HomeMy WebLinkAbout0608 OLD POST ROAD (CT & MM) - Health F608 OLD POST ROAD, COTUIT
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VI4,XGE Cr-Try or ASSESSOR'S MAP & LOT CO3
Dqs 'ALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) "?\"TS (size) (12(.(.01 ;arm
NO.OF BEDROOMS $
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BUILDER OR OWNER La
PERMITDATE: lZ-'E�"� COMPLIANCE DATE: t\ "
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) _fJ J q Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within.100 feet of le ng facility) Al I' Feet
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Commonwealth of Massachusetts o�� 009-003
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 608 Old Post Road
Property Address
Bob Rowan .,
Owner Owner's Nam ',
information is
required for every Cotuit MA 02635 10-30-17
page. City/Town State Zip Code Date of Inspection
t�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling A. General Information
on the computer,
use only the tab �
key to move your 1. Inspector: .z� C,
cursor-do not James D.Sears =��.' JAMES m
use the return Name of Inspector :U
key. Capewide Enterprises
" Company Name 2i� TIFv6. `�.
153 Commercial Street
Company Address
Mashpe MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
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
10-30-17
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.
Z-o j�.� VS
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys em.Page 1 of 17
I '
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal. Tank D Box and two pits.
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and 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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal
Y P Y , P rY,
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 40ZQ= is less than 6" below invert or available volume is less
than '/day flow PITS
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , ' 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the 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
608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. CityrFown 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): 5 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is Cotuit MA 02635 10-30-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. Tank D Box and two pit's.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2015-148,000Ga
g ( y g (gp ))' 2016-78,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date �
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
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: NA
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
r
Commonwealth of Massachusetts
4 - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Around 1983/2014 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 34"
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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 22"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H-10
Sludge depth:
2"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
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
28"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and cover's at 22" below grade. Inlet tee, outlet baffle. No sign of
leakage or over loading.
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
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 11 of 17
P Y 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
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.):
D Box is 16"x16"-2' below grade w/cover at 6"two lines out.
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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth
ea th of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M s 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. Cityrrown 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.):
Leaching is two 1000 Gal.pit's. Pit#1)2' below grade 6"water. Pit#2) 30" below grade 8"water.
No sign of over loading or solid carry over. No high stain line. a
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is Cotuit MA 02635 10-30-17
required for every
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A! /3
57-oj'F,
13
_� s7
o
43 A`t- =38
O3 Q- _ t9
09
O II
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 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N®
Estimated depth to high ground water: 2
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:
Off asbuilt
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
24'+to G.W. per Asbuilt 12-83. Bottom of pit#2 at 9' below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 608 Old Post Road
Property Address
Bob Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 10-30-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I_
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
RI - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owners Name
information is Cotuit MA 02635 8-12-14
required for every _ _
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may,not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When Filling out forms A. General Informationon the _.
use only tab `\� 1��ZH OF rA4,1 ,,'
y 1- Inspector. a I (/ �I 0....... sr�
key to move your y�
cursor-do not James D-Sears : •DAMES N
use the return -
=0I —
Name of Inspector -
key. � H�• SEARS
CapewideEnterprises,LLC
----- ----- — ---
Company Name •. RTIFN O
} 153 Commercial Street iNSQE��
Compa ny Address ......►
Mashpee MA 02649
Cityrrown — State Zip Code
508477-8877 S 1623
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 C M R 15.000).The system:
® Passes ❑ Conditionally Passes ❑. Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-12-14
spectoes Signature Date-
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable,and the approving authority.
****This report only describes conditions at 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.
_ 115 1
t5ins•3n 3 • Title 5 Official Inspection o .Sribsurfaoa Sewage Disposal System•Page 1 of 17
d '�.'
9 6' d 1.9:60 t,1 Z l• 6nV
r..
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fours-Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
information is
required for every Cotuit MA 02635 8-12-1 4
C'
ttY page. !Town State Zi Code
P Date of Inspection
B. Certification (cont.)
Inspection Summary. Check A,B,C,D or E/always complete all of Section D
A) System Passes_
® 1 have not found any information which indicates.that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
f
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•V3 Title 5 Official Inspection Form:sLbsurlace sewage Disposal system•Page 2 of 17
61, d - . dl£:60t,1ZlbnV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name -
information is
required for every Cotuit MA 02635 8-12-14
page. Cityrrown State Zip Code.. Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ 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 Ins person Farm Subsurface Sewage Disposal System•Page 3 of 17
OZ'd dZC:60t,6 ZI. 6nV
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner owner's Name
information is
required for every Cotuit MA 02635 8-12-14
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 fleet 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 -
❑ N Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in ae p aiol is less than 6"below invert or available volume is less
than%day flow
t5uts-3113 71tie 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of'7
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f
Commonwealth of Massachusetts M
Title 5 Official Insp ection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner owner's Name
information is -
required for every Cotuit + MA 02635 8-12-14
page" CltyfTown State Zip Code Date of Inspection
B. Certification (cons)
Yes No -
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s).Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply. .
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-m
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, therefiore 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
❑N El the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes' in Section D above the large system has failed.The owner or operator of any large
system considered a'significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ins-3113 _ Y Title 5 Official.Inspection Form.Subsurface Sewage Disposal System Page 5 ad 17
ZZ d dZ£:60 t l, Z I. 6nV
Commonwealth of Massachusetts '
_ Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
information is
required for every Cotuit _ MA 02635 8-12-14
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No - s
❑ 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?
Z ❑ Were all system components, excluding the SAS, located on site?
Z ❑ 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): , NA Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewagq Disposal System•Page 6 of 17
d r
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Commonwealth of Massachusetts
_ Title 5 Official- Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
608 Old Post Road
Property Address
Nangy Rowan
Owner Owner's Name
information is CotUit
required for every MA 02635 8-12-14
page. City/Town State Zip Code Date of inspection
D. System Information m
Description:
T The s stem is a 1500-Gal. tank D Box and two pits. '' n
Number of current residents: 2
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 IR No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(dpd)): 2012-124,000Ga1
2013-122,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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.):
1
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:
[51ns•3/13 ;Title b Official Inspection Fame Subsurface Sewage Disposal System-Page 7 of 17
t�Z'd d££:60 ti 6 Z I. 5nV
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Uvol:f 608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
inforrnation is
required for every Cotuit MA 02635 8-12-14
page. Cityrfown 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: 8-7-13
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/Altemabv"a 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):'
tsim•3/13 - Tilts 5 Official
a inspection Form:Subsurface Sewage Disposal System•Page 8 of 77
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t ,
608 Old Post Road
Property Address
s
Nancy Rowan
Owner Owner's Name
information is
re uired for every COtUit MA 02635 8-12-14
page. CityMwn State Zip Code Date of Inspection
D. System information (cant.)
Approximate age of all components, date installed(if known) and source of information.-
Around 1983 / 2014 New D. Box
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: Unfeet
Material of construction:
❑ cast iron ®40 PVC 0 other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank (locate on site plan):
Depth below grade: 2-2"
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
a
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H 10
Sludge depth:
t5ins-3113 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
9Z•d dtC:60t,1 Z6 6nV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
608 Old Post Road "
Property Address
Nancy Rowan
Owner Owners Name
information is
required for every Cotuit MA 02635 8-12-14
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 28"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 12"
Distance from bottom of scum to bottom of outlet tee or baffle 18"
r
How were dimensions determined? Asbuilt-Tape
Sludge Judge r
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and cover's at 22" below grade. inlet tee,outlet baffle. No sign of
leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
f •
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions: fi
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 1a cf 17
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LZ' . - d5£:60 ti L Z l sny
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road _
Property Address
Nancy Rowan
Owner Owners Name T information required
is Cotuit MA 02635 8-12-U
required for eery
page. City1rown 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.):
. i
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-3113 Tille 5 Official Vwclien Farm:Subsurface Sewage Disposal System-Page 11 of 17
{
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan _
Owner Owners Name
information is
required for every COtUIt MA 02635 13-12-14
page. Cityrrown State Zip Code gate 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.):
D Box is 16"x16"-2' below grade w/cover at 6"two lines out.
Pump Chamber(locate on site plan):
Pumps in working order. Q Yes Q No"
Alarms in working order: Q Yes Q Noy
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n
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:
l5ins-3113 Title 5 0f1kW Inspection Form:SLOsurface Sewage Disposal System•Page 12 or 17
6Z,d d9C:60 1, Zl, 6ny
Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
information is required for every Cotuit MA 02635 8-12-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number-' 2 ----
❑ leaching chambers number:
r
❑ leaching galleries number:
❑ leaching trenches number, length: --
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system -
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc_):
Leaching is two 1000 Gal. Pits. Pit# 1 )2' Below grade 1'.water. Pit#2) 30" below grade 2'
water. No sign of over loading or solid carry over. No high stain line.
;r
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 Ins• - pection Form`.Subsurface Sewage Disposal System-Page 73 of 17
i
OE d d5C:60 b1 Z l 6ny
I
Commonwealth of Massachusetts
Title 5 .Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
608 Old Post Road
Property Address —
Nancy Rowan
Owner information is Owner's Name
required for every Cotuit MA 02635 8-12-14
page. CityrTown 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.):
t II
4
. t5iru•3/13 - Tide 5 Official Irgm=thm Forth:SuDsutface Sewage Disposal System Page 14 of 17
d
6£' d9£:60.t,1 Z6 shy
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F
. i608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
information is
required for every Cotuit MA 02635 8-12-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cons.)
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
3 G'�RraC�
7 I3
-a - � ,
i
15ins•3/13 Tltle 5 Official Ins- pection Form:Subsurface Sewage Disposal System•page'IS of 17
Z£'d d9£:60t 1, Zl, 6nV
Commonwealth of Massachusetts
Title, 5 Official Inspection. Form
- Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
information is
required for every Cotuit MA 02635 8-12-14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.) .
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
fe ett
Estimated depth to igh ground water: 2
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:
off asbuilt
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
241+ to G.W.per Asbuilt 12-83_ Bottom of pit#2 at 9' below trade.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15ins-3M3 Us 5 bffidal Inspection Forth_Subsurface Sewage Disposal System-Page 16 of 17
I '
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
Subsurface Sewage Disposal
_ System Form Not for Voluntary Assessments
608 Old Post Road
Property Address
Nancy Rowan
Owner Owner's Name
information is Cotuit MA 02635 8-12-14
requiredequired for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C,"D.or E checked
L •
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information- Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
r
.L`
t5ins-3M3 - - Title 5 official Inspection Form:Subsurface Sewage Olsposal System-Page 17 or 17
b£'d dL£:60t,1 Zl 6nV
No. d( d 7 Y Fee_Ilk)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
fiprftation for Disposal 6pstem Construction Perron
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. Ic0$ O c3) POS X0Ab Ow er's Name Address, nd Tel.No.
gut< WAjc-Y �
Assessor's Map/Parcel c):5,4 a6 Q 5$1 WASTV s Cie( P44q Qi64G4 GAVo&-is
Installer's Name,Address,and Tel.No.50 —41?7 7 Designer's Name,Address,and Tel.No.
Lt h ( 440C Es-i WkJ55 U_/1 N�i4
153 60 C
Type of Building:
Dwelling No.of Bedrooms Lot Size 14 3 -5 t0— sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
RcPcACG _D 80 X
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by rMCI Date —�
Application Disapproved by Date
for the following reasons
Permit No. a- —;7 7 T Date Issued — l
- --- --------------------
No. (� 7 L/ - Fee (4'J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitation for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System [Individual Components
,Location Address or Lot No. (®p S 0 d) k6—t dLOAn Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel 05 pb p 5$► STOCS C� B64c { 604gpa-K
Installer's Name,Address,and Tel.No. 50 —477 297 7 Designer's Name,Address,and Tel.No.
CAA6Z4,Y06 E0iW101_1;5 U_X, J
Type of Building:
Dwelling No.of Bedrooms Lot Size 43 15 60- sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of,Septic Tank Type of S.A.S.
Description of Soil
d .
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title'5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date (L/
t Application Approved by Date
v
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
• ��i ,t
THE COMMONWEALTH OF MASSACHUSETTS
n _�G BARNSTABLE,MASSACHUSETTS
P `Ce Certificate of Compliante
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( )
Abandoned( )by C 4 Q c—LOI D C &Zrj�RP.15ZC
at 402 D(-b S%-R0A7) CCyT U I T" has been constructledd in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.d a) 7 , 71 dated
Installer 64G.w('0 E'6�jT6 Ri 41KEC LGG Designer ;
#bedrooms /j Approved design flow A /J A- / gpd
s'�, ( fE /
The issuance of this permit shall not be construed as a guarantee that the system will function as,de signed.
Date t`, ! f 1 Inspector s�,a'fit% �lrl„ r 0 �Pli
'!
_ V
/ /
No. � � �Ll � ) � LI - Fee-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposai *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( )
System located at LO R OLZ (7 ST RDA!) C O (2(-I
,.•�^ . and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date Approved by
COMMONWEALTH OF MASSACHUSETTS
z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A tie
� � I
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION � , -`A:
Property Address: #608 old Post Road '
Cotuit,MA
Owner's Name: Larry&Susan Wheatley a :
Owner's Address: 608 Old Post Road =
Cotu it,MA 02635 >
Date of Inspection: 06-26-07
r�
Name of Inspector: (please print) Mr.Carmen E.Shay r
Company Name: Shay Environmental Services,Inc.
Mailing Address: 185 Ashumet Road
Mashoee,MA 02649
Telephone Number: (508)-548-0796
CERTIFICATION STATEMENT. ,
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
XX Passes . .._,_
cttQ�;fq
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority o CAR'c0EN G
Fails E. rq
v SHAY Z
Inspector's Signature: Date: 06/26/07 0 `�o
9TlF pQ
FS INS?S
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heal q=:
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
No evidence of hydraulic failure noted in leach pit. 3.5'effective depth available in Pit#2.
****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. /
r Q/
Title 5,Inspection FormR 6/15/2000 page 1
r Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(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:
• Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry& Susan Wheatley
Date of Inspection: 06/26/07
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
XX Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
XX Any portion of the SAS,cesspool or privy is below high ground water elevation.
XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
XX Any portion of a cesspool or privy is within a Zone 1 of a public well.
XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large 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"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I1 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
.. 11 r .,..,,.,.,,,. 4
Page 5 of 11
15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
XX Pumping information was provided by the owner,occupant,or Board of Health
XX Were any of the system components pumped out in the previous two weeks
XX _ Has the system received normal flows in the previous two week period'?
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up ?
XX _ Was the site inspected for signs of break out
XX _ Were all system components,excluding the SAS, located on site?
XX _ 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?
XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
XX _ Existing information. For example,a plan at the Board of Health.
XX _ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: #608 Old Post Road.
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: Unknown
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 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: None on File
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX 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:
1983-per BOH Records
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #608 Old Post Road
Cotu it,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction: cast iron _40 PVC XX other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 12"to Top of Tank
Material of construction: XX 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: 5' deep x 5'wide by 10' long 1,500 gallons)
Sludge depth: 4.0'
Distance from top of sludge to bottom of outlet tee or baffle: 2'
Scum thickness: '/ inch scum laver noted
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
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.):
Structural integrity of tank was ok. No evidence of cracks, leaks,or water infiltration/exfiltration. PVC TEE present at inlet
end. OutletTEE present and in good condition. Liquid level equal with outlet invert.
GREASE TRAP:_(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.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
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.):
DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.): D-Box Present -2 outlets.
PUMP CHAMBER: (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.):
9
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
XX leaching pits,number: 2 Leach Pits,both Concrete precaste
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.): No evidence of hydraulic failure of septic tank or of leach either leach pit. . Top of leach pit is 30"
below ground. 1.5' Effective in Leach Pit#1 3.5'effective depth availablein Leach Pit#2
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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
.,..,. 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry& Susan Wheatley
Date of Inspection: 06/26/07
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.
Swing Ties:
A- Tank In—23'
B- Tank In—57'
A—D-Box —38'
B—D-Box —67'
A—Leach Pit#1 —61'
B—Leach Pit #1-68'
A—Leach Pit#2 —4 F
B—Leach Pit #2-59'
Exist House
Garage B
O
Septic Tank O
(1000 Gal.) Water Line
D-Box
Leach Pit#1 Leach Pit#2
O O
10
y Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #608 Old Post Road
Cotuit,MA
Owner: Larry&Susan Wheatley
Date of Inspection: 06/26/07
SITE EXAM
Slope
Surface water -'h mile+/-
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 20' 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:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Quadrangle of USGS Map.
Per USGS MAP PLATE 2:
Elev.of Ground=40 Feet
Elev.Of Groundwater=5 Feet
Elev.Of Bottom of Leach Pit 31 Feet
Therefore: 31 —5 =26 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW-29(B): 1.7 feet
Adjusted Groundwater Separation=31—6.7=24.3 feet between bottom of pit and adi. groundwater
Grade=Elev.40eet
Pit#1
Septic Tank
Bottom of Pit=Elev.31 feet
Adj. Groundwater=Elev.6.7
ay a
'down of Barnstable , -
• i Department of Health, Safety, and Environmental Services
wuasrrAMA
"t"K%639. Health Division
367 Main Street, Hyannis MA 02601
office: 508-790-6265 js Thomas A.McKean
FAX: 508-775-3344 J Director of Public HeaM
June 12, 1995
Susan Wheatley
608 Old Post Road
Cotuit, MA 02635
Dear Ms. Wheatley:
The septic system owned by you located at 608 Old Post Road, Cotuit was inspected on
April 23, 1995 by Julius Morin a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has passed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) . However,'the following should be
corrected:
• No riser provided over septic tank
Please telephone Health Inspector Edward Barry within thirty (30) days to discuss your
intentions in regards to rectifying this.deficiency.
PER ORDER OF THE BOARD OF HEALTH
Poma A. McKean, R.S., C.H.O.
Agent of the Board of Health
ASSESSORS MAP NO:
PARCEL N0:
r�
b
Town of Barnstable
Department of Health, Safety, and Environmental Services
Health Division
t679 ,�
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean
FAX: 508-775-3344 Director of Public Health
June 1, 1995
Bmbwaftellir
Old Post Road
Cotuit, MA 02635
Dear Ms. A�-, W"+t)
603
The septic system owned by you located at 6V Old Post Road, Cotuit was inspected on ~
April 23, 1995 by Julius Morin a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has passed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) . However, the following should be
corrected:
• No riser provided over septic tank.
Please telephone Health Inspector Edward Barry within thirty (30) days to discuss your
intentions in regards to rectifying this deficiency.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
,AWE Town of Barnstable
Department of Health, Safety, and Environmental Services
BARNSTAOM
'""9
039. Health Division
♦�
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A McKean
FAX: 508-775-3344 Director of Public Health
June 1, 1995
Barbara Assella
600 Old Post Road
Cotuit, MA 02635
ORD TO COMPLY TH 310 CMR 15.00, THE S A E ENVIRON TAL
CO , TITLE 5.
The septic system owned by you located at 688 Old Post Road, Cotuit was inspected on
April 23, 1995 by Julius Morin a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has passed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) . However, the following s�all be
corrected: oj)L.
• No riser provided over septic tank.
You redirected to bring th tic system into comp ce within thi 0)'days of `'rece} t, his order letter. ,
erson aggr ' by any order is ed by the local app v 1 authority may peal to VV
any co rt of co tent jurisdiction a pr vided for by the la of the Commo wealth.
4V -� rachi�zy
PER ORDER OF THE BOARD OF HEALTH �``s c`�"`�
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
i
[Installer.letter] `n
TO: e t6 1' �� �� (Date)
l� po e4
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5. ll
z'tT
The septic system owned by you located at prn)- opci. C0 was
inspected on 23 by'�1ij5 M o r,', a Massachusetts licensed septic
inspector.
The inspection of your septic system showed that your system has upder the
guidelines of 1995 TITLE 5 (310 CMR 15.00) mg:
4
You dir o hire a licensed Town of Barnsta >c sy ern inst ller to a
sketc di gram of propose ystem o the of Ba stabI visio O it e
(To n all, 367 in Str t, Hyannis tha ill bring the eptic stem int mpl' ce
wit 10 CMR 15. a State Enviro mental Code, Title thin(14) fourteen days of
receipt of this notice.
You area* directed to bring the septic system into compliance within thirty (30) days of
receipt of this order letter.
Y e her i ec d to aintai a syste by hirin d septage hauler to
p p th a t' sy em to pre ischarge of sewage or effluent into the ui ,
the surface o the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
I
E
4
i
j
r
s 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
M �Q FLOW CONDITIONS
If residential
«i Huai
nun er :ofr'bedrooms
z5� numberwo:f-::.,.current residents
garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: r
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
IU System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
N
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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
.information:
Sewage odors detected when arriving at the site, yes or no
' ASSESSORSMAPN �
PARCELNO:-s14 ��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property
Owner's name UAPR
O tl ED
j Date of Inspection
PART A 8 1995
CHECKLIST DEPT.. ^
TM RNS
",;.�-
Check if the following have been done: x ..."
Pumping information was requested of the owner, occupant, and Board of
Health.
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.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
Cl---,The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
11 /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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance ,of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: 16ao Ste/
(locate on site plan) y
r
depth below grader
material of construction: Ll concrete metal FRP other(explain)
dimensions:
IJ
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
_"2'distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outic� tee or baffle
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, recommendations for repairs, etc. )
.�;
049
DISTRIBUTION BOX:
(locate on site plan)
d depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leak ge into gr out of box, recommendation for repairs, etc.)
PUMP CHAMBER:
(locate on site plan)
pumps in w ro king order, yes or no _
Comments:
(note condition of pump chambers o ition of pumps and appurtenances,
recommendations for mainte ai"ce or rep 'rs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits �and number - �®
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condit of vegetation, reco en atipns for maintenance or repairs,etc. )
CESSPOOLS -�E SPOOLS (locate on site plan) :
number and conf. ion
depth-top of liquid to ' let invert
depth of solids layer
depth of scum 'layer
dimensions of .cesspool
materials of construction
indication of1groundw r
inflow (cesspool st be pumped as
part -of inspec ' on)
Comments:
(note condition of soil, signs of hydraulic failure, level of-ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
i
PRIVY:
(locate; on site plan)
materials of construction
dimensions
depth of solids
Comments: --�
(note con ition of soil, signs of hydraulic failure, vel of ponding,
condition of vegetation,- recommendations for maintenance or repairs,etc. ) .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE �1* =SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
G,
DEPTH TO GROUNDWATER
+ depth to groundwater
method of determination or a proximation:
o �.
4
r
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
l� Discharge or ponding of effluent to the surface of the ground or
surface waters?
-A—j Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert' or available volume< 1/2 di
flow?
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
� Is any portion of the SAS, cesspool or privy:
/ V{/ below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
1 v within 50 feet of a bordering vegetated wetland or' salt marsh
(cesspools and privies only, not the SAS) ?
y " within 50 feet of a private water supply 1 well?
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 ana "
for coliform bacteria, volatile organic compounds, ammonia nitrog y
and nitrate nitrogen..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART D ,
CERTIFICATION
Name of Inspector J u ( t b S 0, as
Company Name
Company Address
Certification Statement
I- certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maiitenance of on-site sewage disposal systems._
Check one: indicates that the system fails
have not found any information which Y
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section -of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature
Date
Original to system owner
Copies to: (fee-�y
Buyer (if applicable)
Approving authority �G2�V$��t�✓'��
I
LO`L ION ' Pcel 5EW8,C4E PERMIT UO.
paA7
iNSTQLLER 5 ►/&ME AD R SS
13U1 ER IJhV-AE , D CT F-p S
D 'C P R ►T IS UED
� E E tvt, 5
DATE COMPU ®MICE ISSUED :
d3� i
v4
�M
e. r
' NoUf S
THE
COMMONWEALTH
AOF F s
BOAR HEALTH
..................OFT
f �...................................
Appliratiun for Disposal Marks Tonstrurtion 11trutit
Application is hereby made for a Permit to Construct (�r Repair ( ) an Individual Sewage Disposal
System at: -/
................___...._O ....��.r .. ......a:....... `o&�_-�.................................... � ( ..................._............_....
Location- ress � ��7 ' or Lot No.
_... ......._ . .__......
Owner Address
w _
.............. ... .Installer........-•-------........... w......................................•-•...Address ..........._.._..--•-•-••............
faY'� Type of ding Size Lot..4_3...57�®.S .
14V ling—No. of Bedrooms.................. ........................Expansion Attic ( ) Garbage Grinde 6
A4 Other—T e of BuildingNo. of persons............................ Showers — Cafeteria
04 Other fixtures -----•-----••--•-•..................................._.__ .
W Design Flow...............6 ........:.,..gallons per person per day. Total daily flow........................ gallons.
WSeptic Tank—Liquid capacity�..4. _gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.................... Width...... ............. Total Length............. Total leaching area--...----per-- -..sq. ft.
Seepage Pit No........... ..... meter.......i........ Depth below inlet............... Total leaching area...4-09..sq. ft.
Z Other Distribution box (6 Dosing tank ( )
0-4 I-APercolation Test Results Performed by... - f' ........ 4_:1�...: ......
Test Pit Nn. 1.....::? minutes per inch Depth of Test Pit......`7Z..... Depth to ground water....r=....
0-4
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W •. ................ ......•------------•----....-••-..............
0 Description of Soil..............•---•--•---....-•--•---•--••----•-•-----•••-•.........---....••--- -------------- ..... ..........
U .................................................................................................�._...-----. *-� ?�.- --..........•--------.......--------••----
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
...................................................•---•---•-----.......----•--•----•...•-••----....._.......-•-......---....---...------•--•-••---........•-----.......---••-......................•••.
Agreement:
The undersigned agrees to install the of Ind' 1 ewa a Disposal System in accordance with
the provisions of iITL1 5 of the State Sanitar h de urther agrees not to place the system in
operation until a Certificate of Compliance has b t h.
ign .. .... .................................... ---... ....... ........_....
to
ApplicationApproved By-- ...... •. :............ ................----•-•-•--------..........•--. ... . ..... ----- 2........
Date '
Application Disapprov for a following reasons--------------------------•--...--------•----•------.....................-•-•-•-----•••....................---
.................................•---•--••-•-•---•-••------••--•------•--•••••.........••--•------•.......---•---••••----•---•--•-----------•----•--.......-----...........-----...................--•--
Date
PermitNo......................................................._ Issued......................................................_
Date
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARC�OF HEALTH
..................OF.....: -i-\.a. ....................................
Appliration for Disposal Works, Tonsuvrtion rnmit
Application is hereby made fora Permit to Construct (Vil"or Repair an Individual Sewage Disposal
System at:
......................................... % ......fl. .........L .......................................)
Location-M�,e.. or Lot No.
...................... ......k I ................................. .....................................................I.......................... ...
Owner Address
...........
Installer
Type, of 3 Iding Size Zssot..A ....ZO..Sq. feet
U I g
4 ling—No. of Bedrooms'-1.1.11111114' ".------------------..Expansion Attic Garbage Grinder ( )
a4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ......................................................................................................................................................
Design Flow............... ........... 4� .....gallons.
;,,...gallons per person per day. Total daily flow.......................9 Septic Tank—Liquid capacity/!�.*..gallons Length................ Width................ Diameter................ epth................
Disposal Trench—No. .................... Width.....0.............. Total Length............. Total leaching area...................sq. ft.
Seepage Pit No........_. ...... iameter......;?........ Depth below inlet..... ./........... Total leaching area...Z�=O.Q...sq. ft.
Z Other Distribution box (;e Dosing tank ( )
0.4 Percolation Test Results Performed b _ Z7-kAL.... ..........4..,1aJ6 ........ ......
Test Pit No. I....Z:Kv�inutes per inch Depth of Test Pit......J..-;2...... Depth to ground water...
0.4 1 %__
LTq Test Pit No. 2................minutes per inch Depth of Test Pit............._._....
Depth to ground water........................
9 ...*"..........................*..............*.....".....*...*..........*'"*......**.......*-------*------*"**'*.............**...----------------
0 Description of Soil........................................................................................................................................................................
......................... ---------*......... .,.......... ...............................................................
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the of In I ew e Disposal System in accordance with
the provisions of TITLE 5 of the State Sanit de s d urther agrees not to place the system in
operation until a Certificate of Compliance ha b su t th.
Sign7. . . .................................... ...... .. ............
te
........ ....
............... ..............................................
Application Approved By.
r 1hefollowing reasons:..........................................................................................................---
Application Disapprov fo
......................................................................................................................................................................................................
Date
PermitNo................................................... Issued.....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(9prfiftrate of Toutpliaurr
T CERTIFY, That the Individual Sewage Disposal System constructed Repaired
or .
....................% ......;�. ........ ............ ... ............byzzff," � .6, . .........................
In�;I"V Inst I
.;....... . .. .. .....
...................
------ 77--
. . .........
at.....e ......... ................ ........ . ....... 21-�__
T! ?. ................
S been installed in accordance with the provisions ' TIT 5 of The State Sanitary Cod�eZ!s d�e;qr- in the
application for Disposal Works Construction Permit No4__ ........Z..q........... dated...;//2 1'—7 .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE
SYSTEM W LL FUfCTION SATISFACTORY.
...........
DATE./�� ..........................................I................... Inspect ...... ...........................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Z owl
...........................................OF..........
...........................................................................
Tottslrudiott rrrmft
Permission is herebanted.../"'
............ n.............
4 __ -1 �_ _1_1"1_**_"_1111_*****--------------
i S w
to Construct i !pa -nd w e ljIS? y
_T
............. ....... .......... ....... ......................... .. ...... ............
......... S
at No...... ............ ..... ...
Street
as shown on the application for Disposal Works Construction Permit No................... Da . .... ....... .................
............ ..... .......................................................
DATE... .................................................... Boa. of Health
FORM C-1255 CITY& TOWN FORMS, INC.369-9708
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as
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1 inch = 40 ft.
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LOCUS n
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CvDk 054-009-004
ppS
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� COTUIT BA Y
•" "•„•",,,•, LOCUS MAP
PLAN REF- 373 26
..............16 "' s•:ss � X ISTsINGs
DEED REF 18283-345
.4
ZONING: "RF"
...."
"s"iHOUSE"s��� SETBACKS. 30'-15'-15'
ASSESSORS '%%%%%%%%-%%%%%'%% s FLOOD ZONE:
054—008 { PANEL NUMBER: 250001 0018 D
LOT 7 DATED: 07-02-1992
ASSESSORS
054-009-001 PLOT PLAN OF LAND
�A ft
LOCATED AT-
o 608 OLD POST ROAD
D CO TUIT, MA.
PREPARED FOR.
LOT 5 j .ROBERT ROWAN
ASSESSORS
054-009-003 z�k OF 1,1,q. ® OCTOBER 02, 2007
AREA=43,560fS.F' �s�S�°�
STEPHEN REV-
J.
J, ran
DO#37 REV.
a.9 � �
ca ;w O pF REV
R=224.10' - o ®® YANKEE LAND SURVEYORS
L=70.12' N81o¢19»yY & CONSULTANTS
7`9
OLD �7-�
n .88' (fXD) P. O. BOX 265
�,S'1 UNIT 1, 40 INDUSTRY ROAD
R04-D MARSTONS MILLS, MA 02648
TEL., 508—428—0055 FAX 508—420—5553._
SHEET 1 OF 1 JOB OF 54284 JF