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0225 OCEAN VIEW AVENUE - Health
_ _ 225 OCEANVIFWANEA AE COTUI f _ A = 033 04I _ -- ---- - ----- i Town of Barnstable Inspectional Services Department • &ARMABM • Public Health Division MASS 0,39. � 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,.CHO Stephen Kidder c/o Hemenway and Barnes 75 State Steet C 617-227-7940 Agreed to voluntarily resolve pool discharge matter: Pool contractor error. § 206-3 Impure waters. No person shall allow any sink water or other impure liquid to run from the house, barn or lot, occupied by him into any street of the Town. https://www.ecode360.com/6557874 1. ,. \>,''• V r \ 'Iat J -Ni;5 \{rt � s+91t i. 7 'c ri t.t..fi {xi °e -Y4 t5 '.. r c•r. N, e, lid` 1 5 '{i t ; b is { z 1 r"Y� '', 11 '°-s}Y RV ttt! i dY yh�}}�. .�k; h � `v `'. y z Y bYt` L! �tt.�ft5�y,�� +x'. -}` l T'r 1 y. '1 i 1. dg i'A{ �t sx�i�Sti', f t at 5. 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SEPTIC TANK CAPACITY U LEACHING FACILITY:(type (size) NO.OF BEDROOM OWNER U l hU u / PERMIT DATE: E DATE: TZ U13 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 ♦ h 4 4 1 h 4 k h k ♦ 1 \ 4 \ \ \ ♦ h k h \ \ ♦ 4 ♦ 4.4: \ \ \ \ 4 4 h ♦ \ \ \ \ h ♦ \ h ♦ \ ♦ h \ ♦ ♦ 4 \ \ 4 1 ♦ ♦ 4 ♦ ♦ 4 4 h \ h \ \ ♦ ♦ h \ h h \ 4 ♦ 4 \ \ h 4 4 4 h \ h 4 4 ♦ 4 4 ♦ ♦ h ♦ \ \ 1 4 \ 4 \ \ ♦ ♦ \ h \ 1 4 4 h h \ ♦ \ \ \ ♦ \ ♦ h 4 \ h ' \ \ \ h h \ \ \ 1 \ 4 ♦ :.:. 35 \ \ \ \ 4 \ \ 4 \ \ \ • 23 40 4 \ 4 4 \ \ \ \ \ h h 4 J f J f r f f ! f J f 23 Commonwealth of Massachusetts a� Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,;tea,,•/ 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 March 15, 2013 ------- -----------._.._..----- every page. City/Town - to of_—peal----- -- -- State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not.be altered in any way. Please see completeness checklist at the end of the form. Important:When(filling out A. General Information � forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell _— cursor-do not Name of Inspector use the return key Septic Inspection Services Co. Company Name t 189 Cammett Road ------ ------ --.._.._.._.._ -- -- --------- --- ----- _ - ---- - -- - Company Address Marstons Mills MA 02648 eRH" City/Town State Zip Code 508.428.1779 S1 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this add;:ss 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: F ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority `V� - March 15, 2013 Job# 13 19- --- �� ' --- ----._.... - - ..- -- - -------- -... --- --- - -— - - ins,p ctor's Signature-- Date The system inspector shall submit a copy of this inspection report to the App oving Authority (Board of Health or DEP) within 30 days of completing his 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. i51ns•09108 T dle 5 Official Inspection Form Subsuriace Sewage Disposal System•Page t cf 17 ml) / B Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanvlew Ave r _ Property Address Carol Carriuolo Owner ---------- --------------------------- Owner's Name information is Cotuit MA ' 02635 March 15, 2013 required for ____- _ _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist-Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumping at time of inspection, leaching field shows no evidence of surcharge or saturation. 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 'Cr 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•09/08 Tale 5 Official Inspection Farm Subsurta a Sewage Disposal System"Page 2 of 17 Commonwealth of Massachusetts n- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments. 225 Oceanvlew Ave Property Address Carol Carriuolo Owner Owner's Name information is Cotuit MA 02635 March 15, 2013 requiredfor ------ —-----------------.._ ..__...--------_-- ---------------------------- every page. City/Town State Zip Code Date of.Inspection — B. Certification (cont.j B) System Conditionally Passes (cont.): - ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): , ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below).- El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑• N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below). ❑ obstruction is removed ❑ Y. ❑ N ❑ ND (Explain below): 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 heallth, 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 15ins°09/08 1',le 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 Df 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "3 'II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is Cotuit MA 02635 March 15, 2013 required for ------- — —- ----- ...— ------—— -- — --- every page. City/Town State Zip Code Date of Inspection — B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: t� ❑ 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. j - ' ❑ 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 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 AU 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 cr available volume is less than_day flow — — 15,ns•09108 Title.5 Official Inspection form Subsurfo�e Sewage Disposal System•Page 4 D1 17 Commonwealth of Massachusetts 4 a Title 5 Official Inspection Form` — _ , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview —— ------—— --— --..---.....-... - - ---- --- -- ---- - Property Address Carol Carriuolo Owner Owner's Name information is Cotuit .MA 02635 March 15, 2013 requiredfor ---- ------..----_...._------------------- -------- -------..------- ---- ---- - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year ,VOT 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. ❑ ® Ariy 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. El ® 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 fee!t 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 .o or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or,"no" to each of the follo',R, ng, 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 ❑ O 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 conl ,ct the appropriate I regional office of the Department. 15ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 ' \ Commonwealth of Massachusetts Title 5 Official Inspection Form !=1, N! Subsurface Sewage Disposal System For Not for Voluntary Assessments - \.,.,,—, / 225 Oceanview Ave Property Address Carol Carriuolo Owner — - — =' - - -.—.....------------------------- Owner's Name information is Cotuit MA 02635 March 15, 2013 requiredfor -------------- ---- --_---- --- ---...---.._.. ---- — ----- —-- every page. CitylTown 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)] . D. "System Information Residential Flow Conditions: 4 Number of bedrooms (design): 4- --- --- Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 15,ns•09/08 Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 6 0!;7 Commonwealth of Massachusetts -,l__-- _; Title 5 Official Inspection Form =t, _ Subsurface Sewage Disposal System form- Not for Voluntary Assessments 225 Oceanview Ave ,.. --------- ----- - -- --------- Property Address Carol Carriuolo ._...------------...---- ---------------- --_.._ Owner Owner's Name information is required for Cotuit ----- --- - -_..-......... -------- - - --- ----- ----------- every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: - ---- Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes M No Laundry system inspected? ❑ Yes ❑, No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): - -- Detail: Water usage inaccurate due to irrigation system and pool Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: ---- -- -..... ----- --- --- ---------- Design flow (based on 310 CMR 15.203): -------.__.--._-_._;da-__-_—_--_....__ .._..----__-- _-----_-------..._-- Gallons.per y(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 ❑ j No Water meter readings, if available: -- -- ---- --- ------- - l5ins•09108 1 ale 5 Official Inspection Form Subsurface Sewage Disposal System Page 7 of 17 r Commonwealth of Massachusetts r Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner -----------------------------_____ _----.....- --__ __..______.. ---------...-------__--------.—._---------------------___ Owner's Name information is required for Cotuit MA 02635 March 15, 2013 ------------------------...----------------__...—.__..:---------_- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: --------------- --------- Date Other(describe below): ------------- General Information Pumping Records: April 2010 Source of information:. .-_. _.-..._.___---.------.---__._._._._.__:__...----------------_---...�-- Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: `........ _.____..__ .—..-------.`------ ----- --____-- gallons How was quantity pumped determined? ------------------------- — — ----- Reason for pumping: -- - '---_.. -------- ---- -------- -=---- Type of System: ® Septic tank, distnbution'box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy y T ❑ 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): t51ns•09/08 ` Ttlle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 cf 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments j; 225 Ciceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is Cotuit MA 02635 March 15, 2013 requiredfor ---------------. ------ - — - — - .—.... ---,.-..._..._._...—--- ------- -- every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source or Information. Leaching system installed in 2000 Were sewage odors detected when arriving at the site? T ❑ Yes ® No Building Sewer (locate on site plan): 2, Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: --- feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 2, Depth below grade: feet _.---------.------___r-.._-.---- 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 8.5' long x 5.2' wide - 1000 gal. — Dimensions. Sludge depth: _. -.__..-- -- ----- !Sins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9)f 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form !V Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Ciceanview Ave Property Address Carol Carriuolo OwnerOwner's Name - -------_.._..-----------—------_--------------- ----..--------..._-._-------- ----- information is Cotuit MA 02635 March 15, 2013 required for --------- ------------------ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle ----------------0 _ --- 11 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 -- ------ --- ------- Measured How were dimensions determined? - - --- -- -------- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are intact and clear and liquid level was at bottom of outlet invert. -- = ------------------------ ------------------ -- - - -----..-.._... - - - --- --------- ----------- 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 -+ --r--------- ---- -----------_----- Date of last pumping: --- -----.._...---- - ---- -- -------- Date [Sins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 o 17 - I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., g p Y Y \a 225 Ciceanview Ave _ Property Address Carol Carriuolo _ Owner — ---------- -_----------------- --------------- —------------------------ Owner's Name information is Cotuit _ MA 02_635_ March 15, 2013 required for ----- ---------- ---�- -- --- - — --- 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ---_ - --- Material of construction: . ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: - ---------- - --- Capacity: gallons---------- ----------- - — Design Flow: ---- -= -- -..--- ..,. -- -- --------- ----— gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -------- --- Alarm in working order: ❑ Yes ❑ No Date of last pumping: - - - ..:------------- .._... --- ------- ------ Date Comments (condition of alarm and float switches, etc.): -- - ------------- -- - ..-----------------.-. _..--- --=- ---=--------- ----- ---- `Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No I 15ins•09108 - 'rrtle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 o�17 - I Commonwealth of Massachusetts a ,Wls Title 5 Official Inspection Form `I; Subsurface Sewage Disposal System Form Not for Voluntary Assessments \ a % 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is Cotuit MA 02635 March 15, 2013 requiredfor =------------ ---- — ---- -- .....---------- ---_------ --- ------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan). oi, Depth of liquid level above outlet invert ---- — - ----- --- — - --- ---------- -- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present.--'- -----_} -- ------- =------------- ------------- — Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required):,' If SAS not located, explain why: I l5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts ^F Title 5 Official Inspection Form _ 1= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Ciceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is otuit MA 02635 MG C Ch 15, 2013 requiredfor --------- - - -------.._M....._.� - -- __.-.__......._....__. —..------ -- ------------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: R — -- Three 500 gal ® leaching chambers number: drywells__ ❑ 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.): Stone and soils surrounding leaching chambers were probed, found no evidence of saturation. SAS showed no signs of surcharge into d-box. 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 t51ns•09/08 Title 5 Official Inspection form Subsurface Sewage Disposal System•Page 13 of 17 ' i Commonwealth of Massachusetts Title 5 Official Inspection Fort7tm -� stem Form - Not for Voluntary Assessments >� Subsurface Sewage Disposal S Y S 9 p Y , 225 Oceanview Ave Property Address Carol Carriuolo -- Owner Owner's Name information is required for Cotuit MA 02635 March 15, 2013 __.-------- ----.._..--- ------- --- every 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, i 15ins•09/08 T life 5 official Inspection Form Subsuriec�'Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ,1 R Subsurface Sewage Disposal System Form Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo - Owner Owner s Name Information is Cotuit 'AA 02635 March 15. 2013 requueo fo every page City:town State tp Code Date of Inspection -..----... ---- ---..-_........_.-........._.__..._._._.......... __.._.. D. System Information (cont.) Sketch Of Sewage Disposal System. Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building Check one of the boxes below ❑ hand-sketch in the area below ® drawing attached separately . . . . . . . .. . . . . 35 23 40 23 Ocean View Ave Commonwealth of Massachusetts , as Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a; 225 Oceanview Ave -- Property Address Carol Carriuolo Owner Owner's Name information is Cotuit _MA 02635 March 15, 2013 required for -- ---- --- ----- - - --- - - -- every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 20+ Estimated depth to high 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: pace ® 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 groundwater elevation: Ocean at rear of property is considerably lower than SAS. i i --- --- ---- -- ---- - ---------------------------..---- ---- -- -- ------- -- m Before.filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•09108 1itle 5 Official Inspection Form Subsurfa. Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment 225 Oceanview Ave --------------------------- Property Address Carol Carriuolo Owner Owner's Name information is Cotuit MA 02635 March 15, 2013 required for — -------—-- -- -- --... --- —---— — ------------- - every 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 t i r. Y R' t51ns•09108 Title 5 Dfhciat Inspection Form Subsuria Sewage Disposal System-Page I7 of 17 i TOWN OF BARNSTABLE LOCATION 5 C64 , %e-uj Av HW*6t#�►'�S� In�LAGE o ASSESSOR'S MAA&PARCEL 'S NAME&PHONE NO. h i ��O-�C UN n l I"� SEPTIC TANK CAPACITY I U220-0 fV LEACHING FACILITY.(type) V ��hcvv\!WS (size) NO.OF BE OOMS OW �`` NER �(�i lJ O 10 PERMIT DATE: DATE:o c P 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 e ' ithin 300 feet of leaching facility) Feet FURNISHED BY r h h 4 h \ h h 4 4 'h h \ h 4 4. 4 h L '•. +. L '•. \ L 4 h `., \ '+ \ h 4 4 +. � f f i ?~? f f i,•?1f i i f ! / F f ? ? f f ? ?�J ? ? f i r f ? f 4�4 h 4 h 4 k '•. 4 \ \ h \ h '•. k \ 4 h h '•. 4 4 •f ! , f f ! r r ! r f f ! f f f ,v ? F / ! / ' h \ h k 4 h 4 4 h 4 h h \ h 1 \ L ♦ h k h 4h?:'L�- r �:" J r / f f ! f I /'/ / / / / ! f / f F / f J / f i♦"' I f f f f f r r f J J I f f ! f r r r I r r J f J ✓ f f I f J ! �vJ 4 4 4 \ 4 h h 4.h h 4 h hJ\I\I\I\IhJ4f\fhlh/4I\ / 3 5-% \ 4 4 L 4 4 4 4 4 4 4 4 2 3 L ' r h \ \ \ h \ 4 \ 4 h 4 r f f , r r f r , r f - • 4 4 h 4 4 k h 4 ♦ \ • \ 4r\f �� hlL 4 4 4 4 4 n 40 . 4 4 h h \ h L h h h k 4 23 x r - �' Commonwealth of Massachusetts • Title '5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 - April 28, 2010 every page. Cityrrown State .Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at"the end of the form. Important. A. General Information When filling out forms on the - • . _ _ -.. r ^ computer,use 1. Inspector: only the tab key to move your Patrick MI. O'Connell cursor-do not Name of Ins ector use the return p key. Septic Inspection Services Co. Company Name vv�,�:A 189 Cammett.Road - Company Address Marstons Mllls MA 02648 Cltylrown State Zip Code 508.428.1779 SI 12855 Telephone Number License,.Number R.Certification z 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 DER approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further I-vah..!ation by the Lc,-al App, vi;�g Authority April 28, 2010 Ins ctor's Sign ture 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. 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage 7posal Syste 1 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304.exist.Any,failure.criteria not evaluated are indicated below. Comments: Tank was pumped as part of inspection leaching field shows no evidence of surcharge or saturation 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.repla_r;ed,Afith.a co ply ng septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April.28, 2010 every page. Cltyfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more\than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remove d ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions'exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is CotUit required for MA 02635 April 28, 2010 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the 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•09108 Title 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 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 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 4 4 (design):. Number of bedrooms.(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Water usage inaccurate due to irrigation system and pool. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.. 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Reason for pumping: Maintinance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology..Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 . April 28, 2010 every 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: Leaching system installed in 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan).- Depth below grade: 2' feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2' 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' Ion x 5.2'wide- 1000 gal. Sludge depth: 011 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 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 was pumped as part of inspection, tees are intact and clear and liquid level was at bottom of outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Ciceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 _`L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is COtUIt required for MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 1. 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09/08 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 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Three 500 galdrywells. ❑ Teaching 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.): Stone and soils surroundingleaching chambers were robed 9 p found no evidence of saturation. SAS showed no signs of surcharge into d-box. 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•09/08 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 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit _ MA 02635 April 28, 2010 every 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.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ICommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name ----------------------- ----- information is Cotuit MA 02635 April 28, 2010 required for —------ -- -----..._..---- ' -- --- —— every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 35 23/ r r .• J r ! f \ \ \ \ \ \ \ \ \ \ \ \ 40 23 V ...x. wm' J.t Ocean View Ave f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is required for Cotuit MA 02635 April 28, 2010 every page. CitylTown 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 now you established the high ground water elevation: Ocean at rear of property is considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Oceanview Ave Property Address Carol Carriuolo Owner Owner's Name information is Cotuit MA 02635 Aril 28, 2010 required for p every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection'Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 'I J i PO V r i i b� oW b l TOWN OF BARNSTABLE ATION V 3- 12e-,an ��✓ f>�� SEWAGE # o Oe7 -7/l`' 3fo � qGE Co¢v, '� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3-0® 4-4C4 4�16 -J- (size) f 3 rY-: NO. OF BEDROOM BUILDER 0 WNER e4 4-rw41,04g, PERMITDATE: 3 / ov COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �t 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 ���' a � J e �3 0 QJ 3-zf, It 03 No.?ej,70"' //—S--- c Fee `S21) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYfcatfou for loiop/ozar *patent Couwuctfon Permit Application for a Permit to Construct( )Repair(t°)Upgrade( )Abandon( ) O Complete System 20I dividual Components Location Address or Lot No.2 Z v�ifT 4 �� Owner's Name,Address and Tel.No. R Assessor's Map/Parcel co f Zl/ r Installer's Name,Address,and Te r ����No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building 2 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 1040 Type of S.A.S. G 4�9olelS Description of Soil 3 7t X lZ�� Z 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 Cetjiff- cate of Compliance has been issued by t Ws Boar f Hoalth. Signed Date Z dQ Application Approved by Date Application Disapproved for the following real ns Permit No. Date Issued sy Fee '.� No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .Yes - 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for �Digpogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair.( )Upgrade( )Abandon( ) ❑Complete System &Individual Components Location Address or Lot No. Z Z �— Qa,�j vli e Gti�Qr Owner's Name,Address and Tel.No. Assessor's Map/Parcel CQ t4W r ��© �C� C�rr��•o�o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. . 77>-139i Type of Building: Dwelling No.of Bedrooms '7r— Lot Size sq.ft. Garbage Grinder( d Other Type of Building e__5 elf'"& No. of Persons Showers( ) Cafeteria( ) Other Fixtures c� Design Flow ��� gallons per day. Calculated daily flow 1149 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ��4G 4'-,�^1511'99 Type of S.A.S. Description of Soil /`��' / 3 7.6 Nature of Repairs or Alterations(Answer whenapplicable) ���! 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 issued by this Board-of Hejalth. _ Signed C Date z y/mod Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS (2 3 3 O'd BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTTY, that the On-site Sew ge Disposal System Constructed( )Repaired ( ✓)Upgraded( ) Abandoned( )by dJG>/ G e.S1`11_1 at Z Z J �CL��°� V! �� � ' �� ��` has�b/ee�tt constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. boo' //tdated Installer t Designer /lr 11 a The issuance of this permit shall n9tft cco sti ued as a guarantee that the s}sfem will function s gne .Date J Inspector �/ � L'(l _ / _ �.. G l� V � -7��------------------ No. -- V73 ail Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 1wigpogar 6pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( ✓)Upgrade( )Abandon( ) System located at Z 2 0 Cet iW and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this e t. Date: 716/_-7 � Approved by NOTICE: This For Is To Betsed For the Repair Of Failed Septic Systems. Only., P _ CERTIFICATION OF SKETCH AND.APPLICATION FOR A DISPOSAL, WORKS CONSTRUMON PERMIT(WITHOUT DESIGNED PLANS) ereby certify that the application for disposal works construction permit sighed by me dated concerning the property located.at /JJo-U,/ e G® %meets all of the following criteria:. /The failed syszem is ca nnectea to a residential dwelling only. There are no commercial or business nses associated with the dweiling. /rhe soil is classified as CLASS I and the oerzoiadon;ate i s less-than or equal to .; ztinutes per incl There are no we•,Iands within 100 feet of the, � ormosea wont system A4 ,were are no private wells within.1:0:err of he proposed septic system. heree is no inc:ease in flow and/or change,_in use proposed There are no variances,requested or needed. The bottom of the proposed leaching facility will not be 1_ ogled less than five feet above she ma.'dmum adjusted groundwater table elevation. (Adjust the groundwater.table.using the:imptor ( � method when applicable], Y if the S.A_S. will be located with 250 feet vegetatedof any s. theoorto om of die proposed leaching facility w not be located less than fourteen(14)feet above the ma.,dmum adjusted ill groundwater table elevation, Please complete the following: A) Top of Ground Surface EIevation(using GIS information) B) G.W.Elevation +the MAX Kigh G.W. Adjustment. 13 } J DIFFERENCE BETWEEN A and B SIGNED DATE: (Sketch Proposed Plan of system oa bade]. �heahh told�r:pert TOWN OF BARNSTABLE LOCATION SEWAGE # o1Z6_ Gd VILLAGE ��'��- ASSESSOR'S MAP & LOT 3-0�1 INSTALLER'S NAME&PHONE NO. ff y vJ 5j6 I SEPTIC TANK CAPACITY LEACHING FACILM: (type) 3?,o Lee Zlr.,,X 'J (size) f 3 Y7,3' NO. OF BEDROOM V BUILDER O WNER .+� rra►iesL� PERMITDATE: COMPLIANCE DATE: r Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t Feet Private Water Supply Well and Leaching Facility (If any wells exist I 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) 6'!� Feet Furnished by dcZ' j . �tfi t I I I i �j 1 ►,