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HomeMy WebLinkAbout0172 OXFORD DRIVE - Health �7�2 OXfOrd Drive Cotuit P A = 021 075 f 1 f �, `�� i � � Commonwealth of Massachusetts Title 5 Official Inspection Form lo, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS c a Property Address t•� 172 OXFORD DRIVE f' Owner Owner's Name/ information is required for every CO MA 02532 10/31/2019 >' ._ page. Cityrrown State Zip Code Date of Inspection, r} - ray 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 on the computer, JR use only the tab OHN P GRACI S key to move your Name of Inspector cursor-do not GRACI SEPTIC INSPECTIONS LLC use the return Company Name key. i t �� PO BOX 2119 I�I Company Address TEATICKET MA 02536 Citylrown State ' Zip Code few 508-548-7500 S1468 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 Evalu ion by the Local Approving Authority 4. ❑ Fails 10/31/2019 Inspector's Signature Date The system inspector sh submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, th nspector 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, an 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS �v Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 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: SYSTEM PASSES TITLE 5 i 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): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .,, MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02632 10/31/2019 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): NA ❑ 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): NA 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY AN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 , Cit lTown State Zip Code Date of Inspection e page. Y P 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: NA **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: NA. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Lug MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE . Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 page. CitylTown 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 Ej ® Liquid depth in cesspool is less than 6" below invert or available'volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® _ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than.50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd-,, ® 10,000 gpd. . The system fails. I have determined that one or more of the.above failure ®` criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be R necessary to correct the failure. 5j 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. t No ® y >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 16, Commonwealth of Massachusetts Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 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)] 4 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is COTUIT MA 02532 `10/31/2019 required for every page. CitylTown State Zip Code Date of Inspection D. System Information 1. 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 Description: GIVEN FROM BOH Number of current residents: OCCUPIED Does residence have a garbage grinder? ❑ 'Yes ® . No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to NA Is laundry on a separate sewage,system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes ® No Seasonal use? Z Yes ❑ No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gp ))� _ . Detail: 2018-51,000 2017-91,000. Sump pump?* ❑ Yes ® No Last date of-occupancy: Date SEA SONAL t6insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: NA Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NA Last date of occupancy/use: NA Date Other(describe below): NA 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 M1lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 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): NA Approximate age of all components, date installed if known and source of information: PP 9 P ( ) 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1,C„ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 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 i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��. � MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTU IT MA 02532 10/31/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK IS CONSTRUCTED OF CONCRETE. If tank is metal, list age`: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON SEPTIC TANK Sludge depth: 28" Distance from top of sludge to bottom of outlet tee or baffle o„ Scum thickness Distance from top of scum to top of outlet tee or baffle 6„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. RECOMMEND PUMPING NOW AND EVERY TWIO- THREE YEARS DEPENDING ON USAGE. RECOMMEND REMOVING SPRINKLER LINE OFF SEPTIC TANK. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is COTUIT MA 02532 10/31/2019 required for every page. City/Town State Zip Code Date of Inspectio�i D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA NA Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, st--uctural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grader Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): NA NA Dimensions: NA Capacity: gallons NA 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 la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 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.' NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of currentpumping 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 BOTTOM OF PIPES 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.): r COMPONENT FUNCTIONING PROPERLY AT TIME OF INSPECTION. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ( i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 page. City/Town State Zip Code Daespection i4 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.): NA " 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: NA Type:. M ❑ leaching pits number: NA � leaching chambers number: 2-500 GALLON NA ❑ leaching galleries number: ❑ leaching trenches number, length: NA ❑ leaching fields number, dimensions:� NA ' NA ❑ overflow cesspool number'. ❑ innovative/alternative system Type/name of technology: NA t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY AN AND DAVID EVANS v Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 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.): 2-500 GALLON LEACHING CHAMBERS WERE EMPTY AT TIME OF INSPECTION. RECOMMEND MOVING SPRINKLER LINE OFF THE LEACH CHAMBER. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments MARY AN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA i 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 la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A2._ h35 51- 3i 2 A3= 52 63- 2q A L3 y, �iSdLl �allun SeDhc �anlL II p S�Ri N i tJ 2 o 3 4 1 N 1CL ntt✓ 2-5bD C. C.i1o4M13�S t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 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: fe e ett 1 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: HAND AUGER } 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•Dage 17 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MARY ANN AND DAVID EVANS Property Address 172 OXFORD DRIVE _ Owner Owner's Name information is required for every COTUIT MA 02532 10/31/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 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 Y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z .DEPARTMENT OF ENVIRONMENTAL PROTECTIO (NAP d PARCEL RECEIVED °�M 5�•�' LOTAPR 7 • - 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 0 1, Owner's Name: DANIEL TOOMBS Owner's Address: 4 MEADOW DRIVE LITTLETON MA 01460 Date of Inspection:3/5/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 I Telephone Number: 508-564-6813 FAX 508-564-7270 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:. X Passes _ Conditionall sses _ Needs Furth 'valuation by the Local Approving Authority _ Fails # Inspector's Signature: Date: 3/5/04 The system inspector shall submit Jcopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sha 1 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 SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND MOVING SPRINKLER LINE. ****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. Titles 5 Tncnactinn Fnrm rill soonn 1 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ° A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.RECOMMEND MOVING SPRINKLER LINE. B. System Conditionally Passes: "" One or more system components as described in the Conditional Pass section need to be replaced — p ced 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 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 n/a "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: n/a Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X 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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(if they were not available note as N/A) X __ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ 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 ? X _ 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 X _ Existing information.For example,a plan at the Board of Health. X _ 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: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: n/a Does residence have a garbage grinder 49or no): ➢W y e.s 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)):-*4- O?j ���1/o Sump pump(yes or no): NO D l 2� `OD Last date of occupancy: n/a b li COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agalIons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _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): n/a Approximate age of all components,date installed(if known)and source of information: 1998 PER AGENT AND ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: H 10' 6" H 5' 7" W 5' 8"-" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 0" 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: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) l Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 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: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a r Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): - n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 WAS VIDEO INSPECTED DUE TO GROUND BEING FROZEN.D-BOX APPEARS TO BE STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a . 3 ' R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: 0 500 GALLON CHAMBERS leaching chambers, number: 2 n/a Teaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a. Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE CHAMBERS DUE TO GROUND BEING FROZEN. SYSTEM SHOWS NO SIGNS OF FAILURE.CHAMBERS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 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: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 = 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: Vv a o lip' Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 172 OXFORD DRIVE COTUIT,MA 02635 Owner: DANIEL TOOMBS Date of Inspection: 3/5/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT. No. Fee V U THE COMMONWEALTH OF MASS ACHUSETTS Entered in computer: A Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS _ Y 0(pplication for Mi!5po5al *p$tem Con5truction Permit =---Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No-OZ O xfOR D X (.OTU f T Ow m ner's Nae,Address and Tel.No. `-7&— 7�6"" 314 /Assessor's Map/Parcel 7 /Q N 1_r - ,t,, 1114. Installer's Name,Address,and Tel.No. � 36 F dj Designer's Name,Address and Tel.No. 77 S—0 7 3 5 Type of Building: Dwelling No.of Bedrooms d9 Lot Size as°d©� sq.ft. Garbage Grinder(NC) Other Type of BuildingUMP t/M#%e_ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flows gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /5&V Type of S.A.S.1.15 -l�/ 6 �l�% Description of Soil 4_5 Nature of Repairs or Alterations(Answer when applicable) 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 provis' s of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ss ed b h' f Health. Signed e ✓� Date Application Approved Date Application Disapp ed for the following reasons Permit No. Date Issued A. t`No. ~ V Fee THE COMMONWEALTH OF MASSACHUSETTS ) Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Otgooar *p.5tem Construction Permit Application for a Permit to Construct( VI/Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No./1 Z�0x f'Qk D DR. COTU/T Owner's Name,Address and Tel.No. q18— V F(O- 3/4 Assessor's Map/Parcel 91 ?5 �Ot, 70044 95 L l ,LF .v M4- Installer's Name,Address,and Tel.No. 40`4F —36 Y S Designer's Name,Address and Tel.No. '77 5— 07 3 5- 4 E D lC tfW 6 )rco " It4ri-t-FOR v tt 55dC Type of Building: Dwelling No.of Bedrooms cl Lot Size Q` �� sq.ft. Garbage Grinder(NtX Other Type of Building U4W P 1FIM016 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �i�D d gallons per'day. Calculated daily flows gallons. Plan Date Number of sheets Revision Date Title _t _���/ Size of Septic Tank 1 C466 4154 ` Type of S.A.S. ! 6 Description of Soil P 1;7R k .. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provis' s of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Y cate of Compliance has been s ed b h' f Health. Signed J �� C 7t✓! Date ✓ ��� /a Application Approved Date Application Disapp ed�forhe following reason Permit No. � ' Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance mow,. THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( )by QU F— b 16 M A-10 at 1 Z— OX t0,e!) D 9 I i/F_ CD T U/T has been construc'red in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated h� � Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date �i• - SS Inspector No.. /� Feel1Qt/ n THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS M­itpb5a1 *pgtem Cow5tCuction 'V ermit -_ - Permission is herebygranted to Construct( Vf Repair( )Upgrade( )Abandon( ) System located at 7z0 XrOK A N t VAE il-D 7-0/7- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be`cgmpleted within three years of the date of tv's pe it. Date: % �""� �GT Approved TOWN OF BARNSTABLE °�� LOCATION Lo4 51 oa6eLd `��. SEWAGE# la ' VILLAGE C' U; • ASSESSOR'S MAP &LOT- INSTALLER'S NAME&PHONE NO. `LAC_e� 4Z8 S0 8's", SEPTIC TANK CAPACITY OU ►�� LEACHING FACILITY: (type) Z SDO !2,4 668 dua(size) �3 f 't Y NO.OF BEDROOMS ?— " ry BUILDER OR OWNER y PERMITDATE: COMPLIANCE DATE: � Ohtq 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 - 1 S2 zq S Lol Lci Co LS 3b TOWN OF BARNSTABLE LOCATION Loy S I OBI PO(L d --x)n. SEWAGE# VU.LAGE ('Qq u ASSESSOR'S MAP&LOT (L_f 0 7S INSTALLER'S NAME&PHONE N0.Cc-e� �1LS Q�3S� SEPTIC TANK CAPACITY (Sao a�� LEACHING FACILITY: (type) Z S00 !2A C 66k (size) �3 NO.OF BEDROOMS BUE DER OR OWNER U E PERMITDATE: OMPLIANCE DATE: Separation Distance Between the: 1 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 ; r within 300 feet of leaching facility) f Feet Furnished by { i i • .,� b'L it 01 S i Jz 2S h 0 _0A TEST HOLE LOG 50 DATE: FEB. 17,1998 P-9106 2'3,o(:;> SOIL EVALUATOR D.MASON,CSE WITNESS: G.DUNNING PERC RATE: <2 MIN./IN. L-r-T 51 0" AP-LOAMY SAND 52.0 R2/6 3" O.ORGAW S7 9" v ISY 51.2 wr•LOAMYaAND IF dW-LOAMY SAND NYRY6 ��do t#YRSA 15" 5&7 32" 493 sw-LOAMY SAND (� IeYRSIS 39" 4u p C-MEDIUM SAND r;,T 2.6Y716 C-MEDIUM SAND LSY716 120" 42.0 120" 42.0 1, � \ , NO WATER ENCOUNTERED 10 31`� DESIGN DATA DAILY FLOW: (2)BDRMS.1110 GPD= 220 GPD SEPTIC TANK: 220 GPD 1200/e 440 GPD USE: 1500 GALLON PRECAST SEPTIC TANK 3s Two LEACHING FACILITY: USE: (2)500 GAL.DRYWELLS w/4'OF STONE CAPACITY: SO— - ------ -!-- -- --- - -- - - - --- -- - ---- --:_� _ SIDEWALL: 761210.74= 112.5 BOTTOM: 13'125'10.74= 240.5 5� TOTAL: 353.0 GPD < NOTE: THIS PROPERTY LIES WITHIN THE GROUNDWATER PROTECTION(GP)ZONE. t1xis 0 r4 O DAtM L NAM AN CIVIL V No.32686C q NOTES: $TEIIEN }q �4IST��� 4"� 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. h E- 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION a, BOX. !�4 J ;a 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN Z3- t a 2.-7' 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEL 2'LAYER OF"'PEASTONE OVER I In*WASID2D STONE ALL AROUND TOP OF FOUND. ,S Q EL. 53.5 If" 14' 5o h� 0.00 \ 4q.23 �ffa-f a r::i-•47 o0 49.�5 47.oc> SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION 172 OXFORD DR. COTUIT MA. OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR > > TO ANY EXCAVATION OR CONSTRUCTION. LOT 51 -PLAN BOOK 271 PAGE 56 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH 310 CMR 1&00:TITLE V. PREPARED FOR 3. THIS DETERMINIS NOT ATIONTO BE USED FOR PROPERTY LINE BAYSIDE BUILDING CO. 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. DATE: FEBRUARY 19, 1998 SCALE: P =301 S CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLER & ASSOCIATES FFIE645ALMOUTH ROAD CENTERVILLE, MA. 02632 EL: (508)775-0735 FAX: (508)7754754 • APPROVED BY: