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HomeMy WebLinkAbout1025 OLD POST ROAD (CT & MM) - Health 1025 Old Post Rd 074-003-003 Cotuit i r Commonwealth of Massachusetts r ��a�� w ,�.p Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Na e information is required for every Cotuit MA 02635 07/01/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S14F ILkiaLt on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road r� Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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. ❑ Fails 07/03/2020 In pector'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 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 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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: ® 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 30 exist. Any failure criteria not evaluated are indicated below. Comments: This system is for the pool house and garage. It has a 1500 gallon septic tank with D-Box feeding a leaching pit with stone. At the time of inspection the leaching was dry and no visible failure criteria was found. 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 InspectionI Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts ►(,g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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): ❑ 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): 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 • 1 Commonwealth of Massachusetts �v Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is Cotuit MA 02635 07/01/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I; u- 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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 '/z 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 I.? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner, Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have 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) ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is Cotuit MA 02635 07/01/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 1 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 plus GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gpd))� Detail: In 2019-9,000 gallons were used and in 2018-56,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n ,4.4 Title 5 Official Inspection Form + 11� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown State Zip Code Date of Inspection 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: 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page.• Cityrrown 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: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Note: there are 2 sewer pipes Distance from private water supply well or suction line. town water feet -Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is Cotuit MA 02635 07/01/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"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 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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 u � 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Citylrown 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, condition 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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form <I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage V� Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection leaching was dry and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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 Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every COtuit MA 02635 07/01/2020 page. Citylrown 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 ;hov-\ cL n6 lec_4T�Cal 1 I nes p(N Cover Z) 60 43 c1� ` 3 PSI � o Nayse, t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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: 18 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole.within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elvation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 111 lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Pool House/Garage Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 0 "�4- 003 -003 Commonwealth of Massachusetts 6P Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Na information is Cotuit MA 02635 07/01/2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. Inspector Information -G on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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. ❑ Fails 07/03/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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: ® 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: This 4 bedroom home has a 2000 gallon septic tank with D-Box feeding 2 leaching pits with stone. At the time of inspection the leaching was dry and no visible failure criteria was found 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 f -71 Commonwealth of Massachusetts a Title 5 Official Inspection Form i1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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): ❑ 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): 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 �n Title 5 Official Inspection Form r 1l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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: Y pp Y 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityfrown 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 %day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 + <Iii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have 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) ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. u � 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD. Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 town water 9 ( Y 9 (gPd))� Detail: In 2019-9,000 gallons were used and in 2018-56,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2019Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n _ ,`� Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown State Zip Code Date of Inspection 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: 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I Commonwealth of Massachusetts ,P Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): " Depth below grade: 31 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came free) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �v ,�.p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gallon I Sludge depth: 3„ Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. 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 11b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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 I Commonwealth of Massachusetts p Title 5 Official Inspection Form 11 � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I; u 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �v - ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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, condition 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: 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,(!p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection leaching was dry and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18• Commonwealth of Massachusetts p Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1025 Old Post Road Main House IR—'P. — Property Address Lawrence Best Owner Owners Name information is required for every COtUIt MA 02635 07/01/2020 page. Cityrrown 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 F�ow� i y ! Pr cad6�j a 9 Q �� Ariuerr� i ;N 50 a5 14 ' Sn l c� Cover c t� A(AV_ .3 Co tAA�on' MrrkykNQ o,rn t F- IetO'riC I tnc5 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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: 18 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1025 Old Post Road Main House Property Address Lawrence Best Owner Owner's Name information is required for every Cotuit MA 02635 07/01/2020 page. Cityrrown 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: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 '-- 1() 43 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP 4. PARCEL ; N0 3�3 LOT TITLE S OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1025 Old Post Road-Pool House/Garage Cotuit,-MA 02635 Owner's Name: Robert&Syrul Lurie , Owner's Address: 36 Green Hill Road Brookline, MA 02445 Date of Inspection: March 22, 2004 2 � CD I sz7; z Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford C) v i Mailing Address: P.O. Box 49 - Osterville,MA 02655-0049 •• �' r � Telephone Number: (508) 862-9400Ln . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further,Evaluation by the Local Approving Authority F ' Inspector's Signature: Date: March 25, 2004 The system inspector shVsubaof this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 'Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 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 a ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1025 Old Post.Road-Pool House/Garage Cotuit, AM Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for.all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ 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 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 System: 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- 1WPA)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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 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: Yes No _ Existing information. For example, a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 1 Number of bedrooms(actual): I DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required) Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1994-per plans 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: 1025 Old Post Road Pool House/Garage Cotuit, AM Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 28" Material of construction: ✓ 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: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, A14 Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ if resent must be opened) locate on site plan) ( P P )( P ) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (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.): 8 I Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, AM Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: P Y Type ✓ leaching pits,number: I - 6'x 6'(1000 gal) 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.): The pit was dry. The interior was clean and no scum line was present. There did not appear to be any signs of failure. The bottom to grade was 9.0'. CESSPOOLS: None (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: None (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: 1025 Old Post Road-Pool House/Garage Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 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. d 60 bo M (b O J Go `9 / cb C� M C-6 M 3 Pc,,o I A ' a l�ovse. B i o 10 f Page 11 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road-Pool House/Garage Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 22, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 18 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 18'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 I COMMONWEALTH OF MASSACHUSETT'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION iviAP PARCEL LOT : �P► �I--•-� TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1025 Old Post Road Main House System Cotuit, MA 02635 Owner's Name: Robert&Syrul Lurie N Owner's Address: 36 Green Hill Road = C) } Brookline, MA 02445 Date of Inspection: March 16, 2004 -n z Name of Inspector:(Please Print) James M. Ford > Company Name: James M. Ford a M. U') Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: March I7, 2004 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1025 Old Post Road Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 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: 1025 Old Post Road Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address: 1025 Old Post Road Cotuit MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or`no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _ ✓ 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 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 System: 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 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 "ryes"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. 4 I Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1025 Old Post Road Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)). 5 f Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1025 Old Post Road Cotuit, M4 Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 6 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: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): god 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1994-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road Coto, MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ 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: 2000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f • Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road Cotuit, M4 Owner: Robert&Svrul Lurie Date of Inspection: March 16, 2004 TIGHT or HOLDING TANK: None (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: eallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (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.): 1 8 I Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'w/4'stone-per as built card 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.): Both pits were dry. The interiors were clean and no scum line was present. There did not appear to be any signs offailure. The pits appeared to be in new condition. The bottom to grade was 9.5. Steel covers were to grade. CESSPOOLS: None (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: None (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 f Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road Cotuit, AM Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 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. A3 rl.� O rtvcwgy P-r c ovc,f a fa 13 -r 9,,edL ayb 50 1� Arwcw,n� r A 3 a c 6A(A6L 3 3y ya to 10 Page l l of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1025 Old Post Road Cotuit, MA Owner: Robert&Syrul Lurie Date of Inspection: March 16, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 18"+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic may and the Cape Cod Commission water contours map,the maps were showing approximately 18'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 ,avv 1.J _V 1VL L TV 101 1)r,1t i1v I A U L L'.. 1Lh141'd 111U, J) "A N11j Du ) !JI! rz`'d r, j Town of Barnstable Zoning Board of Appeals Decision and Notice Appeal No.1995-131-Syrul Lurie Variance to Section 3-1.4(2)Accessory Uses Summary Withdrawn Without Prejudice Applicant: Syrul Lurie Property Address. 1025 Old Post Road,Cotuit,MA Assessor's Map/Parcel 7413-3 Area 4.3 Acres Zoning: RF Residential-F Zoning District. Appeal No. 1995-131 Variance to Section 3-1.4(2)Accessory Uses to permit a caretaker's apartment over the garage Background: The locus of this appeal is 1025 Old Post Road, Cotuit. The applicant sought to construct a caretaker apartment in a garage located on a lot designated as Lot 3-3 on Assessor's Map 74, The lot has frontage on North Bay and contains 4.30 acres. The property is located in the RF Zoning District which requires one acre of upland and 150'frontage per lot. The applicant proposed a 507 square feet apartment with a kitchen unit to be used as living quarters for an employee of the owner of the premises. The applicant indicated the property is isolated and is of a size and value that requires full time domestic help. The principal dwelling has 5,300 square feet and there are two outbuildings on the lot in addition to the garage. The total floor area on the site is 6,700 sq. ft. Procedural Summary: This appeal was filed at the Town Clerk's Office and at the.Office of the Zoning Board of Appeals on August 21, 1995. A Public Hearing before the Zoning Board of Appeals was duly advertised and notices sent to all abutters in accordance with MGL Chapter 40A, The Hearing was opened on October 4, 1995 at which time the Board found to allow the appeal to be Withdrawn Without Prejudice. Board members sitting on this appeal were: Ron Jansson, Richard Boy, Emmett Glynn, Elizabeth Nilsson, and Chairman Gail Nightingale. Attorney John Alger represented the Petitioner and requested this appeal be Withdrawn Without Prejudice due to the fact that in Appeal No. 1995-130 the Board found to over-rule the Building Commissioner. Decision: Based upon the applicant's request a motion was duty made and seconded to allow the appeal to be Withdrawn without Prejudice The Vote was as follows: AYE: : Ron Jansson, Richard Boy, Emmett Glynn, Elizabeth Nilsson,and Chairman Gail Nightingale, NAY: None Order: The appeal has been Withdrawn without Prejudice. A?peals of this decision, if any,shall be made to the Barnstable Superior Court pursuant to MGL Chapter 40A, Section 17, within twenty (20)days after the date of the filing of this decision in the office of the Town Clerk. ' 1995 Gail Nightingale, Chairman Date Signed I Linda Leppanen,Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty (20) days have elapsed since the Zoning Board of Appeals fled this decision and that no appeal of the decision has been filed in the office of the Town Clerk. Signed and sealed this day of 1995 under the pains and penalties of perjury. Linda Leppanen, Town Clerk Town of Barnstable Zoning Board of Appeals Decision and Notice - - Appeal Number 1995-130 -Lurie Appeal -Building Commissioner Decision Interpretation of Section 4-1.1 Accessory Uses =' Summary 1995-130 Overruled Decision of the Building Commissioner Applicant&Owner: Syrul Lurie Applicant's Address: 1025 Old Post Road, Cotuit Assessor's Map/Parcel: 74/3-3 Zoning: RF Residential F Zoning District Applicant's Request: Appeal Number 1995-130 Syrul Lurie has appealed to the Zoning Board of Appeals a decision of the Building Commissioner that a caretaker apartment with bath and kitchen is not accessory to the residence and therefore not in compliance with Section 4-1.1. Background Information: The locus of this appeal is 1025 Old Post Road, Cotuit. The applicant is seeking to construct a caretaker apartment in a garage located on a lot designated as Lot 3-3 on Assessor's Map 74. The lot has frontage on North Bay and contains 4.30 acres. The property is located in the RF Zoning District which requires one acre of upland and 150'frontage per lot. This zone permits one single family residence and its accessory structures only. The applicant has proposed an apartment with a kitchen unit to be used as living quarters for an employee of the owner of the premises. The size of the apartment is proposed to be 507 square feet. The applicant has indicated the property is isolated and is of a size and value that requires full time domestic help. The principal dwelling has 5,300 square feet and there are two outbuildings on the lot in addition to the garage. The total floor area on the site is 6,700 sq. ft. The applicant's request for a building permit for the house and garage with apartment on this site was denied by the Building Commissioner. The denial was made on the grounds that the proposed living quarters constitute an apartment because an equipped kitchen unit will be provided, and an apartment is not an allowed accessory use in the RF zone. On this basis, this request was found not in compliance with Section 4-1.1 of the Zoning Ordinance. Procedural Summary: This appeal was filed at the Town Clerk's Office and at the Office of the Zoning Board of Appeals on August 21, 1995. A Public Hearing before the Zoning Board of Appeals was duly advertised and notices sent to all abutters in accordance with MGL Chapter 40A. The hearing was opened on October 04, 1995, at which time the Board found to overrule the decision of the Building Commissioner. Board members hearing this appeal were Emmett Glynn, Richard Boy, Ron Jansson, Elizabeth Nilsson, and Chairman Gail Nightingale. Attorney John Alger represented the petitioners in this appeal. Mrs. Syrul Lurie is the owner of the home. In July 1994, a foundation permit was issued and in Sept. 1994 permits were issued for a house, pool house, a cabana, a garage and a garage with apartment over the garage. The property is in Residential F Zoning District. Within this Zoning District accessory uses or accessory buildings are permitted, provided any such use or building is customarily incidental to Zoning Board of Appeals-Decision and Notice Appeal Number 1995-130-Lurie subordinate to and on the same lot as the principal use it serves. The lot is 4.3 acres. The principal dwelling is 5,300 sq. ft. and with the other buildings there is a total in excess of 6,700 sq. ft. Over the garage is a single bedroom, bath and living room with a "Murphy kitchen." There is quite a substantial single family residence on this large lot and this apartment is intended to be used as a caretaker's apartment only. There is potential for renting that unit; however, it is unreasonable to believe it would be rented. This home will only be used for 3-4 months and a caretaker is needed to maintain the house for the remainder of the year. Speaking in favor of the appeal were Craig Ashworth, the builder and Doreve Nichaeloeff, the Architect. No one spoke in opposition of this appeal Finding of Facts: Based upon the testimony given during the public hearing on this appeal, the Board unanimously, found the following findings of fact: 1. In this instance, this building and proposed use is customarily incidental to, subordinate to and on the same lot as the principal residence it serves and is in compliance with Section 4-1.1 Accessory Uses for the Town of Barnstable Zoning Ordinance. 2. The proposed caretaker apartment is in fact customary to a home of this size an involved and is subordinate d area of land lnate d to the principal dwelling. Decision: Based upon the positive findings a'motion was duly made and seconded to overrule the decision of the Building Commissioner as requested in Appeal No. 1995-130. The Vote was as follows: AYE: Emmett Glynn, Richard Boy, Ron Jansson, Elizabeth Nilsson; and Chairman Gail Nightingale NAY: None Order: In Appeal No. 1995- 130 the Decision of the Building Commission has been Overruled. This decision must be recorded at the Registry of Deeds for it to be in effect. The relief authorized by this decision must be exercised in one year. Appeals of this decision, if any, shall be made to the Barnstable Superior Court pursuant to MGL Chapter 40A, Section 17, within twenty (20)days after the date of the filing of this decision in the office of the To n Clerk. be,- / , 1995 G Nightingale hairm Date Signed I Linda Leppanen, Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty (20) days have elapsed since the Zoning Board of Appeals filed this decision and that no appeal of the decision has been filed in thA office oft a Town Clerk. Signed and sealed this day of 1995 under the pains and penalties of perjury. Linda Leppanen, Tow Jerk 2 DESIGN DEVELOPMENT POOL PAVILION AND GARAGE 3 -LURIE...RESIDENC.E :i `;'• ,y u�ir - i r. • 3 fib• — ,�• t ---- --- FIRST FLOOR PLAN_ _SECOND :FLOOR....PLAN[.-, �-i=o• ;-_ GARAGE.. C61J PPrl0tre0 WY : P6<Zr0C.l D4'6r) PSI -M s`i r S, i►� I®4� FP�t-MouTT,� P20Ao, �lyPtr�r�l s , NP\ 62810 1 1�Ip. uc. 1195G aasi c?cLSsouc&e ojo-rms . Coin 5V8,-r 75• 3A42- sl j 6 �S� OKE Dr:�f�ECTORS REVIEWED BAPNQTP,BL`r_ BUILDING DEPT. DATE J FIRE DEPARTMENT DATE 30 i N iG,�v:TUBES ARE RI QUIREia FOR PERMITTING "C Soa.`r1��344�2, o CH) I s OLD PosT Rb" , l-6T ��o�- CGS Pk6t z 4 � Town of Barnstable _ 4 Buildin" 1i .,,,�, � Post This Card So That it is ble From the Street-Approved Plans Must be Retamed;on Job and this Card `Must be Kept" D Q i6�� �8 Pasted Until final Inspection Has Been Made } , Z 00 ¢ WCnm a,Certificate of Occupancy is Required,such Building shall Not be Occupied ui7ttl=a Final lnspect�on has been made Permit �. _, . . , �a. .,.E. ��. C Permit NO. B-17-3233 Applicant Name: E J JAXTIMER, BUILDER, INC. C Approvals m Date Issued: 30/11/2017 Current Use: n r• Structure GZ Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04 11 2018 0 (� i / / Foundation: O Residential � z 3 � Q p 2 ,�, Location: 1025 OLD POST ROAD(CT&MM),COTUIT Map/Lot: 074 003-003 Zoning District: RF m `� -- Sheathing: pp h ,n Contractor NdIT1e E J JAXTIMfR, BUILDER, INC. Framing: 1 Owner on Record: BEST, LAWRENCE Contractor License 110609 Address: 3 COMMONWEALTH AVE u 2 C ^�` BOSTON, MA 02116 € Est Protect Cost: $ 12,000.00 Chimney: Pe'rmltYFee: Description: renovate bathroom new finishes,fixtures and tile.No partition $ 111.20 :Fee Paid: Insulation: t changes or structural work. Work area at existing pool cabana, it is $ 111.20 _ unheated . Date 10/11/2017 Final: O i Project Review Req: *t Plumbing/Gas $ _ Rough Plumbing: Building Official Final Plumbing: O 0 O n O This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within Mi months after issuance. C 3 CD cD All work authorized by this permit shall conform to the a Rough Gas: D fll CD approved application and the approved construction documents for which this permit has been granted. m �p m 00 All construction,alterations and changes of use of any building and structures shall.be in compliance with the local zoning by taws and codes. Final Gas: --I of � N This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for J.` work until P , ublic.ins=ec Jon C7 the completion of the same. F? P, for the entire duration of the O O Z -�1 r3 < k Electrical m -0 3 The Certificate of Occupancy will not be issued CD 3 until all applicable signatures b the Buildm Y and fire Official g sar .• rll � CD Minimum of Five CallInspections _.,e provided on thu ermit. Service:cp a P ce. R e cared f , ., . ,.-. .x.- q or All Construction Work. • }, �,. D 1.Foundation or Footing ' '�:..: Rough: O 0 2.Sheathing Inspection Zh 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection O 1 cA (.Q 5.Prior to Covering Structural Members(Frame Inspection)J 6.Insulation Low Voltage Rough: t^' _ C4 S1 J 7.Final Inspection before Occupancy Low Voltage Final: �; Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health -� Work shall not proceed until the Inspector has approved the various stages of construction. g Final: L -'l "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department -r \ 4 Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT n `R V� Q aO J a �g�e FinaQ� 11 O ,essor's office(1st Floor): , ������ V V assessor's map and lot number ` �, ®�� e SE 3-272 COM Conservation(4th Floor): ����� �°�TH T'TLE Board of Health(3rd floor): ® � � riva Sewage Permit number 9 4-4 0 +m 0 g Department 3rd floor), "�ULATio o r Engineering P ( /0 ��, _ House number 19 7 - %,.i�'l Definitive Plan Approved by Planning Board; /� APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPEC TOR APPLICATION FOR PERMIT TO Construct Dwelling "��z VL TYPE OF CONSTRUCTION _ Wood Frame 71i1y 22 19 94 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 1025 Old Post Road Cotuit MA 02635 LaT Proposed Use Residence Zoning District �� Fire District Name of Owner Robert I. Lurie Address 29 Catlin Road Brookline MA 02146 77S-d Name of BuilderE. B. Norris & Son Inc. Addres�T75 Sea Street , Hyannis, MA 02601 Name of Architect Doreve Nicholaeff Address Main Street , Osterville, MA 02655 Number of Rooms 20 Foundation Poured Concrete Wood Shingle Roofing Red Cedar Shingle Exterior Floors Wood Interior Gyp Board/Plaster Heating FHA by Oil Plumbing 4 Full/ 2 Half baths Fireplace One Chimney w/two fireplaces Approximate Cost $1 ,750 ,000 .00 Area 30� � Fee .��, Diagram of Lot and Building with imlions ** all first floor 5309 all second floor 2370 all third floor 225 one Pool OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above constructio . eC TOWN OF BARNSTABLE ; LQCAT10N Q 0 SEWAGE # yo3 4ft+21� Whe VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) S (size)_ NO. OF BEDROOMS2PRIVATE WELL OR PUBLIC.WATER�C BUILDER OR OWNERn��. �j DATE PERMIT ISSUED: r) DATE COMPLIANCE ISSUED: ' VARIANCE GRANTED: Yes No a F O)OL TOWN OF BARNSTABLE LOCATION l� , —SEWAGE # ?�Y`�� VILLAG ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO t) 4(005 � ic�` SEPTIC TANK CAPACITY jaQ0 7,2t7 LEACHING FACILITY:(type) ,I/ (size) NO. OF BEDROOMS L/ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER l DATE PERMIT ISSUED: I DATE COMPLIANCE ISSUED: �'�® �,oq i VARIANCE GRANTED: Yes No I 20 18 /1 Tb iU4:YrW=[.. .:I/.:�1" f'a�' /NUE!?T,'.Ij .¢ .5J2f1": 20 10' WIDE —DIRT WAY s 22 20 18 4 � UTILITY POLE #10 10' WIQ DIRT WA` 2¢s 8 is r-; -.. Y"►4t r-t t o"S 4 . F` "Y f TOWN OF BARNSTABLE LOCATION OLD PO S► 20 SEWAGE# b v7�-�U3�-vv3 VILLAGE. ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. U M P-I N Q 13 2 D S . CONS i2ZCccl/Qel -! SEPTIC TANK CAPACITY S b D LEACHING FAClLrTY: (type) ?&FcwsT 'p,T (size) loY-9 w f 4 f STh tE. NO.OF BEDROOMS I BUILDER OR OWNER f Z 0 3S 2T -t-S�Z cc c kL-(2 t 1, . PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by P.c1U2tcs4 -fOhi(-A-f£/L 9 r t loco �� H2o cis, =rzo�-r 4 (Y-0vc2s P-AISCO TO fm",L 3 ; C�•R�4fa- TOWN OF BARNSTABLE GaG LOCATION - S 02-L•O SEWAGE# 7 -Doi- ©D?? VILLAGE --LA2-TLL l T ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. 2 Q-� • CCVY S SEPTIC TANK CAPACITY LEACHING FACILITY: (type) � aid CFI S7- Pi?— � (size) X NO.OF BEDROOMS BUILDER OR OWNER R0-13s.2r -rS-f tzu L {.0 Ej 5L PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) , Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by)n t) (J., P"tZi/7Lf r.c &U10-•(i P j�MPI�S COt,L 2 a poor. Q \ , P'r• ► Jb 13� . 4 r r, l OWNN OF BARnNSJTABLE q LOCATION 6 a•S 1-Osr 1''C• SEWAGE # 7 r03 VILLAGE CdTU+ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) bx®� S (�)(size) NO. OF BEDROOMS I BUILDER OR OWNER tR0661 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 Tnrpwt)n �0/ 'D OVLWAy P,'-r C ovcff a i Q 5".4CL A ► aye so` h prwGw� r I 3 a c Ara6� 3 3y ya �Q [P(ab/ �-��� a- GA-45c- TOWN OF BARNSTnABLE LOCATION �0�� OLc' �osT 2c� SEWAGE # VILLAGE C MU+1 ASSESSOR'S MAP & LOT( INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �SG� LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER �O���I �V r/L PERMIT DATE: 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 leachi g facility) Feet Furnished by 1/�SACOn �D/C qboa- rbGo M .! J rb M 3 G c: .-. � aid;; a i �� • t "f' No.. t�t. •�C :v Fps.. ``... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratilan for Dhipaaal Workfi Tomitrurttnn Prrntit Application is hereby made for a Permit to Construct (<), or Repair ( ) an Individual Sewage Disposal System at: /0 rv5 OLc� }�nsd- I�oo oQ i ui'f' .................... 4ssessoe-s /�/s .d._¢�. 0/'ea/ 3 �Larz� Location-Address, . or Lot No. Re► r 4 V 1 1 5........_ 02 ---•- -------- •--••.................•--------•--------------- l--.�'_.e_�!!.n_..mealy..�l�crA./.�i.�e--f-.l.�'IR.�............. /(/� ]��//J�JOwner Address -.-----•-••-•--------- -•-•-•----------.-•--•-------•--- ------- ...._..... Installer Address Type of Building Size Lot...9s!.5!!s---- . U Dwelling—No. of Bedrooms___ 5�x............................., .__Expansion Attic ('(,lO) Garbage Grinder (yam) 04 Other—Type of Building .::_ _._:' ' No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .. ------------•-- •--- ••. --` ---- ---................................... W Design Flow...................................SS_gallons per person per day. Total daily flow---------......................6 AP...gallons. WSeptic Tank—Liquid capacity#2QaQ.gallons Length�Z�—a_.`_�_'Width_4'__!n6_.."_ Diameter________________ Depth.S Anaf x Disposal Trench—No. .................... Width.....:.............._ Total Length............ ....... Total leaching area---------------------sq. ft.. Seepage Pit No----- 4�.------ Diameter.......U.1- Depth below inlet..._,Cu•_. �? _.__.__. Total leaching area ..aq. ft. Z Other Distribution box (X) Dosing tank ( ) aPercolation Test Results Performed by._:5+cp_h". .A.....W�.1_s W?'�. �.,............ .Date_ 3../✓o �lcc 1�_9.3 Test Pit No. 1.__-1s�TA.....minutes per inch Depth of Test Pit----l2 _....__. Depth to"ground water, ..__. (s, Test Pit No. 2......^......minutes per inch Depth of Test pit----!Z.____...... Depth to ground AN"�A' - INZ t - -- ---------------------------------+--.......�Description of Soil.."1"F'.._ ._}_.__9._-1�...�.._Tap oi.L.E_Sy bso_i-I 1 --1- -•.3 S_TEPHEN vm.__.Ssinta�• TP°� ...`n-_��' T'acn:/r. v�6 rsz._/ ---- 1t r xiy_..__. . ri_ la U Nature of Repairs or Alterations—Answer when applicable._.__-_.................................................. .::. . Agreement: iz�i2 93 The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste n accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further rees not t place the system in operation until a Certificate of Compl' n e has bee is ed by th" board of h.-Al Signed -- -- - ---------- :�. .�j Application Approved By j ...---- . ... '- - --- --- -- --------- ----- - .... ------ - e . v`� Dace -.... ...... Application Disapproved for the following rear .. .... ......:.........:.... .. .. '.......-....--...... :.....::....... . . ..--- ... Permit No. ... Issued ice.. No. �. .........._....... Fins............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /0cur7 ..................I . ....................OF.............................. Appliration for Uiopoiittl Works Tontrnrtion Famit Application is hereby made for a Permit to Construct ()C) or Repair ( ) an Individual Sewage Disposal System at: 3 A Old- Pos+ Rao.J - Cc,+-ui♦ ASScsso�s ` ................-•--------........... ..--- •----------•--•-----._....-----•-•-•• -----•......---...._.._....f�---- .A. ---- ........ ..... Location Address r Lot No. R o 4X r i• �.v r l c o?/ sy/n "4/, '/o o<c%'1' ......................---•..................................................................•.... .................................. •.. ........................_..... Owner Address Installer Address Type of Building Size Lot__q,3 Qcr cs . Dwelling—No. of Bedrooms............................................Expansion Attic (AA) Garbage Grinder (y�) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow..................................''!5 gallons per person per q;xy. Total daily flow..__.._.._.................. �.P....gallons. WSeptic Tank—Liquid capacity ���.gallons Length._-:�..... Width�'_'�°_..... Diameter................ Depth s=8 x Disposal Trench—tNoo...................... Width I...?_........._.... Total Length...........7....... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet....�......._.... Total leaching area..67 6....sq. ft. Z Other Distribution box (X ) Dosin tank ( ' '-' Percolation Test Results Performed b k-C.....................................h cn W i i s r.V-t Q? Date.g3 ....93 YfV--------------••-- aa Test Pit No. 1.. `?°.....minutes per inch Depth of Test Pit...12_��._.____.. Depth to ground water........................ Test Pit No. 2...... ......minutes per inch Depth of Test Pit---- ............... Depth to ground w OxG IyGi-ylUiII-rJ•`-�-C•inC7A ,r Z �loi/c sv�so�/ � r 'r��- ---•---•---------------------- ......•...-•-- .. Z-P / gi ion of Soil ) P • - - ------••... -r ..... --••- ----•----- --•---•--- - - - ---------)----•-----•------ t Y ,,• 7 df a = TP . _ -••-------.I-------••---L .......................................... ... "/ZJ /UM .S'-,'c/ N.L.....-l.........-- -•----•--....-•--••--------•---....--•-••-----------------------•-•---._......------....------......---.........._.... ... ............. ,y . ► U Nature of Repairs or Alterations—Answer when applicable - 1...............�zx / P PP r . . Agreement: 93 ce wit The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in a t i z�z a c d`anh the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of CompVance has been issued by the board of health. -- �Signed i ' ' I l� ' 4 .....r!I ....................... Application Approved B '' r .........................1 / I Dace Application Disapproved for the following reasons: ... ..... ........ .............. ............. ... ....................................................................... -Dace Permit No. .. tJ` .. r...l.. �...L... Issued ...---.......... .......... r................................................ Dare ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................................. OF ---------- ...............----...........------.........--------------------------- CPx#ifirate of QVIlaraylittx><>ce THIS IS�TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by _ .. .....; ..... /--: / r ��...•>�.� --- ...........-J n--..-- ............ has been installed in accordance with the provisions of TITLEiSo T>'State-Environmental Code as described in the application for Disposal Works Construction Permit No. ... ..I . ..J........ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. C------`".-g-.-`��-----.............---.-------------............ Inspector � ........................................... THE COMMONWEALTH OF MASSACHUSETTS / BOARDOF HEALTH 1'f L6 ....... ..................... No.........L......... FEE........................ i u ttl; nrk Tonotruai n Prrmit /(-/ry C.> Permissiois hereby granted-------------•-•••-•-- •••• ...........--•--�1••---.........•......•-••---••--•--••....-----------••-•-............................ to Construct,.( ) or Repair ( ) an Indiy.idual)Sewage Disposal-Sy-tem- at No - . �!..l� ..J- L t/ , ....... -....... :-... Street as shown on the application for Disposal Works Construction Permit No...................._ Dated.._ ._...._._....._....... ........... I J -, 1 7� 1 Board of Health DATE.............1-/............ .. ............................•-•-......... � Form 1255 H HOBBS&WARRENTM Publishers 22 20 - LOT , 1 - WN j5rT Ala r1 D' : :WIDE DIRT 'WAY , . 22 r U TI LI TY POLE' . t t LOT2 4. 30 AG ; a so D #, ' f ;a 10 _1 i ,y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma v 71: t P p Parcelm Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 1.0 A,,5- 614 as`� /?, Village C! �►� Owner S Address �Q (Z� P� t /Ll►� Telephone 'A Permit Request ( � �11 +h �� P rA JV4A if e -k�10� � e I �► - — and Hwy �e T� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type N Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft:) Basement Unfinished Area (sq.ft) Number of.Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new V ) �, Total Room Count`(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: 0 existing ❑ new size — Barn: ❑existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No . If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) .0 A Name A ccrT -,, a.�� l�-t Telephone Number c� — Address Mm4 "" Kit • License # 1 9- C>uy1y� >S Home Improvement Contractor# N-L\*, Email �OlSSl1C� r �aHw�S.GDw1 Worker's Compensation #WcC5QT7-r-�6Oy/yglo/Z A ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR DATE - ,. `.f - ._+ra., ... ,.; -:7"..�.,.. i•.: � .A.� -T'•• '�- 2.. k-a .�1 ,,i,.,.. r -.' ..:,.,\_ ..:. .•.,. _: .. ...�. ,.. ... .:fir: „- .. . ... .,e .. J < •a »'..:.,. ,,. s h , _ At 30 28 26 .14 I , A g•4 r l I 24 24 26 28 28 F 26 I cp i �29,45 24 ' o a 22 7A a g+ 2 LOT 1 , r,.. �t e.'K. T� �� �t'9.�.1_ v e`/cam t:'i• f".-. u /rJ4/r:t�c''���,,' vj �"� �a Y .,.. fir' `° • 18 pi 18 20 ,.••,° .x*''� ".,. 'Sri r W TE TE `'� \ t �.,,�, .'. ..,: 1._ �, 10' WIDE G -, DIRT WAY 22 #]LIT �� '` za :._ „ . _., 20 18 16 P OL :. - ^. UTILITY 14 #S -�.,, -� POLE 12 EDGE OF «. f #10 10' WIDE 108 SALT ND _ - 6 MARSH UY WI E DIRT WAY L 0 T 2 � ' 2 22 4. 3 0 AC 4s 4 .86 s \ 2 i 4 «`4 30 28 26 24 w` y� /� EXISTING (I 22 20 f; , t _ 6 / PIER I 1814 2a � r __ I NORTH c # . - 20 _ ,x- ` BA�I bsc _ e 16 ft T, A L_� 18 16 — 127.19 I B#6 xN BEACH 14 18 ' I � N AREAS 4 16 18 _J COASTAL S BANK � g � LOT 3 ;' , 141210 1 Diu LRl�frr l_ G1�lrr _i f _ �rc �.s�rc,;r✓ bc� f�IAra►ham t ti �� itCt:( 2,0 t-lGVi� `` -� J cill work- i DATUM: NGVD f s; 3 1z j�2i93 Aar ►� ;�.k.t;. �,. . 2 10/27/93 ADD COASTAL BANK & SALT MARSH CF t ' E 6 30 93 1 i INITIAL ISSUE PAL j N0. DATE DESCRIPTION BY 1` f TOPOGRAPHIC PLAN OF LAND IN � o C O TUIT, MAS S AC HUS LTTS for ''lam Robert Lurie _t S _SCALE: 1 " = 40'— JOB NO. 1690 /1690 STEPHEN ALLYN 0 40 80 120 WILSON 30216 LEVY, ELDREDGE & WAGNER ASSOCIATES INC. B KHO LANDSCAPE ARCHITECTS PLANNERS LAND SURVEYORS ` 586 STRAWBERRY -HILL RD. CENTERVILLE MA 02632� - ,r i '. <. r .,._.. '�L�ae��� .' �iM'7FLi ifir.�lY3 .Stt�M«4:.eYaNlnuc�r;3rS:1+SF�NWi114� : ViFWIR,fil -... :'.. ..., .. _.d'S.r..� .. Y +. r . •, &W, :,,:. . 20' MINIMUM OR AS INDICATED ON PLAN NOTES: .Y • \ 1 10� \\\vvv 1 . ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P � \ \� •• BELOW GRADTENSION To ,z- A`prl r TITLE 5 ; THE TOWN OF .u���',�1s � _____ RULES AND +E \� �� , TOP OF FOUNLATION Te• MIN. - , �, ,�AN _ REGULATIONS FOR THE SUBSURFACE GISPOSAL OF SEWAGE; <<,IS � '_ MASONRY EXTENSION To ,z- AND THE REQUIREMENTS OF THIS P! AN. �- BELOW GRADE CjrE'�� 2 ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT C, PI^& WITHIN 12" OF FINISHED GRADE. it 4" SCH. 40 PVC PIPE -- � I —MIN PITCH ,/9- PER Er n 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE �'L. _�--" 2" LAYER of SHALL BE MORTARED IN PLACE. �. + PCR FLOW LINE 1/e- - 1/2- 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE 10" TEE WASHED STONE C w�+� OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR o 17. 2 3" MIN nS< 2'-0- GALLON \ o- J'4, ~ ��_j L2" 111" LEVEL Q LEACH WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING /7 0 MIND" � f1-_ ` � PIT 3/4- - , ,/2• I SHALL BE USED UNDER OR WITHIN 10 FT OF DRIVES OR /!_,� � LIQUIDWASHED STONE PARKING. �n LEVEL DISTRIBUTION Box pN 6 5. NO DETERMINATION HAS BEEN MADE AS T ,. r �- I���'`ell •„�. • �1� - 0 COMPLIANCE WITH DEED --- -- RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL / d Q ovk Asp^d OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY. LOCATION MAP GALLON SEPTIC TANK L=� J z I 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE ASSESSORS MAP - PARCEL 3 �� �J & WAGNER MELD NOTEBOOK` #_�J �.0 `� 2 LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW O LINE r — — BOTTOM OF TEST HOLE . 4 FEET 14 INCHES 5 FEET 19 INCHES OR USGS PROBABLE HIGH WATER LEVEL i 6 FEET -- 24 INCHES — J -- 'wTE ' -- ter''""'"y 's f° 've- P"Vtd CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS 4 wt4. MoIc. Gov2 r• 4r�� tr''l►ltt IL �'d SEWAGE DISPOSAL SYSTEM PROFILE lod brought +e �..de , MIN. FRONT SETBACK O FEET NUMBER OF BEDROOMS __ NOT To SCALE MIN. SIDE SETBACK FEET GARBAGE DISPOSAL UNIT TOTAL ESTIMATED FLOW MIN. REAR SETBACK % == FEET ( //G GAL./BR./DAY X BR.) GAL. /DAY REQUIRED SEPTIC TANK CAPACITY _0- GAL. ACTUAL SIZE OF SEPTIC TANK ,aOO GAL. PERCOLATION SOIL TEST LEACHING AREA REQUIREMENTS SIDEWALL AREA .% GPD./S.F. ; BOTTOM AREA /- c GPD./S.F. DATE OF SOIL TEST SIDEWALL 2'T( iz /2)C!)SF x 2.S GPD/SF = 565 GAL/DAY TEST BY BOTTOM 7T ( /Z 2)T SF x /. O GPD/SF = / 1 .3 GAL/DAY WITNESSED BY _ - _ 33C Sr xZ 6 7 Ex ._. PERCOLATION RATE — _ MIN./INCH -(676 SIF GAL/DAY TEST PIT #1 TEST PIT #2 BREAKOUT CALCULATION: I ELEV= ELEV= -0.00 -0.00 � I ! R F r F h Tb,�=YX�eAPHIG Pk.f k' j LEGEND : I EXISTING SPOT ELEVATION 30.0 X EXISTING CONTOUR-------00 -- ! FINAL SPOT ELEVATION 00.0 FINAL CONTOUR BOTTOM OF TEST HOLE BOTTOM OF TEST HOLE SOIL TEST PIT LOCATION OR WATER ELEV. OR WATER ELEV. TOWN WATER = -W--W I SEPTIC TANK DISTRIBUTION BOX ❑ WATER LEVEL ADJUSTMENT: PRIMARY LEACHING PIT O RESERVE LEACHING PIT R; i TEST DATE WATER LEVEL INDEX WELL - -- WATER LEVEL RANGE ZONE ./,z1/13 INITIAL ISSUE h DEPTH TO WATER LEVEL FOR INDEX WELL NO. DATE DESCRIPTION BY FOR MONTH OF 'DEfpj Tr-IC SYST-Wnl 1>ETaLLS WATER LEVEL ADJUSTMENT Robert, L.vr1G DEPTH TO HIGH WATER Old? h?aat Road I I.0rUIT I APPROVED: BOARD OF HEALTH STEPHEN r DATE AGENT AL "ALE: 4s No f,c d JOB NO. / SITE PLAN ,���SWO�N 30216 IVY, ELDREDGE & WAGNER ASSOCIA`I`ES INC. PERMIT I,11 sco A cffn 5 PIJN?m 1AR SUmofiS n CID l5 STRAWBERRY FIILL RD. CENTERVUlY MA 02632 NEW f NGLAND REPROGRAPHICS k `.UPPL Y Ci)