road Cotuit P A = 018 079 - - 5 Town of Barnstable �fIHE, Regulatory Services Thomas F. Oeiler, Director Public Health Division snxrrsrnsLE, 9 MASS. g Thomas McKean,Director 1639. �0 20f.)7 a 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 16, 2008 Susan Rhodes 449 Old North Avenue Weston, MA 02493 As of October 1 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 29 Nickerson Ave., Cotuit. Enclosed is an application. Please use a separate application for each rental unit you own. Should you need more applications, they are available online at wvG,,Ar.town.barnstable.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them 011ie Health Division with the appropriate 2008 fees included. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperatio . Timothy B. O'Connell Health Inspector. Health Division Direct#508-862-4646 TOWN OF BAMSTABLE CC. LOCATION a 9 Al i c_ke rf t)r 9 SEWAGE # Daft)V-,'1 VUI LAGE Cyl v( - ASSESSOR'S MAP & LOT Q, -07q INSTALLER'S NAME&PHONE NO.-, ce"n co SEPTIC TANK CAPACITY Kep 'A C LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 4_ BUILDER OR OWNER PERMIT DATE: a ° COMPLIANCE DATE: a U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnispvd by T ;�t erg TOWN OF BARNSTABLE LOCATION &!C k'-rlfSf41 lf'al SEWAGE # VILLAGE 1— ASSESSOR'S MAP 6z LOT ®�$ /A/S/o£c%%es B EAR'S NAME & PHONE NO. A & B C M 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITYAtype) (size) NO.OF BEDROOMS PRIVATE WELL.OR PUBLIC WATER +2•�, � _ {� ' w - rid }:i BUILDER OR OWNER p O IQ fle S DATE PERMIT ISSUED: %ev j £C 7/ DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t�i y 0.s �- � �a W �l9 O '` i a t. COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. signature item 4 if Restricted Delivery Is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we Can return the card to you.. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on.the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No 14 rj 6Q�p pq '1,,,�. vl l 3. Service Type 13 Certified Mail ❑Express Mail b ❑Registered ❑ m RetuReceiptforMerchandise�93 ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) i #17 q0 6 215 0 D H 2 10 4:1 i 19 0 6 8 'PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class M7Paid Postage&FUSPS Permit No.G I � • Sender: Please print your name, address, and 4,IP+4 in! -is box.* j j I Town of Barnstable w co j Health Division 200 Main Street 1 Hyannis,MA 02601 I I I I I !lI1.11fi111M31.1i.)Hlll11111!ullIf Ill 4Jd,1hiI/illIhid fCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635_ November 5, 2007 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. Important:When filling out A. General Information , forms on the a' computer,use 1. Inspector: L I��Q only the tab key to move your David D. Coughanowr ` (� I cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name ran 43 Triangle Circle Company Address Sandwich MA 02563 'EIIYA City/Town State Zip Code 508 364-0894 1328 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 November 5, 2007 } Inspector's Signature Date — f i� 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 isla 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. t5-2813.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5, 2007 every page. CityfTown 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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 t5-2813.doc•08/06 Title 5 Official Inspec5on Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W ; Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5, 2007 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 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: 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. ' ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2813.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow El ® 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. t5-2813.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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Nickerson Road ' 4 Property Address Caroline McKellar - Owner Owner's Name . information is Cotuit MA 02635 November 5, 2007 required for 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- 1 0,000g pd. ❑ : ® 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. t5-2813.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is Cotu►t MA 02635 November 5, 2007 required for 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? ® El available 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)] t5-2813.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts N W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Nickerson Road ' Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5 2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 2-3 DESIGN flow based on 310 CMR 15.203 (for example:`110 gpd x#of bedrooms): n/a—no plan Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundrysystem inspected? Yes No Y P ❑ ❑ Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 244 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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): t5-2813.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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: Age unknown. D-box was replaced 4127104(Board of Health permit#2004-201) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2813.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5, 2007 every page. City/Town 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.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): 0 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 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 1 in Distance from top of sludge to bottom of outlet tee or baffle 33 in Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? measure t5-2813.doc•08106 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 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid Levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete. ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 4 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): t5-2813.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotu►t MA 02635 November 5 2007 every page. City/Town 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 At outlet invert 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 appears structurally.sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2813.doc•08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 F ' Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ® leaching pits number: 1 ❑ leaching chambers number: El 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into the leach pit. t5-2813.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is Cotuit MA required for 02635 November 5 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert 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.): t5-2813.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 'Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M0 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for Cotuit MA 02635 November 5, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. NICKERSON ROAD LOCATIONS A B 1 10 FE 20 FL 2 13 FE 17.5 FE LINER 3 21 FE 17 FE ENTERS HERE EXISTING DWELLING # 29 . f A 8- SEPTIC TANK 3 LEACH .. D-BOX PIT O NOT TO SCALE t5-2813.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 o • Commonwealth of Massachusetts W . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Nickerson Road Property Address Caroline McKellar Owner Owner's Name information is required for cotuit MA 02635 November 5 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope . ❑ Surface water ❑ Check cellar ❑ Shallow wells 20+ Estimated depth to ground water: 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2813.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1HE Town of Barnstable �pt� yP� Regulatory Services • BARNSTABLE, t Thomas F. Geiler,Director 9� 116 9. � Public Health .Division ATFD Nlf►r" Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r�t� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pphration for Miopozaf *p$tem Con5truction Permit Application for a Permit to Construct( . )Repair( / Upgrade( )Abandon( ) El Complete System A�vidual Components Location Address or Lot No. Owner's Name,Address and Tel.No. /')/4 v✓?n P o 1V�le Assessor's Map/Parcel Co7—aj r -d? CA � OV)Ck Yles,x-, / co-T(,7 . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 99 zf-,6 Cw ti co 3 S.0 Type of Building: vs f Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. 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 Certifi- cate of Compliance has been is d by this Board of Health. Signed Date �V Application Approved by Date 7 7 Application Disapproved for th following reasons Permit No. 9�Qo q — d I Date Issued a ? u u ? �'£io. 1 U Fee �} THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes M PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS-- Y Z(pplicartion for Migvotal *pgtem Couttruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System Al vidual Components Location Address or Lot No. Owner's Name,Address and Tel.No. P-9 A//C/r£iP-S"a ke �� /4 4/f?/4 P o W£iP Assessor's Map/Parcel \ Co7Tai r -011 02 5 V1CAr F/c SaN Ab Co/c.i-7 Installer's Name,Address,and Tel.No, S'A r 7 95--o2 Po° Designer's Name,Address and Tel.No. A ?(-6 C/41v cO Type of Building: o us r Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. 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) £ c £ 0 O�' 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 Certifi- cate of Compliance has been is ed by this Board of Health. t Signed ^f,14- A-a-- Date Application Approved by 1 �?,J• " i z S. Date I-1 �7 r =�L/ Application Disapproved for thg-following reasons Permit No. 90C, �� 'a d Date Issued a 7 V on1 y• THE COMMONWEALTH OF MASSACHUSETTS �E_P yy BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS'IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(�j upgraded( } Abandoned( )by C/a/L C o at 4P 9 All C k F/P -S a ti of a. C'oTy r has been constructed in accordance with the pro ' ions of Title 5 and the for Disposal System Construction Permit No.�0U c/— dated y1,2 7 °y Installer _ SS" Designer The issuance of this pirmit shall not be construed as a guarantee that the s _tern will4function 1 esigned. Date 1 �/ Inspector (�� f ' 1- - No. �) L/- 2 0 I Fee 5 y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migooal *raem Construction Permit Permission is hereby granted to Construct( )Repair(✓)Upgrade( )Abandon( ) System located at o� `7 A" F/P S'A' /P.3 Y' 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:Construcyi*on must be completed within three years of the date of rmit. Date: �/C� L/ A roved b (!\ e l PP Y TOWN OF BrARNSTABLE cc LOCATION i L e 0 SEWAGE # ;Z VU —,2 V VILLAGE ASSESSOR'S MAP & LOT OI —07GI INSTALLER'S NAME&PHONE NO. TI CG✓t C� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO, OF BEDROOMS BUILDER OR OWNER PERMITDATE: ? °L/ COMPLIANCE DATE: a U Separation Distance Between the: ' Maximum Adjusted Groundwater ble 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 leacWg facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Funu d by Coe 0 J'?a 7 --000 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + DEPARTMENT OF ENVIRONMENTAL PROTECTION A F ti f C iagM SV0v0 w. ©� V 350 MAIN STREET MAP WEST YARMOUTH,MA PARCEL Ci 508-775-2800 _ SOT �_....�.....��. ._ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 018 PAR 079 Property Address: 29 NICKERSON.ROAD COTUIT,MA 02635 Owner's Name: POWERS,MAURA Owner's Address: 29 NICKERSON ROAD COTUIT,MA 02635 Date of Inspection APRIL 30,2004 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco LOO Mailing Address: 350 Main Street �11P West Yannouth,MA 02673 TOWN OF BARNSTABLE Ty E-�k ,, I, Telephone Number: 508-775-2800 �E1�T -.,..._--.--• - - '-" CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:. ' Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 tot he 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 1 Page 2 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 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 CM R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 C. Further Evaluation is Required by the Board of Health: N/A _ 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 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than'/x 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn.) NO (Yes/No)The system fails. I have detennined 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 detennine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service 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 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation 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 nonnal 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)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)] Title 5 Inspection Form 6/15/2600 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002 42,000/2003 79,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT - COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,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 information: N/A 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1978,NEW DISTRIBUTION BOX IN 2004 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 3" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private.water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 3" Material of construction: ✓ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age continued by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scum thickness: F, Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions detennined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL.OUTLET BAFFLE.NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/M00 7 Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarm level: Alarm 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: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or but of box,etc.,): DISTRIBUTION BOX IS NEW MAY 2004. DISTRIBUTION BOX IS 16"xl6", 15"BELOW GRADE.ONE LINE IN,ONE LINE OUT. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 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.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.8"TO COVER, F WATER WITH STAIN LINE AT 20". NO SIGN OF OVERLOADING OR SOLID CARRYOVER. CESSPOOLS: N/A (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): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 0 of l l. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635 Owner: POWERS,MAURA Date of-Inspection: APRIL 30,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tie s to at least two p ennanent reference landmarks or . benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1 I i -J 6 l Title 5 Inspection Forin 6/15/2000 10 Page 1 1 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C =fit SYSTEM INFORMATION (continued) Property Address: 29 NICKERSON ROAD COTUIT,MA 02635. Owner: POWERS,MAURA Date of Inspection: APRIL 30,2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 10 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ./ Observation 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: TEST HOLE 10' NO WATER. TEST HOLEY BELOW BOTTOM OF PIT. 7 Title 5 Inspection Form 6/15/2000 11 y - � • yt- -. .ire - . .. + A No................_....... ..... .......... . .Fps .. .. - THE COMMONWEALTH OF MASSACHUSETTS } blq BOA R® O 1-1 EA TI-� t ............. / �--....OF:.... . .. ..... .- --__---- ---- Appliration for 14iiVnllal Works Toulitrurtion Urrmit Application is hereby made for a Permit to ,Construct ( ) or,Repair ( ) an Individual Sewage Disposal System at* ocation-Address / -- - - or Lot No- ..............��,�. .........._.._...._........__--•-....____-_---- ----•-•-••••••-•----._....---..._..._----- - --••-....._....-----•-•-------............._._ O er Address Installer Address Q Type of Building Size Lot.................... .....Sq. feet U Dwelling—No. of Bedrooms________________________ Expansion Attic ( ) Garbage Grinder (/ ' Other—Type of Building .__.____ No. of ersons__________________.__.._.._ Showers — Cafeteria Q' Other fixtures ----...-•--•--•-••-----•-•••-•• . d ' ------------------..............•... -•-...--•• W Design Flow______________. _................gallons per person per day. Total daily flow____._ WSeptic Tank—Liquid capacity./&IjOVgallons Length................ Width................ Diameter________________ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No......./........... Diameter.___/0_______ Depth below inlet___..!......... Total leaching area__oU4._.sq. ft. Z Other Distribution box Dosing tank,/( ) '~ Percolation Test Results Performed by........./lt:t�119,................................................. Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________- (i, Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water___________________.___. a •---••••-•-•-----------•---••---••••-•-•--••••••--••••••-•-•--.....-•-•-•••-••--••-------•-••----•••......................................................... 0 Description of Soil _ -------------------------------- x A /� - -- W - � J. . • - -•• , ---_ •- -�" ------------------------------------- Jr. ----.��� ...._... U Nature of Repairs or Alt rations—Xnswer when pplicable................................. ________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal stem in accordance with the provisions of iITL� 5 of the State Sanitary Code— The undersigned further agr e not to place the system in operation until a Certificate of Compliance has been issue y t o f heal " / Sign •--• - _- _. .. �- ----------------------------•-- Date Application Approved BY / • • - -&�°�•t� ------------ ... "Date' Application Disapproved for the following reasons:--•------•-•---•-•--•--------------•----•-------------------------------•-•----•-------•---•••••--._....-•-•---- ...__...••--._...••--••-••-•--•-•-.._.._...-•---._...--•-•--•-------•--••--•---•••••........_•-•••-•-•--•---••••-•-••-•••••--••••-••---••••••----•-•------••--•----------------•...._..-•--•••-•••-•-••- ` 7 Date Permit No. v/.... Issued -51- ---.......--..•---•--•---- Date No.........::....®...... Fus.. 5..... .�.... THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH t `� `'1 OF...........i .......... C�.................... .lisp!? - .....---......----------- Appliration for DhipmFal Works Tnnitrnrtinn Prntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at W1,-IrV Al ...:..........-............................................................. ...-----....----.................-•------------.....---------------............................ Location Address or Lot No. .............. ��T// /T!/(al.........................-•--•-•-------•---------. O ner v Address a 4 P� ,C----------------------••••. --•-•••....._.............._._.....------.._... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedro ..................................................•.......__....Expansion Attic ( ) Garbage Grinder W4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -=..................................................... W Design Flow................. ..................gallons per person per day. Total daily flow----- 4 2,,9._....................._.gallons. WSeptic Tank—Liquid capacity.A4?./Cgallons Length................ Width................ Diameter_--_--______.._- Depth................ x Disposal Trench—No. .................... Width.................... Total Length........ Total leaching area....................sq. ft. Seepage Pit No......./............ Diameter----467__..... Depth below inlet....... ....._.... Total leaching area-.44 — ....sq. ft. Z Other Distribution box (/ ) Dosing tank ( ) Percolation Test Results Performed by........./ '✓1J ................................................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-__---_-___---_.___. Q+' •-•-----------••••----- .........---•-••--------•-••....................•--•--------....••........--•...-••.........••-••-••-••-•-•---•.............•.....-- 0 Description of Soil........'-.................................. --------------• - -----------------------------------------------------------•----------------------•.------.----- W -------------------------- -----------------------------------------------------------------••-••-----•-----•••--------.:.._..•----•----------•---•-------••--------•-•---•-------•--•--•---------_.._. UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------•--------------------------------------------------------.---------•-•-----••-••--------------•••-•-••-----------•--•••----•-•-•-•------••----------•--.....-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agr e not to place the system in operation until a Certificate of Compliance has been issued�by theoard of heal""' ySigned......... `'�i�-,`4t'�`, ✓/..........----•-------------•---•- ..............................•. /. / t t��'" Application Approved By. .._.f. w._ a I/ / Date Application Disapproved for the following reasons:.........................................................................................D-te.............. .....................•-----.....--•---------•--------------------•---------------•---------•-•----.....---••---•••--•---•--••-------•--••-•--------•--••-------•----••-•-----••--•-•---•--•-•--......... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i�A!...............OF..........; �/(. .:x!r :...s! C '..:......................... fit wrtifirtttr of TnntpliFanrr � THIS ISITO CERTIFY, That the-Individual Sewage Disposal System constructed ( ) or Repaired ( ) t . Installer at........... :. f- /..t f , ,�/{•d /. _ r'1 rf"f......................................... has been installed in accordance with the provisions of TIT I 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.�l--��_..��'�_ �_.___..._. da.ted___? -_` '- 7S:�.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector /�} DATE--------..••-_._ `. .. ..............••••• ...i-------� = ........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . , Lr"' ''.t...... ..OF.......: ......................... F e i n ail wAl Permission is hereby granted-.!n------ - 'w........ --u-- to Construct ( ) or Repair ( > ) an Individual Sewage Disposal System atNo. ............................................ ....................-......................................... Street as shown on the application for Disposal Works Construction Per No__ .I_..- _ Dated., -- ...'��"+ � '' ' alth Board i DATE---. �-------------•--/------------........................................ = of He r . FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '-