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HomeMy WebLinkAbout0040 OLD KINGS ROAD - Health 40 OLD KINGS ROAD, COTUIT A= 022 105 r i UPC 10334 No. 2-153 "___ -- � r _ _ �, .,� ,, I j I r { i I I 1 I 1 �',�/ Pa /'�`J� �� � l/UL ca' e G1 _ C�L� ' r� No?— 06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Tit M 40 Old Kings Rd. Property Address Thomas �--4 Owner information Owner's Name CID is required for every page. Cotuit ✓ MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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. 1 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 4/11/18 Inspecto ignatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /ail dVs r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of.Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vv 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due l to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No - ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name everyrequiredge. r Cotuit MA 02635 4/11/18 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 7 Number of bedrooms (actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 770 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name everyage.ed r Cotuit MA 02635 4/11/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1983 permit for 7 bedroom system on file Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Sept 2017 Date Commerciallindustrial 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.doc-rev.6/16 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 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown 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: Pumped 2016 per 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)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.doc•rev.6/16 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 40 Old Kings Rd. Property Address Thomas Owner information Owners Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1983 per BOH record with D-box replacement in 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " Depth below grade: feet 12 Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): -Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-20 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000g Sludge depth: 3" t5ins.doc-rev.6/16 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 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name everyage.ed r Cotuit MA 02635 4/11/18 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle >12 11 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2„ Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3 years to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Poly d-box is 2'6" below grade, no adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 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 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Pit"C" is 3' below grade and was video inspected, effluent level was approximately 12" below the invert, no indication of hydraulic failure, Pit"D"was excavated it is 12" below grade and dry at this time, stain line about half way up the sidewall, no indication of past hydraulic failure Cesspools (cesspool mu st 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown 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.): Soils are compact and dry Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 il` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 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 �r 3s a k V') 3 'S �,c 3 a-� s�t6 7Z,S�) s1 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M 't 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown 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: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: previous inspection GW>20' ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USG database-explain: Site is on 60'contour and nearest surface water is at 20' msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 Old Kings Rd. Property Address Thomas Owner information Owner's Name is required for every page. Cotuit MA 02635 4/11/18 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Old Kings Road Property Address Gergyes Thomas Trust _ Owner Owner's Name information is Cotult MA 02635 /%pril 3, 2014 required for — every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out 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 — ---- — -- -- ----- Company Name r� PO Box 1487 Company Address Marstons Mills MA 02648 rertrn City/Town State Zip Code 508-776-4186 S 112855 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 April 3, 2014 Job# 14-23 VIrpecto7s i ature 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 o ner shall submit the report to the appropriate regional office of the DER The original should,be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection or Subsurface Sewage Disposal System• age t of 17 Commonwealth. of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Old Kings Road Property Address Gergyes Thomas Trust Owner Owner's Name information is required for Cotuit MA 02635 A'zril 3, 2014 every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section-D, A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below: Comments: Tank was pumped following inspection. Leaching pits were empty: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): !Sins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17 ,t i Commonwealth of Massachusetts • Title 5 Official Inspection Form . o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 40 Old Kings Road Property Address Gergyes Thomas Trust Owner Owner's Name information is required for Cotuit MA 02635 April 3, 2014 - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational,. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): - ❑ Observation of sewage backup or'break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El broken pipe(s) are replaced ❑ Y ❑ :N '❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑, N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board,of Health): broken pipe(s) are replaced ❑ Y ❑ N: ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 ' 15ins•3113 Title 5 Official Inspection form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 40 Old Kings Road Property Address Gergyes Thomas Trust _ Owner Owner's Name information is COtuit MA 02635 April 3, 2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well" Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate."Yes" or "No"to each of the following for all inspections: Yes , No : ® Backup of sewage into facility or system component due to overloaded or Fl clogged SAS or cesspool 0: ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow 15ins•3/13 1itle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Old Kings Road Property Address Gergyes Thomas Trust _ Owner Owner's Name information is required for Cotuit MA 02635 April 3, 2014 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 NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high groundwater 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. ❑ Z 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 god to 15,000 god. 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 off a surface"drinking water supply j ❑ ❑ . 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—1WPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of-any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 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 40 Old Kings Road _ Property Address Gergyes Thomas Trust Owner Owner's Name -- ---- ------ -- information is Cotuit MA_ 02635 April 3, 2014 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 th-- 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) M ❑ 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, an,-. the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms.(design): 7 Number of bedrooms (actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 770 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments «� 40 Old Kings Road yv,,• Property Address Gergyes Thomas Trust _ Owner Owner's Name information is required for Cotuit MA 02635 April 3, 2014 __— every page. City/Town State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: - Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No N/A Irrigation Water meter readings, if available(last 2 years usage (gpd)): system. Detail: - Sump pump? ❑ Yes ® No Last date of occupancy: 12/31/13 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' ------- - 15ins•3/13 Title 5 Official Inspection Form:Subsurfe,a Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Old Kings Road Property Address ----- ---- --- --------- --- Gergyes Thomas Trust Owner --- ---------------------------- Owner's Name information is it Cotu MA 02635 _ April 3, 2014 required for ------------ -- --- P 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: Pumped 4/8/10 and was pu_-iped following inspection. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: — -------- - --- - gallons How was quantity pumped determined? -- —= Reason for pumping: - -- -- - ---- - ---- - —— Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ms•3113 1nie 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 40 Old Kings Road _ Property Address Gergyes Thomas Trust _ Owner Owner's Name — ---- ----------------=-----..-- information is required for Cotuit MA 02635 April 3, 2014 __ 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: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1 Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): — ------ --- Distance from private water supply well or suction.line. feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑'polyethylene ❑ other(explain) If tank is metal, list age: ye years Is age confirmed by-a Certificate of Compliance? (attach a copy of certificate)• ' ❑ Yes ❑ No _, Dimensions: 2000 gal.A -- Sludge depth: . 3 ----- -- t5ins•3/13 1itle 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 40 Old Kings Road Property Address - ----- --- ----- Gergyes Thomas Trust 'Owner Owner's Name information is Cotuit MA 02635 _April_3, 2014 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` 30" Scum thickness ----- ------ Distance from top of scum to top of outlet tee or baffle 6" - Distance from bottom of scum to bottom of outlet tee or baffle 12------ 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.): ; Liquid level was at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): '.Dim --- ---- ----- ---- —ensions: 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 15ins+3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form - Not for Voluntary Assessments 40 Old Kings Road Property Address "+ Gergyes Thomas Trust Owner Owner's Name ---=- ------ - --.:.---—------ ----- - information is,required for Cotuit MA 02635 April 3, 2014 - _ every page. CityfTown 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 ❑-pol eth lene. y y El other(explain): Dimensions: =-- ------- ------ r, Capacity: gallons- ------ — Design FIOw: '' gallons per day - -- --- ----- -- Alarm present: ❑ Yes ❑ No Alarm level` --------------- Alarm in working order ❑ Yes ❑ No Date of last pumping: Dade --- --- ---- - Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 - Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M a>.• 40 Old Kings Road Property Address ----------..._._._..— --._-__......... —---- Gergyes Thomas Trust Owner ---— — Owner's Name --- ---------- `--- -- information is required for Cotuit — M_.A _..- —026---3--5 _April 3, 2014, eve ry page. City Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 -- --------- — Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No`solids or high stains present. Liquid level was at bottom of outlet pipes_ Pump Chamber(locate on site plan): Pumps in working order: ElYes ❑ No' Alarms in working order. ❑ Yes ❑ No` Comments (note condition of pump chamber,condition of pumps and appurtenances, etc..): If pumps or alarms are not in working order, system is a conditional pass. . Soil Absorption.System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: t51ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ., 40 Old Kings Road Property Address Gergyes Thomas Trust Owner Owner's Name — --- -- information is required for Cotuit — ___ MA 02635 Aipril 3, 2014 every page. City own State Zip Code Date of Inspection D. System Information (cont.) Type: ® leachingIts Two 6x6 pits_ P number: — ❑ leaching chambers number: El leaching galleries number: El leaching trenches number,length: -- ❑ leaching fields number, dimensions: - ❑ overflow cesspool number. - ❑ innovative/alternative system Type/name of technology; ---- =--------- --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit#1 was-empty with no evidence of surcharge. Pit#2 was not opened 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•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 1,7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Old Kings Road Property Address — ---- ------ ------- -- Gergyes Thomas Trust Owner Owner's Name - -------- ---—----------- ---information is Cotuit MA 02635_ April 3, 2014� required for 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.): 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 40 Old Kings Road Property Address Gergyes Thomas Trust Owner Owner's Name informations Cotuit MA 0263.5 April 3, 2014 required for _... - every page City/Town _._ _ State Zip Code Ddte 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 #2 pl #1 26 Back Yard. 4 s,tz;i t yt, ?\` 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment 40 Old Kings Road _ Property Address — -- -. Gergyes Thomas Trust Owner Owner's Name ---- — —-- information is required for Cotuit MA 02635 . April 3, 2014__ every page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to,high groundwater 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: El Checked with local excavators, installers - (attach documentatlan) ® Accessed USGS database - explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Topo map.shows propelmore than 20 feet higher than high groundwater in area. r , Before filing this Inspection Report, please see Report Completeness 0'1ecklist on next page. , t5ins•3113 Title 5 Official inspection Form,Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 92) Title 5 Official Inspection Form o Subsurface Sewage Disposal,.System Form -,Not for Voluntary Assessments 40 Old Kings Road M Property Address Gergyes Thomas Trust Owner - ---- -=--_ _ Owner's Name ------ require tifo is Cotuit MA 02635 Aril 3, 2014 required for =_---- -- -- - --- •' p 1 every page. CityFrown 'State ' Zip,Code Da,e o(.Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,.D,or E checked x ® 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 .. - if - Y _ t5ins•3/13 - ' fate 5 Official Inspection Form Subsurface Sewage Disposal System.Page 17..of l ?r• [ � t COMMONWEALTH OF MASSACRUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION q Property Address: I .. Owner's Name: 4 Owners Addres Date of Inspection: n D Name of Inspetplease print to Company Na e F �. z i �2 V) Mailing Address: n t u Telephone Number: • ��io '� N co CERTIFICATION STATEMENT 1 certify that I have.personally inspected the sewage disposal system at this address and tha 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 Nye s Further Evaluation by the Local Approviri�Authority a� _ /-T Inspector's Sigiiature: 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. 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 6115/2000 page 1 a � f Page 2 of 1 1 s.t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONI FORM PART A CERTIFICATION (continued) Property Address: r� Owner: A JA Date of h spection: 2*/Z � , , /. �a Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair; as approved by the Board of Health, Will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. y 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: 2 Paee 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of 4ectiom �• 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. l.. 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 surface water supply or tributary to a surface water supply. _ The system has a septic rank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 3-0 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. I' 3. Other: L 3 1 r Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 ` Owner:4-nection: �'Date of ,%, J y j D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Ng 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 invertdue to an overloaded]or clogged SAS or / cesspool 1/ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,.cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100-feet of a surface water supply or tributary to a surface .. water supply. y . Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet.of a private water supply well. Any portion of.a cesspool or privy is less than 100 feet but greater than 50 feet.from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria,and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] �J, 0 (Yes[No).The system fails. I have determined that one or more of the above failure criteria.exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what ,will be necessary to correct the failure. , E. Large 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• You must indicate either"yes"or"no"=o 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—I WPA)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. ,d Page 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: L 0 ,, 4,IA-1110 Owner: Date of In pection.�riP,�tP., rt 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 f 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 thAaffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum? IV _ 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 wSoil Absorption System(SAS)cn the site has been determined based on: Y�e ,,no . Existing information. For example, a plan at the Board of Health. Determined in the-field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:/-/(-) .41d /, o Owner: 1 , Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 3 10 CM 15.203 or exa ple: 11.0 gpd x#of bedroo s): Number.of current residents: AX Does residence have a garbage-grinder(yes or no): Is laundry on a separate sewage system ( es or no):W Qfif yes separate inspection required] .Laundry system inspected (yes or no Seasonal use: (yes or no):�G, f Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes'or no):A6. Last date of occupancy: Q��,(,tt � G�% 2J� R' ' ' `� a4, COMMERCIAL/INDUSTRIAL` Z Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_. Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records < Source of information: Was system pumped as part of the inspection(yes or no): eJ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYWOF SYSTEM t 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: Were sewage odors detected when arriving at the site(yes or no),/J/ a 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: /19.01110r(W � g � Owner: Date of In `ection: Q00 BUILDING SEWER(locate on site plan Depth below grade: Materials of construction:_cast iron _40 PVC other.(explain): 'Distance from-privatetwater:supplywell or`suction line:- Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: /Oocate on siteplan) t� Depth below grade: ] � Material of construction: . t/concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): —(attach a copy of certificate) , Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness '�� Distance from top of scum to top of outlet tee or baffle: 1 r Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recomme dations, inlet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert, evid nce of leakage, etc.): GREASE TRAP:A/(p(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: - Comments(on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): 7 , Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner d 1 Date of In ection: 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/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.): DISTR'1BUTION BOX: (if present must be opened)(loca'te"on site plan) Depth of liquid level above outlet invert: �l(�d �� Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of jk a,,3 e into or out of box,*el�,. , PUMP CHAMBER-4�(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.): R Pa,e 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: e) s ( fy Owner: Date of Inspection: ,+f� /� '"� L SOIL ABSORPTION SYSTEM (SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,number: 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): �j �k•/,JRd CESSPOOLS: (cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and'confi,uration: 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.): PRIVYA.Lo .(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: . (`J 1 b olCr��r`y Owner: i � ° Date of Iti ct�on: au,/2-4 Ae-kv Ileoo,� 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. I Ion .�� U LP r � duo � _ I Page 11 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' 4 Property Address: �� 10-01 rJ �� OwnerE_ �1 .(A �j �' Date of ection: c t t7 061 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked; date of design'plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A/ a ll 5 • Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: C/! n /l'� C. l Lot No. Owner: �r✓'4� /' / ,zlal rk� Address: Contractor: ,e ff./ld i �ar� Address:y gg6Z 2 <1✓ .�'¢//' Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ......................................................................... Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate sit and A.eApp opha el index well.................. OWater-level range zone ......................................:........:..... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... � month'/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .................:........ . '................................................................ STEP 5 Estimate depth to high water by subtracting the water , level adjustment (STEP 4) from measured depth to water 4 levelat site (STEP 1) ..............................................................:............................................... ' Figure 13.--Reproducible computation form. 5 5: . • i i 1 = .. - £ � •.ail s p � F� � _ s q1' 4 ' 11 ; , i i <S j COMMUNWEAI;I.'.I.l Ol MASSAd-1U5(�'l"1', U'xi 'urjVT; OFFIC1�, OI l�NV1R0NMrN,rA1, AFFA.1RS - 1)1�,1.'A)N'M.h,N'1' OF LNVIRONMENTAf, PRO'ITCI'.ION (rNl WINT R S'T'itt;E'I', TTOS'I'ON 114A 02109 (617) 297.- 0(1 t5 'T'RUDY COXF; 350 MAIN STREET Sccrnt.nry WEST YARMOUTH, MA ARGGO i'ALII, C(;I,LUCCI 508-775-2800 1)Av1T) R. S'tR[1115 C,overnorC�It11111SF1(tilnr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 22 PAR 105 PROPERTY ADDRESS: 40 OLD KINGS ROAD;COTUIT ADDRESS OF OWNER: DATE OF INSPECTION: JANUARY 5, 2000 MICHAEL HUGHES NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15:340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: PASSES X CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: —S_C70 The system Inspector shall submit a copy of,this inspection report.to the Approving Ault ority(Board Ile alth or DEP) within thirty(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 Department oLEnvironmental Protection. The original should he sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: D BOX NEEDS TO BE REPLACED SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED UN CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION. THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. O,. Q cc CA revised. 9/2/98 :, I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5,2000 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: N/A I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: YES X 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection-,or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septi4 tank is replaced with a conforming septic tank as approved by the Board of Health. The distribution box is broken The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed X distribution box is replaced The system required pumping more than four 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 revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 OLD KINGS ROAD, COTUIT. Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5,2000 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER i revised 9/2/98 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES t Date of Inspection: JANUARY 5, 2000 D] SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded 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 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any jportion 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. If the well has been analyzed to be acceptable;attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: ' 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5,2000 Check if the following have,been done:You must indicate either 'Yes or"No"as to each of the following' Yes No X Pumping information was provided by the owner,occupant. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the'interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information. Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at.issue,approximation of distance is unacceptable)115.302(3)(b)j X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 , • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5,2000 FLOW CONDITIONS RESIDENTIAL: YES Design flow: 770 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 7 Number of bedrooms(actual): Total DESIGN flow Number of current residents: N/A Garbage grinder(yes or no): NO Laundry(separate 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 two(2)year usage(gpd): 1999—245,000/1998—206,000 Sump Pump(yes or no): NO Last date of occupancy:. N/A COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow: Gpd(Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 6/99 System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP,Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: 1983 PERMIT#83-564 BARNSTABLE HEALTH DEPT. j Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 OLDS KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5, 2000 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron 40 PVC - other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 12" Material of construction X concrete _ metal — Fiberglass Polyethylene other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 2,000 GALLON PRE CAST Sludge depth: t" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: V, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: I'g^ How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,INLET TEE,OUTLET BAFFLE H2O COVERS TANK&COVERS 12"BELOW GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal — Fiberglass Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 OLDS KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5, 2000 TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to,or 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 Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES (locate on site plan) Depth of liquid level above outlet invert: p^ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D BOX IS 16"X 20",26"BELOW GRADE.SIDES ARE GONE ON D BOX COVER IS BROKEN,ONE LINE IN,TWO LINES OUT D BOX NEEDS TO BE REPLACED 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.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5, 2000 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 2 Leaching chambers,number: Leaching galleries,number. Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, ` Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) TWO 1,000 GALLON PRE CAST PITS.PIT(1) V WATER HIGH WATER MARK AT 2' PIT&COVER 1 BELOW GRADE PIT(2)DRY. HIGH WATER MARK 1 .PIT&COVER'BELOW GRADE CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure, ,level of ponding;condition of vegetation,etc.) it 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.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued.) Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5, 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) -. SP� / y 4 Vb Kovt s xJ) revised 9/2/98 10 - ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 40 OLD KINGS ROAD, COTUIT Owner: MICHAEL HUGHES Date of Inspection: JANUARY 5, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to no groundwater, 14 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site-Observation hole Determine it from local conditions . Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: TEST HOLE NOTED ON REPORT 1995 NO WATER AT 14' HAND DUG TEST HOLE 1995 TEST HOLE NOTED ON PAGE 10 revised 9/2/98 11 No. a �V l Fee 601 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprtcatton for 33tgozar *p.5tem Congtructton Fermat Application for a Pen-nit to Construct( )Repair(k4pgrade( )Abandon( ) ❑Complete System dividual Components Location Address or Lot No. �J ]� Owner's Name,Address and Tel.No. Assessor's Map/Parcel `-""'� a k1j1A9CS fZd <�6 v/1 o Id X4v d Cn of i Installer's Name,Address,and Tel.No. Desig 's Name,Address and Tel.No. 17 Q` C C 350 lYd/dV 'S Type of Building: 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) 7 1-2,L► �j-- AC,Ca m6M�(� 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 iss by this Board of Health. Signed "0011t, xq­ 40 Date on Application.Approved by P' Date Application Disapproved for the ollowing reasons - Permit No. Date Issued Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: j7j Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for Oigoml *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System $Individual Components r Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel .OLIO cie vii % o 14 X;tug s d GoTv i Installer's Name,Address,and Tel.NA, Design 's Name,Address and Tel.No. 47* 6 e ame4A2S Type of Building: 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 µ Nature of Repairs or Alterations(Answer when applicable) en b' g�:/I^(� -fit, _ •_ 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 iss by this Board of Health. .S--- Signed ! o Date o 0 Application Approved by /T m �4C Date Application Disapproved for t e ollowing reasons V Permit No. �"' Date Issued -------------=------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( �)Upgraded( ) Abandoned( )by 4 V A C 14 a C 0 3_s . &AfZ -_ r j 4,• cr/�,� at 5l D /A"Z S P b (%o,7v T ha een onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system.will function as'�dtesignedt. J//`�r Date ! /�, �; Inspector �/i 3 IA m�. . .A� vilh m Nv ah` K --------------------------------------- No. 6Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogal *potent Congtruction Permit Permission is hereby granted to Construct( )Repair( .Y�Upgrade( )Abandon( ) System located at S/D */A-x 5 -) 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 ust b,6 completed within three years of the date o t is p rmit. G� �' �� Date: 0 t_/ Approved by /� l�,J ,r 1 �/f�' //Lf,�(1 ,`J 9 � ASSESSORSMONM Z a gppp� No. FeefJ:y C, PARCEL N0: D THE COMWNWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSA HUSETTS 0[pprccation for Migaal *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(V )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. (40 C3\4 v.As Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(!"Q Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 2,2d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature o epairs or Alterations(Answer when ap licable) ` T—' Date last inspected: l® ZO 1Gt Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of th mental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Boar ealth. Signed ate. / Application Approved by -- Application Disapproved for the following reasons z6> Permit No. � `_1A Date Issued a n aT�K v No. L/ C /,,� /Dv Fee:�y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSAHUSETTS Zipplica.tion for Migozar *pg;tem Cott!9truction Permit Application is hereby made for a Permit to Construct( )or Repair(✓)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.. Installer's Name,Address,and Tel.No. ^ _ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms—? Garbage Grinder(No Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 226 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title I Description of Soil Nature o epairs or Alterations(Answer when ap licable) �C\ \ S, 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 oft mental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this oar ealth. Sigr >cu Date e Application Approved by �-- Application Disapproved for the following reasons Permit No. !7 �' Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System installed( )or repaired/replaced on by for N CA^ -,,- Mc: r cu a' 14o (-3NA /has been constructed in accordance with the provisions of Title 5 the fo Disposal System Construction Permit No dated„ /—g— " Use of this system is conditioned on compliance with the provisions set forth below: 01 No. low— Fe.� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wigogal *pgtem Con,5truction Permit Permission is hereby granted to _ to construct l )repair( �an On-s�SewageSystemloca�te �������� 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. F All construction must be completed within t ars of the date below. Date: /'� Approved `'" ,. TOWN OF BARNSTABLE / LOCATION 1/0 OLD /NG�" �'B� SEWAGE# VIL LAGS ��1 ASSESSOR'S MAP&LOT Ili;STALLER'S NAME&PHONE NOh C l�V e® 974_"�L?" SEPTIC TANK CAPACITY d��L �i9�'°'/r Did LEACHING FACILITY: (type) P/75— (size) 0'" �DL NO.OF BEDROOMS 7 BUILDER O OWNER A" C � Ilq PERMTTDATE:' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 r, .4 04�/r TOWN OF BARNSTABLE LOCATION i/O ®J-a e SEWAGE # VILLAGE CU 7 ASSESSOR'S MAP Sz LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) i. NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 'BUILDER OR OWNER f',V DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No an ,���R on. ��� 3-/ �n �` ,�/ �3 C°J � 0 w r LO CATION SEWAGE PERMIT NO. V.1LLAGE &Tv/T INSTA LLER'S NNAME i ADDRESS 8 U I L D E R OR OWNER /� ��i l�i� S • /yg-/2C�'o5 DATE PERMIT ISSUED 8/ �/93 DAT E COMPLIANCE ISSUED Ao_.;?o_f3 M �. �s C {J L� ... /� �� 8h l.' v �,�; r � No..... ..._3�6.y _ FEB10 ..........,,. ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................O F..................................................----........---------...............--•- Appliration for Bhipviittl Works Ton.strnrtion amit Application is hereby made for a Permit to Construct,( ) or Repair (1,1'an Individual Sewage Disposal System at: L- , ( ,rAt'-'4— .......... -l ... ./ LocatioA r s or Lot No. Al Di /0 0/ C� ..............................................._....... �1....,� --.... ....... -------------- w /a77� Address -2- ._ ....._.. ../... �Z .`J.. ... .....................•-......_.._....._.........................•.............. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) ..-- A-t� No. of persons............................ Showers — p`�., Other—Type of Building � p ( ) Cafeteria ( ) Q' Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------------_- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) . aPercolation Test Results Performed by....................................................................... . 1-4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....-................... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil........................................................................................................................................................................ x U •-••••••-•----•--------...-•••••--.........-•••--•---•---•.............•-•--.....--••------•-•---•••-------•-•-•-••••••.....•--•.......-------••-•-...-•-------•---•----------....--•---•-----•---•----- UW --•--- -•---•... ... ..e.- Nature of Repairs or lteratio —Answer when applicab,]�. 1 z. .......- otf ..... ?........... ......,� /..... ... r,c ::; 5!....._. 75. ------------------------------------ Agreement:S The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL IIL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until pa of Compliance has been issued e o eat . pp++ateAp�on r --.._..---• ----------- ------- ---•-----'�/...5►°f........... Date Application Disapproved for the following reasons:............................................................................................................... ...................................... ••...............•-......--•••- Date PermitNo......................................................... Issued........................................................ Date No.­11_50 ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ............OF Appliratiou for Mipoiial Workii Toutitrurtiou ramit Application is hereby made for a Permit to Construct or Repair (&*Jan Individual Sewage Disposal System at: ............................... ................................................w.................................................:�5A Id L 4fio , or Lot No. 6. -A....:.A le U..4 ................................................................................Dt....... . ..... A7 ----- .. Address &&.--0.0. .................................................................................................. Installer Address W Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms............................................Expansion Attic Garbage Grinder Pk Other—Type of Building ---1.1­4*-xw�— No. of persons............................ Showers Cafeteria P4Other fixtures ..................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow..........................................*Ions. W 04 Septic Tank—Liquid capacity------------gallons Length................ Width__............__ Diameter._-__........._. Depth-.'............. Disposal Trench—No.> .................... Width.............__._... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No.-........ .......... Diameter..______.___.___.__. Depth below inlet_..__._...._._____.. Total leaching area..................sq. f t. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date--------------........--------.......... Test Pit No. I................minutes per inch Depth of Test Pit..._..._............ Depth to ground water.......______.......,... Test Pit No. 2................minutes per inch Depth of Test Pit..._........._._.... Depth to ground water___......_.............. ........................................................... I ....*.......*.....;.................*­........................."------ 0 Description of Soil.....................................................................................................................I................................................... X U ......................................................................................................................................................................................................... . ...................................................................................................................................... --------- ........ ....... - ---------- --------- ;jature of Repairs or Al=ations—Answer when applicablF.-U. P�td:e....... ....... U .... ...... ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T LZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a 0 Certificat f Compliance has been issued tw a Tealt'h-.--, '7 ;4'4'1--Signed.! �.... .... ... .. ................. . .. . .............. ........ ...... ... Application Approved By...... .. ..... ....... V?/ . ....... Date Application Disapproved for the following reasons:............................................................................................................... ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued........................................................ Date J. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... Trrfifiratr of Toutplitturr THIS IS TO__CZRTIFY, That the Individual—Sewage Disposal System constructed or Repaired by...............................I_�. �..... ...... ....... ...................................................................................................... Installer at. .......... ..&-/ ............................................................... .............................:!��...... ...... has been installed in accordance with the provisions of TIT I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._....JJ?�-5. Y...... dated....._-____................. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... L�.J%,v 10 ......... Inspector......... J�......................... ....................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................�OF...................................................................................... NO .................. ... FEE........................ Riipoiiat Works T_ o n" iltrudion rautit Permission is hereby granteA T--," If I --- 4.J. .......7--...... ............................ to Construct or Repair ) all In4ivictual Seurag Disposal S st atNo............. ...........j;� ..... ----_-------- ....................................................................--- ------- Street as shown on the application for Disposal Works Construction Permit No.........-.--------- Dated.......................................... ......................................................... DATE--------------------------------- sir . ....... Board of Health FORM 1255 A. M. SULKIN, INC., 130STON