Loading...
HomeMy WebLinkAbout0644 OLD POST ROAD (CT & MM) - Health 1 i 644 Old PoNst Road Cotuit J J / TOWN OFF "UNSTAB u ,� SEWAGE# Lt?CA`IZQN : F5TALLER`S:i`tAl &3'Fi ldir NO SAC TANK At;IT'X Li�AC�TIIt�IGFACII:iTY ( ) _ N4.t)FBiI3 �OMS BtJ3I[)ER OR OWi+IER PERMITDI�TE. �(3ivf'Pf.fANCE DA"�' Scparstion Dcstancc Between`tic `� - ` Feet Maxum 13 Adiustesl GroundwaterTable to the Bottom of Leaching Facility' Pnvat 1taterSuppty Well atid�eacna Facie ► El :'auY�aretts.east as seta or vntinn?Alf feet of ieach►`n8 f��y) Edge of VFTettand and°Lsactung ' tYY wetlau�ds exist Feet whin 3QE3'`feet of teactua faccirt�►� L� Pp T C 1A.pP j D � 3 a 3 A -3� ` r¢q- ��` Commonwealth of Massachusetts D 09_D Oa-- r� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f f� bra P 644 Old Post Rd Property Address , Carol Ball Ryan Owner Owner's N2e information is required for every Cotuit MA 02635 1-15-20 ` - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information (54 /y3Sb Shawn Mcelroy Name of Inspector Upper Cape Septic Services A Company Name P.O. Box 73 Company Address E. Falmouth, MA 02536 City/Town f State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposalisystem at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes { 2. ❑ Conditionally Passes , 3. ;❑ Needs Further Evaluation,by the Local Approving Authority 4;nspector's El Fails 1-15-20 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 r Commonwealth of Massachusetts ' Title 5 Official Inspection Form �rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary , Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:.x , ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. System has signs of tree root intrusion. Recommend regular pumpings to keep under control. 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 t , c Commonwealth of Massachusetts Title 5 Official Inspection Form !A Ibi Subsurface Sewage Disposal SystemiForm -Not for Vol u ntary,Assessments •a =>` 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is Cotuit MA 02635 1-15-20 ' required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) , 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational..System will pass with Board of Health approval if pumps/alarms are repaired. ` ❑ 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): - r ❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑N '❑ ND (Explain below): ❑ 'distribution box is leveled or replaced ❑Yr ❑ N ❑ 'ND (Explain below): t ❑ 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): 3) 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. ` a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form 'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a rI- ,> 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is Cotuit MA 02635 1-15-20 required for every - page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) n - ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. []The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or " more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 , qrj!, Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form I� w' ,- : i6lI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. A, 644 Old Post Rd - Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) . Yes ,No ® Static liquid level in the.distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available.volume is less than '/2 day flow ' ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd.- ❑ ®' 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: 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. .- .� 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you ihave answered "yes"to any question in Section C.5 the system is considered a significant threat; or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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) ® El,, 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? ® ❑ Wasthe 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts ; r"� 3 Title 5 Official Inspection Form 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . °.. 644 Old Post Rd ;Property Address Carol Ball Ryan 0-1 Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information _ 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: r,• 0 Does residence have a garbage grinder? El Yes ® No Does residence have a water treatment unit? _ - '.t .,, ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: t Sump pump? ❑ Yes ® No Last date of occupancy: 2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 r Commonwealth of Massachusetts r -, Title 5 Official Inspection Form i,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 City/Town/Town State Zip Code Date of Inspection page. Y p p D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts - pl,, Title 5 Official Inspection Form ! i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? - -❑ Yes ® No f 5. Building Sewer(locate on,site plan): 24" Depth below grade: feet Material of construction: '•,r ` ' ji ❑ cast iron ® 40 PVC ❑lother'(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts rr Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 644 Old Post Rd Property Address - Carol Ball Ryan Owner Owner's Name information is required for every Cotuit ' MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 18" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12° Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" . Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Recommend pumping for solids. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 ` Commonwealth of Massachusetts , Title 5 Official Inspection Form ! 1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 644 Old Post Rd � Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) -� 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): �' , 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments > 1.: 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) : 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 r Commonwealth of Massachusetts - r Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 644 Old Post Rd ' Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit - MA 02635 1-15-20 page. City/Town . State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condit ion of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not.required): If SAS not located, explain why: Type: ' ❑ 'leaching pits' ` .,, number: ® leaching chambers number: 3-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 I Commonwealth of Massachusetts - r1 -� Title 15 Official Inspection Form 54 Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments �:_�J, 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach ,chambers in good condition and empty at inspection with stain line at 3"off bottom of chamber. I I 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depthl—top of liquid to inlet invert Depth of solids layer Depth of scum layer I Dimensions of cesspool Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):!. i i j t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 l i Commonwealth of Massachusetts r Title 5 Official Inspection Form ISM Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 644 Old Post Rd Property Address r . Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official lnspection Form ? il Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is Cotuit MA 02635 1-15-20 required for every • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 33 30i , � r t5insp.doc•rev.7/26/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 16 of 18 r . Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form - i-'G Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' a 644 Old Post Rd ' Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)' 15. Site Exam: _ ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 124 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record Y 9 1 ,If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts - / Title 5 Official Inspection. Form ,I C�i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 644 Old Post Rd Property Address Carol Ball Ryan Owner Owner's Name information is required for every Cotuit MA 02635 1-15-20 page. City/Town , State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 11, 2, 3, or 5 completed as appropriate i 4 (Failure Criteria) and 6 (Checklist) completed I ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached for 15: Explanation of estimated depth to high groundwater included I I { t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BAM STABLE OP 7/d//Iotl LOCATION C9 q DLD p.6� SEWAGE # 21Zg Q T VILLAGE_ ��t31 ASSESSOR'S MAP&LOT t(1U694r & INSTALLER'S NAME&PHONE NO. ION[ ilCyltl�0 I.�DSJ� Z�' � SEPTIC'TANK CAPACITY LEACHING FACILITY: (type) WC (size) ✓.�.xl� 'NO.OF BEDROOMS 3 ` BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by zf 7 �Yr 3 b . q No• h Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for igpogal *pgtem Conmruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Pe6omplete System ❑Individual Components Location Address or Lot No. &`/T OLD P05T R D Owner's Name,Address and Tel.No. L , Assessor's Map/Parcel co-ro i,r b/9LC. Installer's Name,Address,and Tel.No. _Q Designer's Name,Address and Tel.No. 7 Z5-Q-7 3 S Type of Building: Dwelling No.of Bedrooms 3 Lot Size tl��S60 sq.ft. Garbage Grinder(d/�y Other Type of Building WOOD FM4L No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design FlowD gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �S V0 Type of S.A.S. PZ775 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a.Certifi- cate of Compliance has been issued by this Board of Health. Date Application Appro b Date a'�n�eL1 Application Disa the fol �in,,easons Permit No. c9OO "oS �' Date Issued ——————————————————————————————————————— P No. :.� _ r Fee tHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH-,-DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication`for �Digpogar *pgtern Congtruction Permit i Application for a Permit to Construct(V)Repair( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. pq O D PQ S T R t Owner's Name,Address and Tel.No. o-rtJ /T MZOL l3t9LL �Y11ti Assessor's Map/Parcel .SL/ D P Goa C� A fi Y5/� (/9 �7/_ Installer's Name,Address,and/Tel.No. _ ?6 Designer's Name,Address and Tel.No. "?7 5'`Q-7 3/� D M 1<1 9NA4/ lJ y GUI GGIEW 7- /1 556 C Type of Building: ;J Dwelling No.of Bedrooms .3 Lot Size q3, sq.ft. Garbage Grinder(.r,/,y Other Type of Building WOOD FP'A*&f No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 100' gallons per day. Calculated daily flow gallons. Plan Date 4/ A V A:2 Number of sheets Revision Date Title Size of Septic Tank /:5 00 Type of S.A.S. e.ZTS Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last-inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. �Si_gned, Date Application Approved b, by Date a 1!'7jaq Application Disapp ued fob the f6117 mg easons Permit No. •v�U V —0 51' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired ( )Upgraded( ) Abandoned( )by V(W K,!FNXIr-h y at 6 < </ OLD 5 Q !/I 1— has be-en constructed in accordance with the provisions o_f_Title'5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of thi permitlshall not be construed as a guarantee t the syste I n tion as designed. Date �,��1.-7/d��} Insspctor t ' No. f��V T U 5 Fee 0© THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigoga[ /*pgtem �Congtruction Permit Permission is hereby granted to Construct(V)Repair( )Upgrade( )Abandon( ) System located at 1/�( %1 L b &5� cd ro i T and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi, e nit. Date:_ "7��' `'� Approved-by TOWN OF BARNSTABLE 7/01//0� LOCATION (P,lq OLD Pe D_ SEWAGE # q—65W. VILLAG ASSESSOR'S /MAP & LOT INSTALLER'S NAME&PHONE NO. IDa[ KCAK"f.�48J,3lo2 � SEPTIC TANK CAPACITY. DO H�1 LEACHING FACILITY: (type) !�C (size)Of NO.OF BEDROOMS 3 BUILDER OR OWNER 1 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /c IOU �rDY1 z�7.. y9 " Town of Barnstable �OFTHE Tpk� Regulatory Services Thomas F. Geiler,Director r * BARNSTABLE, 9�A MASS. �' Public Health Division 659. Thomas McKean,Director - 200 Main Street,Hyannis,MA 02601 t , Office: 508-862-4644 Fax: 508-790-6304 . i I Installer & Designer Certification Form Date: g^o Designer: Installer: Address: /�� „ � �� Address: J"7,�Gl//A�w s/ PAd On was issued a permit to install a (date) (installer) septic system a 4,d2 cx . 5;0 based on a design drawn by (address) ' -� , dated (desi er) I certify that the septic system referenced above was installed substantially according to k the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. M I certify.that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as,-built by designer to follow. I"OF DANIEL BRAMAN (Installer's Sign e CIVIL N No."32686C " n ASS/OVAL ECG\ (Designer's Signature} (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form °PYRE ra,, Town of Barnstable Inspectional Services r t * * MUMSTABLE, 9 MASS. pr039.�6 Public Health Division . Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 , Certified Mail: 7015 1730 0001 4990 0256 October 22,2018 Carol Ball Ryan 644 Old Post Road Cotuit, MA Finding of Unfitness for Human Habitation and Determination of Immediate Danger In accordance with M.G.L: c.111, sec. 127A and 127B, 105 CMR 400.000: State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Humans. Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable on October 22, 201.8 conducted an investigation of a dwelling unit located at 644 Old Post Road, Cotuit, MA. The owner's name of this dwelling unit is Carol Ball Ryan. The tenant(s)name(s) are Carol Ball Ryan and Richard Ryan. Based on the results of that investigation, the Barnstable Health Department finds that the dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and 105 CMR 410.831 (D), (E) the Health Department further finds that the conditions within the dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay may be permitted in making this finding. Conditions found within the dwelling,which give rise to the emergency finding of unfitness and determination of immediate danger, include: 410. 750: Conditions Deemed to Endanger or Impair Health or Safety 410.750 (B) - Failure to provide heat. 410.750 (C) - Shutoff and/or failure to restore electricity, gas or water Based upon these findings any and all occupants are hereby ordered to vacate within (24) twenty-four hours and the landlord/owner is ordered to secure the subject dwelling within 48 hours of receipt of this order. If any person refuses to leave a dwelling or portion thereof,which was ordered vacated they may be forcibly removed by the local Board of Health(Massachusetts General Laws C. 127B), or by local police authorities at-request of the Board of Health. QAOrder Letters\Condemnations\644 old post t ' You may request a hearing before the Board of Health if written petition requesting same is received within forty-eight(48)hours after the date the order is served. Furthermore, anyone who fails to comply with any order of the board of health may be subject to fines ranging from$104500. Each day's failure to comply with an order shall constitute a separate violation. Note: This is an important legal_document. It may affect your rights. PER ORDER OF T E BOARD OF HEALTH omas A. McKean, CHOIRS Director of Public Health Town of Barnstable CC: Steven Ryan Richard Ryan QAOrder Letters\Condemnations\644 old post Health Master Detail Page 1 of 1 . UST A,. Logged In As: TOWN\oconnelt Health 4,I Master Detail Monday, October 22 2018 Application Center Parcel Lookup Selection Items " Parcel Septic Perc Well Fuel Tank Parcel: 054-009-002 Location: 644 OLD POST ROAD (CT&MM), Cotuit Owner: RYAN, CAROL BALL Business name: Business phone: Rental property: ❑ Deed restricted: ❑ Number of bedrooms : Or Contaminant released: ❑ Fuel storage tank permit: ❑ Save Parcel Changes F Return to Lookup Parcel Info Parcel ID: 054-009-002 Developer lot:LOT 6 Location:644 OLD POST ROAD (CT& MM) Primary frontage:150 Secondary road:EAGLESTONE WAY Secondary frontage:285 village:Cotuit Fire district:COTUIT Town sewer exists at this address: No Road index:1165 Asbuilt Septic Scan: 0540090021 Interactive map ^ ; Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info owner: RYAN, CAROL BALL Co-owner: Streeti:644 OLD POST ROAD. Street2: F. City:COTUIT state:MA zip: 02635 Country: Deed date:1/4/2008 Deed reference:22585/183 Land Info Acres: 1.00 use: Single Fam MDL-01 zoning:RF Neighborhood: 0110 Topography: Road: -Utilities: Location: Construction Info Building N Year Buil Gross Area Living Are Bedrooms Bathroorns 1 P004 16024 P202 13 Bedroom 2 Full-1 Half 1. Buildings value:$242,100.00 Extra features: $56,400.00 Land value: $325,000.00 r http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=054009002 10/22/2018 Pa e3of3 3 CRESCENTDR117F yannis::�ran<coTseefions?nexto an ncoRe° in armafio - ,. ._ . . `.U�its ors ap�.�.arce_el�OJ. 9 0111M Building number. Address: 4 Crescent Drive Unit number: 4Crescent©nve g Check one: Single family dwelling unit: ❑ Apartment building/Condo: constructed priopartrlt n197et: ❑9? Yes Duplex: Number of bedrooms: 1 Private drinking well? Yes No Dwelling Will there be any children under the age of six who will be occupying the rental unit? Yes No 3320 Occupant name Wgee�kb Email: Daytime phone 7T4-552 9170 Cell phone s Address: 4 Crescent Drive Building number: Unit number: 6 Cues ent Dnve apartment: ❑ . Duplex: ❑ Check one: Single family dwelling unit: ❑ Apartment building/Condo: x0 Accessory Number of bedrooms: 1 Private drinking well? Yes No Dwelling constructed prior to 1979? Yes No Will there be any children under the age of six who will be occupying the rental unit? Yes No 3730 Occupant name: Vacant Daytime phone: Cell phone: Email: �► ' i I Q 3 L V I 1T�I \ APEW-coGG -- WDN 18kID I a PAIR - N WA is 410 b ' v h 12° lyl\ V _ 1. DIO?Up- 1 HeATI dr0R._DRIT. \ ., 0 i ' � i I S�vH"t4" \ .� DN'.14` IAff..rY¢J=sNEtl:--41"H1GN'.WA{,L ,('-o # FUTURE DELI (n,l.G� . _ � - r O' a v• 5.�,., .L,o Ge sag tOOL00- zOH Y- 'ra, / 't �I ^�AfASTER.BATH ROONI%• Z'- "I2i SHDWE¢_ .:DRESSING I O 9E 1 Nou'L FIRE 2AT41', 11 N 1 LAYER 518"TYPE X N 4Y ; Ko.cE l u,.i4 T✓D5. GA GE ' 'dT0203.L_I 1 n�— I 4'�, \ '�O BE 618-TTPc% G w.ED 7I 6 7,L• 7-O. O . I ZO 7=0 p 6.0" WOOP.:PfDOII � IZ.c• I � � ur WINDOW MODEL NU1xBcR5 BASED OH ANDS P3EN 1.0• I-- --I 2.._D.OD,>z:S PAN¢.-.T'PE, ..AS APPROVEp BY OWNE2 ----- 3...FLOOE$PT-'FO...BE WOOD , AS hPPl-AaO BY OWNERS G0W,:a5TE STEP .$%IEPT. ..._GBRAnI{L . TLE A' SA-MROOMS 4 TOILE,TS �1 _ 0 _�p -- I -' Q WALL=.TO-WALL. CA,2PET k•f Z°FL-BEDROOM�j F126T. 1 LQOp' '�J•,�N j1 LONG¢¢TE k. Aw.. APPLIANCES,,,FIK-lJeES., GABINET2Y AS AFT..—rD :11 AP¢Od... - .6GPh'L£ y4'>a..1=0'� _ I �d".tout sLAe.- PIrLH&D_JOWN y" S '.COORDIN A7C :INSTAU"hTION OF ALL E�.ELT2ILAL _ I F Dowu �.F XTV Rfis AND GOHT.Rots.. w{TH owNER. �• INNA{-L GENT"LA FOPCED I407 ML. AND GENT¢Al— .`7tIR CONDITIONING ZYSTEM oDGTS TO F9Z0 FIST FRDM BASEMENT, SFL.OND FLOOC FPOM I f " 36PA¢ATE UN17 IN ATT1G.. (GAs FI RE.D LOD¢D,IHATE 'L-A-4'S .OG GONT¢LI/, R6l.I5TEQ5, - — —J 1 .("� .(" - GR1.LLES......ETG.r WITL1,_ _OWNEIL ALL INSTALLAT{ON PIPE LOG j'4EQ'D 3_ --- _ ... Q . -------7 3SAM ABO+E- WID[LZ N Ff�O��R.7%o•O.H.DOO¢I I I I I I � - I � I I - _ i • WDH i26310 JAN 5, 200.Q Andrejs R. Strikis Architect . 85 River vine une, Centerville,Mass hu&W 02812 •Telephone(508)79007 i FFIQ5T 'F(.� ?L ahl ZYAN RESIDEi�G.E OI.V 105—, IZCAD. Z11 O^ i -SC 4NT; KV 2838 « Rm�Bel-ow ...VP..IMW/.ROOF I M714 GD17 � SEO ROO.N) p IT O N 3 —___ .(Yµ.poy/u.lauose TO A�Ct1L 3 y ok x i s I ` • . ls£f.ON�.,TrLGV2. PL�kIJ Pm 13a i - —.-: 7ITT12."FI,pO@.-�UNGIAl1SµED� 1 I 1 / WON 26310 I JAN S, 20�>4 i Andrejs R. Strikis Architect fly River View L. , Cenenville,M."_huselts 02632 •Telephone(SOB)790.09M = 0 ,+I.Lb2 PLAN 2 514 mp POST ZOAr. G- T rr. MA r2G35 I PRf ;ffILE: NOT TO SCALE 1-�5T f-1OLE LOCH N I'LAYER Off'>/'PEA5TONE EL- /,2 S r`IR5T P1PE' LEN3TH OVER-1/4"-1 V2"POUN-E r0f' rr�LWAncN GO&R6 rO MrHIN ro ref `SET LLVLL WASt1 STOIL= DATE: 2-j Z-->C>3 -j N EL- ./G-, 5 A' OP I'MI51-F1� 6RADr- I`OR MIN. 2' TEST f5Y:�l I l� rIN60 6_RADE WITNESS: J, GcJ.�,//TE fi��ACT�I AryE� 18.) tea, 7,` �ri'q�t a- G PER RATE: L-A � j�c.��.✓.�inic�-/ kr q" A" PV i TOP 0 EL �IZ. O.i Q AO D IS ) 1507cm a EL i 7_ i iwrrM.L&A rg y2.5 y 4/ N N _ r DiST. DOX / �/� 7 d 2 � l G' 6E ARAT ON / �1 tJ ,BctJ G• 5�,, 6/�1.DN G. 5 1 .CEP V, TAW, I `lv y�/,2 zy` y3. c C 1 2, /Zo" •Z DES I CAN DATA �b 7� � 3 3o C�'D FLOW: (3)pEDROOMS x 119 GPD= SEPTL TANK:33�GPD x2O0%_ ;'6-o GPD U6E:/52>OGALLON PRECAST SEPT6 TANK j LEACHING FAGIL(rY: �- USE: 63) S'x r GAPAGITY: ` SIDEWA-L: x �! POTTOM: 13 '.��> X�.�,� j �G" GENERAL NO-EL / J TOTAL: Q �I CONTRACTOR TO P5E RE6PONSI3LE FOR THE LOGATONOF ALL UTLFES, A15OVE AND UNDERGROUND,PROR TO ANY LXGAVAT-ON OR GONSTRUGTON. v 2. SEPTG SYSTEM TO 13E NSTALLED N GOMPLANGE W(rt13O GMR C�DO:T(rLE V n- 3. Tf15 PLAN 5 NOT TO 15E U5E9 FOR PROPERTY LNE DETERMNATON II V .4. ALL P5TURt5ED AREAS TO�E LOAMED AND SEEDED / Q 5. GONTRAGTOR TO PROVDE 2A HOUR NOT-OE FOR ANY RELZURED N5PEGTt2N5 No 00 U �e ow�«•-`may �� / V �_, 10 Mid# l I / i � I � 1TE �ff�Aa' ��AN ,l�f L. �0.3 LOCATION: G%�5� �� �a�T" =✓. ��Tv/ T PREPARED FOR: ' DRAWN f3Y: •5 , J05 N1�113ER: DATE: - WELD A�� A7ff�5 OG ! ,•. SUITE 40 GENTERVILLE, MA 0Uo32 TEL.: (505) 775-0735 I=AX: (505) 775-075A4 PROFESSIONAL ENINfffRS & LAND SURVEYORS