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HomeMy WebLinkAbout0095 OXFORD DRIVE - Health 95 OXFORD DRIVE, COTUIT A= 021 051 II No. 0 / �/�� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair 00 Upgrade( ) Abandon( ) ❑Complete System [Andividual Components Location Address or Lot No. C(5 0Kf:Z9Ut> t>RA ire Owner's Name,Address and Tel.No. Assessor's Map/Parcel ®�),( 1-051 ® C,f I)P— :1070 f t Installer's Name,Address,and Tel.No. �®R-4-17 —88`77 Designer's N/a^me,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _L 0 S'd*fk. A)CI1 dD -130 Q G.r N_- ?4L&, :iU S DgLL A,-�[Jd 1 d c� cg. �t,� c D &-1Te_F.T Date last inspected: i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal gned Date Application Approved by Date A) Application Disapproved by Date for the following reasons Permit No. o Date Issued 07 brG,`�n`�r.S�rY..-v-•�lr* ,•i,d^"rr„f'_.�'.'�,�+'.�'C.+^.',,,,�':"v'rf...`%'�y'-w• ^-,n.�:p'�gyp:,?x{:",r•lr y:�r.,,..,t;an„' .:.-,>1..:k i .^{-nc-,� 'i 'r. .t ie+',...F, ..^` ` i No. t7v/ 7 371 Fee 7 / THE COMMONWEALTH OF MA�SSACHOSETTS F Entered in computer: Y_&/ es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Disposal *pstettt Construrtion Permit ' Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) [:]Complete System Individual Components Location Address or Lot No. 9.5 0)<FppI>R(dam Owner's Name,Address and Tel.No. <°o'T0jT' O'Ae K i�F{C.(W Assessor's Map/Parcel 0;i j ,0 5 5 f�ogv 1);L GAv-TCN T., Installer's.Name,Address,and Tel.No. 5'0$-4Y7 a$$? Designer's Name,Address,and Tel.No. Type of Building: y, Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 4 Nature of Repairs or Alterations(Answer when applicable) -TN A)CW 1'_"p i C>✓t?1� �Z[�� ::r1j S 3gLA, &AfVej Jl cw xy IB6 QU &Jrcj=;r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in N. accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until,a Certificate of Compliance has been issued by this' Board of Health Signed _/' Date Application Approved by _ Date /O Application Disapproved by Date ~ for the following reasons Permit No.�QPI-2 3 7 Date Issued s THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( ) Abandoned( )by 42APEL1 06 -. at xycjo D C_�V LT-- has been constructed in accordance jT with the provisions of Title 5 and the for Disposal System Construction Permit No-:k-✓i 37 dated �/� � j'"►�-''� Installer aP&W tDe_- &�"� Owtl Designer #bedrooms Approved design flow ' gpd The issuance of this permit shall not be construed as a guarantee that the system will function asndesigned. Date Inspector ------------- ------- ----------• --------- ---------Fee------------------- No. �7 ~37 THE COMMONWEALTH OF MASSACHUSETTS ( �C PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( ) System located at 'S oxF6ph P.4j V F evT U t r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thisGermit. Date Approved Approved by tOtATION SEWAGE PERMIT NO. UXF6KD DR, VILLAGE a C7— IN TA LLER'S NAME i ADDRESS 31 GEDAA JT PV, d341fIVS1`l',I-6 2- G 3 U I L 0 E R OR OWNER Cec/t 74 �C .z Fej g zt),& . DATE PERMIT ISSUED DAT E C0M ►LIANCE ISSUED ,���� S r . '����. �.! '� a �V/y � °' 1.Y 1 �� . � �, �. .... _ �� . '•� LJ d r, NO.................. FEB...s-.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .�.. ... ........OF......`.. ?hk.. ---- ---------------vr,��o-----------------------_----- App iratiou for Biipaaaal Wor s mitrurtiou Famit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual ewage Disposal System at ��__ ...1 c? � ...... ��^ .. t F ! _..`. � /�:------. ......................... . ocation-Address �.� �Gc or Lot No. ✓ 'Owner Addrr � wiCC.2 - at7 .......................................... �t±r S .- 1.., t 2�iS � ----.. Installer Address QType of Building Size Lotc2l,:V --------Sq. feet Dwelling—No. of Bedrooms_3 _ >________________Expansion Attic ( ) Garbage Grinder (A(b) 1-4 Other—T e of Building ............................ No. of persons____________________________ Showers — Cafeteria Q' Other fixtures ........................._.......................... W Design Flow____ , _....\W....................gallons per person per day. Total daily flow_-___3-0.............................gallons. WSeptic Tank L Liquid capacity j ft.._.gallons Lengt .______ Width---------------- Diameter......_.......__ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......t............. Diameter......./1�_...... Depth below inlet......... -....... Total ing area___r�__�.._4�.,.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �' , Percolation Test Results Performed by---_------� ___�_� ,.______________________ Date----�l!-_/.S`_ :-••.--.. aminutes per inch Depth of Test Pit.._�: _ p ground Test Pit No. 1"__ __._.__. De th to ound water........................ (i Test Pit No. 2_____ _________minutes per inch Depth of Test Pit------ :__________ Depth to ground water..44 3__________- a ------------ •----•••---... -o _ z �,----1---ate � Description of Soil _.... -- �.. -•... - _= W ••-•-------•--- -----------------------------------------------------------------------•------------------------------------------------------------------ ......................................... UNature of Repairs or Alterations—Answer when applicable.___--__________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTL y g g p y of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. tgne ............• -•--•--•------•-•--•-•-------------------•••••--•------------------- ------------Da,te..._••------- /���� 9/''["fs4 ) Date Application Approved BY------------ --��' -•---�/- - ---- ----•---------------•- ---{------�--�-�--- -�-Date Application Disapproved for the following reasons:---------------------------f------------------------------------------------------------------------------ _ ---••-•----------------------------••-••----•-•---------------....... - . ---•- •--•--------•--------•-------------------••••••-----•---- ate PermitNo......................................................... Issued_ Date No....... .... F .. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • I �Z+.�2 v .........._ . .............OF...... ................ `4-...... Applirtt#ilan for Uiipn,i al Workii Tonstrurtinn Prrulit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: '�. ..2_/J �`� ..... �lz`` -...... r� �........•. -•^----•-----•...........................................................................: t Lq a iot Address Lot t '-` Owner r AddressL Installer Address •— Type of Building Size LOt_17 �)_______Sq. feet Dwelling—No. of Bedrooms__ e v'eo�-- Expansion Attic ( ) Garbage Grinder (J�01 PL4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a4 � Other fixtures --------------------------------------------------------------------------------------------------------------------------------------•--•--------- W Design Flow__ 110 ... per person per day. Total daily flow--- �7_____...______.-_______._.___gallons. , WSeptic .Tank Liquid'capacityl}�...gallons Length................ Width................ Diameter---------------- Depth__-______.__. 3 x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage'Pit No....../------------- Diameter__-----/0..... Depth below inlet......... _...... Total 1 c ing area...A.w/4,sq. ft. z Other Distribution box ( ) Dosing tank '~ Percolation Test Resul„�s Performed b _._ _______________________ Date____ /nIS:t.__ _. g Y---------- j -- Test Pit No. 1.... __________minutes per inch .Depth of Test Pit-_-_ ___ Depth to ground water_.- .,• fs, Test Pit No. 2..... ........minutes per inch: Depth of Test Pit_--_- ___________ Depth to ground water---14CkA._\ Description of Soil.....V ----- - W --- ----------------------------------------------------------- --• .--..------------------------------------------------------------------------------------•--------------------------__•••••- UNature of Repairs or Alterations'—Ariswer when applicable:::----------------------------_---_-__----_-_---_--_--_-`_-, ............................... S Agreement: '+ x The,-undersigned agrees to install tfie aforedescribed -Individual Sewage Disposal System in accordance .with the provisions of I-i y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. igne ................ J Date n Application Approved- BY•• / 3�'' Application Disapproved for the following reasons_...........................•--•-•................... _........................ _______--:.. Date---•••--•-•-- ..•--•••---•••-••-••-::...............•-------•-----._...-----------------------•--••-------------- ------ --------- Date PermitNo........................................_- - -__ t°�'� � Issued..............................-= '------• ' -------•- --- --•-- ._ � ,•.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ . ..A( i........OF.......... ..:... , .1.........--...................................... Tnrtifirat e of Tuntplianrr T I is TO CERT That the Individual Sewage Disposal System constructed ( Repaired ( ) by..... .......- ---C 1` —••-•--•-• n to le ... .... ............ --------------- has been in ,lied in accordance with the provisions of T . j o T e State"Sanitary Code as described in the - -f_application for Disposal Works Construction Permit No._. .. _`._-. _____________ dated_.../'ti1 ...1"40_--._.__.._______. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS AAGUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATI:..... .`�`3.1.�.... ...... .........•------.....----------•---- Inspector r T R ---------............ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH � ....... ........OF.... No-------------•--'---•---- FEE.... ............ Disposa "' nrkii T trluqwtt Trani# Permission ' eb a>�ted.,.,__ r --------- Permission - : to Constr ( ;or- air '( ) ridividdu6rT Se!, a i, osSy 11 (/ Street as shown on e application for Disposal Works Constructio ermit o__________________ Dated.......................................... y + oard of Hea DATE.......•'•--------------------................................................... FORM 125 HoeBS & WARREN, INC.. PUBLISHERS- F. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Oxford Drive Property Address 0 Jack Ahlin Owner Owner's Name ` information ist required for every Cotuit MA 02635 11-3-17 +, °+ 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. General Information I a 7 07 on the computer, `` VTN OF fA4,q use only the tab 1. Inspector: °�4` ' sq�''�.� key to move your y cursor-do not ��: JAMES use the return James D.Sears _ key. Name of Inspector SEARS Co z Capewide Enterprises Company Name %, 1�FRTIp 153 Commercial Street 'ii�F b'�N SPEG`\\`p� Company Address �++ Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-3-17 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste m •Page 1 of 17 i + Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber'pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due 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 'ON ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to.a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool I ❑ ® Liquid depth in 11 It AM is less than 6" below invert or available volume is less than '/2 day flow Piz' t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is Cotuit MA 02635 11-3-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: - El ® 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 Y Y laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead.Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M •°' 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2015-78,000GaIs g ( y g (gpd)) 2016-38,000 Gals Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title.5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Oxford Drive - Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980 Permit # 80-54. 2017 New D Box and outlet tee. Were sewage odors detected when arriving at the site? ❑ Yes I� No Building Sewer(locate on site plan): Depth below grade: 20" feet Material of construction: ❑ cast iron ®40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40 & SCH -20. Septic Tank(locate on site plan): Depth below grade: 10" 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: 1000 Gal. Precast H -10 Sludge depth: 2° t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•' 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 10" below grade. Inlet Tee, outlet Tee. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: !Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16-2' below grade w/one line out. D Box is New 2017 w/cover at 6". Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located explain why: p Y t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•' 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635_ 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal precast pit w/2'stone. Pit and cover at 28" below grade w/1'water in pit. No sign of over loading or solid carry over. no high stain . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R EAR g 0 O T y i ry 0,9 -�- J-y t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts L v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,•°' 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1980 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: p You must describe how you established the high ground water elevation: T.H.on Design 1980- 12' no G.W. Bottom of pit at 8' below grade. Bottom of pit at 4'+above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Oxford Drive Property Address Jack Ahlin Owner Owner's Name information is required for every Cotuit MA 02635 11-3-17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ' I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r V�' TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property CJ S 6 X ��;✓� o" ;v c Co- r7- 114 co. Owner's name& o / CA, 1,1 d C- ; Ile G- c, 16 b Mailing address Date of Inspection 71c7 O 1l5 PART A CHECKLIST Check if the following have been done: V/Pumping information was requested of the owner, occupant and Board of Health. ✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. _L The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. I/ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. _ZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SSDS. Page 1 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms o number of current residents No garbage grinder, yes or no YES laundry connected to system, yes or no N o seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 9y = v?4/(off 000 y u l l K S 53 000 y� ilo�s 4 Lc-u , '� e-d . Last date of occupancy GENERAL INFORMATION Puming.records and source of information: O �64u l J sh gk✓n c mac- tb /� cc / -vt.. t- 4- IG V fi //0 System pumped as part of inspection,yes or no If yes, volume pumped Reason for pumping: Type of system �v-' Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (If yes, attach previous inspection records, if any) Other(explain) Approximate age of all components. Date installed, if known. Source of information: I 1 c -4, 1/ ccA 3113/ leo c,. r - 6,, ; 14- n 44-c,h .l I c I�Gr v 4- . ' bC L I e AT 6.11 I A/0 Sewage odors detected when arriving at the site,yes or no c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: ) / . material of construction: concrete metal FRP other(explain) dimensions: S' X 9 X 6 l o y 0 �k - l l o -' /' sludge depth 3'distance from top of sludge to bottom of outlet tee or baffle Wove 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) to 1 V C /cG A.— /v� �t4 c,,,,, -A G.o,,, r�4• !cG r Ov-}lc f o r IC Alo b <J c., vI; ti G - DISTRIBUTION BOX:_ (locate on site plan) �cti a depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation U h / ommendation for repairs; etc) ,�?? 0- !'�o K 74 c/ ( u c' Ire cJ i h t.-+ ✓ {'C i h G de r -- /v u 2 J, CA -h O 7r It C+. k c. K, P - PUMP CHAMBER: 7 (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc.) .9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits and number 6 q 'X 6 L p L. w 3 ' �. leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 9,_(,k 3s ' �3� 5y6 ya q-QO X 1600 b,► 3 � t��c . DEPTH TO GROUNDWATER Sc b to w depth to groundwater method of determination or approximation: lJ NZ,1, of /qk4 s a/� I�, A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no or not determined (Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? A/ Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow? M Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration?tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? _AL_within 50 feet of a surface water? Y within 100 feet of a surface water supply or tributary to a surface water supply? R within a Zone I of a public well? _A/ within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies only, not the SAS)? within 50 feet of a private water supply well? _ less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Troy Williams Company Name TROY WILLIAMS SEPTIC INSPECTIONS Company Address 40 Old Bass River Road, South Dennis, MA 02660 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. the inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: i/ I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date 7 A)o Original to system owner Copies to Buyer(if applicable) -S 6 /t 2?0./f Approving authority PROPERTY ADDRESS: CJ S O x -o Cl A2cl r '72 w 4lo �o zo y 3�� C o`ru j5rnS. ti C t. 3 1—I J TU t SC �� a / 5, t 9 IM �1 YP C) 5 - 1 49'75 L��- a o n �oFT. D mow! +� a� CA►,iC• EAGNf�1G� �sT AAAA lS ' - - - + Gp �< Z"a� 1`_i ;' a A AAA AA & t i3dr' PTT EL4V OLA> C eDuisl7 , Loa►,.� p. . — _Di S 1 c-c lq* D A-rA ; hl C TE.r�-r Z `Oif V1 Eta r Pp LE c 1 l O 61PPD NtNC, � �n 'SE t> 10604LPt"ttk .. .. i ,, .P.ii�•nf 41u 'rt� `4 ' 1 ! *"� i 'i_l .. 't•'a .sy� -l' `�' N", �� . k`�� �`' a ♦S •t .l- :1�•4. 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SEPTIC TANK CAPACITY �d LEACHING FACILITY: (type) P,> (size) NO.OF BEDROOMS—:?__ BUILDER OR OWNER l/`6 41 C. PERMIT DATE: 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 I—. 0 I w �/� pd- b/r W se ll�A 6 1 a 0 m , 0 . a — r W :r