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HomeMy WebLinkAbout0082 PINE RIDGE ROAD - Health 82 PINE RIDGE ROAD, COTUIT A= 018 017 -- r Town of Barnstable Barnstable Regulatory Services Department Public Health Division A " 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7014 1200 0001 03.58 3377 May 14, 2015 John & Beverly Rogers 6051 Laurel Drive #310 Golden Valley, MN 55416 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 82 Pine Ridge Road, Cotuit, MA was last inspected on 5/01/2015 by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution-box is rotted and needs to be replaced You are ordered to repair or replace the septic system within one (1) year from j the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Ltr not sent work in Progress-2015- 128 Thomas McKean, R.S. CHO Agent of the Board of Health S Q:\SEPTIC\Conditionally Passes Ltr\82 Pine Ridge Rd Cot May 2015.doc { 0* Town of Barnstable Regulatory Services Department rFD MA'S� Publie Health Division 200 Main Street, Hyannis MA 02601 Office: 508-8624644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/28/15 DEADLINES TO REPAIR FAILED SYSTEMS . (Town'Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the:❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA s ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe, ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a'pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <1.2" below pit (per Town Code §360-9.1) OTHER — J— �o Repair deadline: I WSEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit _ MA 02635 '" 511-/1`5'" 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 A. General Information filling out forms / � _ on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of inspector DiBuono Sewer and Drain rea Company Name 8 Johns path Company Address S Yarmouth MA 02664 Cityrrown State Zip Code 508-364-9587 S113522 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 5/1/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If.the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform ' the fu ure under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'' 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is _. required for every Cotuit MA 02635 5/1/15" page. Cityrrown State Zip Code Date of Inspection, B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria des i cribed in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1,000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is rotted and in need of replacement. The leaching is made up of a single 1,000 gallon leach pit. Staining inside leach pit indicates the level has been to within 32 inches of invert pipe. i 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 bythe 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): .. I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 "' 5/1/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally-Passes•(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): System passes as long as Dbox is replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 11. 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 pub.lic 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•3/13 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 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 5/1/1-5 page. City/Town 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 5/1/1'5`" page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. -t5ins•3113, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 0263"5° " 5/1/16' 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? E ❑ Were as,built plans of the system obtained and examined? (If they were not available note as N/A) El ❑ Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? El ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 1'7 Commonwealth of !Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal.System Form - Not for Voluntary.Assessments 82.Pine Ridge Road Property Address Beverly Rogers Owner Owners Name information is Cotuit required for every MA 02635 5/1/15" page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system contains a 1,000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is rotted and in need of replacement. The leaching is made up of a single 1,000'gallon Ieach`pit. Staining inside leach pit indicates'the level has been to within 32 inches of invert pipe. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage-system? (Include laundry system-inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 148.4 gpd 9 ( Y 9 (gpd)): Detail: 2013: 49,000 gal 2014: 59,000 gal Sump pump? ® Yes ® No Last date of occupancy: Occupied 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: !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 82 Pine Ridge Road Property Address Beverly Rcgers Owner Owners Name information is required for every Cotuit MA 02635 5/1/15' 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: Bortolotti Construction (2003 last pumped) Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, voPume 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): l - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Pine Ridge Road M Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 29 Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s 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.): System is vented throu ht the roof. Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete - ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 gallon If tank is metal, list age: years Is age confirmed by a Certificate.of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: 3"s t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 82 Pine Ridge Road Property Address Beverly Rogers Owner Owners Name information is required for every Cotuit MA 02635 " 5/1/15" page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance..frocn.top.of.sludge,to bottom of outlet tee or baffle 24 s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape Measure Comments (on-pumping-recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping at this time. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts u Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 5/11157 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.): No evidence of leaking. Pumping is recommended 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 15ins•3/13 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 M 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 5/1/15 . 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]iquid•level above outlet invert Needs to be replaced 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.): Distribution Box is in need of replacement Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms 6n working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 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 82 Pine Ridge Road Property Address Beverly Rogers Owner Owners Name information is required for every Cotuit MA 02635- 5/171'5.. page. Cityfrown State Zip Code Date of Inspection D. System Information (coot.) Type: ® leaching-pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leachingfields number, dimensio ns: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over. no si ns of h drualic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,•'' 82 Pine Ridge Road Property Address Beverly Rogers Owner Owners Name information is required for every Cotuit MA 02635 5/1/15 page. Cityrrown 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.): No signs of ponding or hydrualic failure. 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•3/13 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 c�N 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635 511/TS page. Cityrrown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Assessing As-Built Cards Page 1 of 2 La,� � 0CATTION aE>� A. CE PERIAIT NO, L rS YG 4 Y7 e I L C c c _ Co7-vi r INSYALLIR'S NA NE b ADDRESS 0 U I L D E R OR OWNER FoD^�Eyi✓.So�tl GATE PERMIT 15SUED DAi E C 0 M P L I A H C E ISSUED, i r a Maly ao B,gcK F K6' f(On 7- littp://town.barnstable.ma.us/Assessing/HMdisplay,asp?niappar=018017&seq=1 4/27/2015 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M •'•v 82 Pine Ridge Road Property Address Beverly Rogers Owner Owners Name information is required for every Cotuit MA 02635 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ ft 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: usgs map You must describe how you established the high ground water elevation: Property sits 20 ft above nearest water venue. " Swamp at middle of rd" According to usgs maps system is approximately 20 + ft above ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 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 wM 82 Pine Ridge Road Property Address Beverly Rogers Owner Owner's Name information is required for every Cotuit MA 02635' page. Cityfrown 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 System sj completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE .LOCATION . t(Lam' Pct I SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL - INSTALLER'S NAME&PHONE NO.-7�ea=d ( (L''T. �O�"7�Yf SEPTIC TANK CAPACITY err 4*At LEACHING FACILITY:(type) Fir (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ` � A- t J4 3 Noe No. t� �1 Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered incom uter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 9ppliLation for Disposal *pstrm. Construction 3per it Application for a Permit to Construct( ) Repair(-v Upgrade( ) Abandon( ) ❑Complete System endividual Components Location Address or Lot No. ng,�' Owner's N _A-ddrreess,and Tel.No.?(03-$<.6--1)6Z)/ Assessor's Map/Parcel(� p��} �..V1Ct td �C'�11n ak l �QCISY Installer's e,A dress,and T 1.No. J�af-97/-93j5? Designer's Nam , dress,and Tel.No. �r-k to� - Ao. X ! /U ,4 or-,( 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 Li I Nature of Repairs or Alterations(Answer when applicable) 11,2 a- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmen o and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Sign Date �� J Application Approved by Date f Application Disapproved by Date for the following reasons Permit No. ` _"1 M Date Issued 7 No. U Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered incom Hier: eYs PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zippl.catlon for Disposal. *'stern Construction Permit Application for a Permit to Construct( ) Repair(IvUpgrade( ) Abandon( ) ❑Complete System AIndividual Components Location Address or Lot No. 04. A;d6a_ Owner's Name Address,and Tel.No. Or- Assessor's Map/Parcel 01g �, 7 C— c ,. ,�n� / ` Installer's Name,Address,and Tel.No. .�a6J- /)7/- 93 y9 Designer's Name, d'dress,and Tel.No. Cor-�o(c tU_ Qx-r r�00,T�,c 3.01 pox -26V N � £)� oYnt Q _ Type of Building: Dwelling No.of Bedrooms Lot Size ;sq.ft. Garbage Grinder( ) i 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) _ q, �Y,t.r`K�blteAvaa _ Date last inspected: Agreement: _....i ce / ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal systemin-- - accordance with the provisions of Title 5 of the Environme tal-Co nd not to p lace the syst m in operation until a Certificate of Compliance has been issued b Y this Board of Health. P Sig _ Date Application Approved by Date ! Application Disapproved by Date l� for the following reasons k r Permit No. Date Issued ---------------------------------------`------------------------------------------_-----------------------------------`--------`------- - - Cv� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A" Upgraded( ) Abandoned b rr c 0 � � nC atj ' P_ - has been constructed in accordance with the provisions of Titre 5 and the for Disposal System Construction Permit No. �� `O dated 7 Id Installer r'z)rWatt{ C '�,-,skn,Lon Designer ti -#bedrooms A= Approved design flow /V gpd The issuance of this permit shall not be construed as a guarantee that the system wi'1 cti n as 11>signed. Date SI �I f`� Inspector ----------------------------------------------------------------------------------------------------------------------------------------- No. U �' Fee Uv- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal &pstem Construction pertnit Permission is hereby granted to Construc ( ) Repair(�� Upgrade( ) Abandon( ) System located at n U C 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:Construe ion m st be completed within three years of the date of this permit. Date / Approved by f DATE: 11 /6/96 PROPERTY ADDRESS: 82 P nlidge Road , Cotuit,Mass . 02635 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . T-1000 gallon tank. 2. 1 -Distribution box. 3 . 171000 gallon leach pit. Based on my Insrwction, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) 2. The septic system is in proper working order at the present time. 3. The septic tank -should be pumped. 4. No repairs needed at the present time. SIGNATURE: Name: J. P.Macomber Jr... Company: J. P .Macomber & Son- -Inc ., P Y --------"------=---- � P� Centerville , Mass_ N0�_02632 s Phone:_ s' THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 � U Commonwealth of Massachusetts Executive Office of Environmental Affairs 3epartment of !Irtdironmental Protection Trudy Cox• S—"7 David 8. Struhs U.Gor%1; CaefvnWioewr • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: William F. Tripp Address of Owner. Date of Inspeotioa: 11 /6/9 6 (If different) Name of Inspector. Joseph P.Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ,,,Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails n Inspector's Signature: Y' r Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner.wd copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check,, B, C, or D: Al 3Y9TE�( PASSES: yI/have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: A)� One or more rystem components used to be replaced or repaired. The system, upon completion of the replacement or repair,paases inspection. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If'hot determined",explain why not) ID The septic tank is metal, cra:ked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by th. Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617) 5545-1049 • Telephone (617)292-5500 t� Primed on R"Ied Paper r .\J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Pro 82 Pinerid e Road Cotuit,Mass . 02635 Owner. g William F. Tripp Date of Inspection: 11 /6 96 B) SYSTEM CONDITIONALLY PASSES(continued) ,dam Sewage backup or breakout or ho static water I"observed in the distribution box is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumper mo7e than four times a year des to broken or obstructed pips(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require Anther evaluation by the Board of Health in order to determine if the system is failing to protect t.hs public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIOMNG IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 60 feet of a surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tnbut&.ry to a surface water supply. AV The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. 10 The rysum has a septic tank and soil absorption system and is within 60 feet of a private water suppb wall. A,O The system has a septic tank and soil absorption systam and is Is"than 100 fast but 60 fset or more from a private avatar rupply wall,ualesa a well water analysis for coliform bacteria and volatile organic compounds indicates that the wall is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. 9) ,O'THF41 �C ' f - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontlnued) Property Address: 82 Pineridge Road Cotuit,Mass . 02635 Owner. William F. Tripp Date of Inspeotlon: 1 1 /6/96 D) SYSTEM FAILS: • AID_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. Tha basis for this determination is identified below. The Board of Health should be contacted to determine what will be naoeasary to oorrect the failure. Backup of"wage into facility or system compoaent.due to an overloaded or clogged SAS or cesspool. dLU Discbarge or ponding of effluent to the surface of dw ground or surface waters due to an overloaded or clogged SAS or cesspool. Ij Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. AW Liquid depth in osespoel is is" than 6"below invert or available volume is less than U2 day flow. d,O Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times;pumped I" 01L)a Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. �f Any portion of a cesspool or privy is less than 100 feet but greater than 60 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 sad nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large system) and the system L a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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"nsitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional oMce of the Department for further information.. v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: William F. Tripp Owner. 82 Pineridge Road Date of IInspeotlon:C o tui t Mass . 0205 11 /6/96 Check if the following have been done: ` Pumping information was requested of the owner,occupant,and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d that period. Large volumes of water have not been introduced into the system recently or as part of this inspecti /b on. built plans have been obtained and examined. Note P if they are not available with N/A 'he facility or dwelling was inspected for signs of sewage back-up. Ze system does not receive non-sanitary or industrial waste flow K i�site was inspected for signs of breakout. ZAll system components,gLuding the Soil Absorption System, have been located on the site. .L/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. ZTba size and location of the Soil Absorption System on the site has been determined based on existing information or proaimated by non-intrusive methods. The facility owner(and occupants, if different from owner)were rovideId with 3 I P information on the proper maintenance of Sub. Surface Disp osal System. (revised 11/03/95) 4 5 SUBSURFACE SEWAGE D19PO9AL 9YSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Add1C0: 82 Pineridge Road Cotuit,Mass . 02535 GWncr: William F. Tripp Date of Inapoutiur:: 11 /6/96 FLOW CONDITIONS RES I D F_NTIAL- Design flow: oa per�►' Number of bedrooms: Number of current maidents Garbage grinder(yes or no): Laundry oonaected to ry*te'a (yes or no):-&S Seasonal use (yes or no): eg Water meter readings, if »/U Last date of occupancy:2L-k-!�� _CONMERCLAL/INDU9TRIAL- Type of establishment: A Y¢ De+ti,e-n Dow:�nllons/day Grease trap present: (yes or no),d2e* ladustrial Waste Holding Tank present: (yea or no)A/—d Non-sanitary wasto discharged to the Title 5 system: kyvs or no)eLA Water meter readutZ;o, if available:_�� Last daw of occ upaacy: OTTIER: (Describe) AM _ Lan date of occupancy: R GENERAL I NFO RMATI 0 N PUMPING RECORDS and source of irtfoncation: System pumped as pan of inspection. (yes or no) y U yes, volume pumped: ''au Reason for pumping. 4/f TYPE OFi9Y9TE.�i _�/Septic tali4Jdistri ution box/soil absorption s)stem Overflow u.:spuol Privy Shared ryvtem (yes or no) (Lf yes, attach prvvious inspection records, if any) Other(explain) e ll ' APPROXIMATE AGE of ull compo enta date ir:.+t.LL!td (if luiown) and source of information: /) Sewage odors 4.FoA "i i ` Y .o �o� I f LOCATION p 3E ►VACE PERMIT NQ. Lors y6 .� y7 VILLA6E !Y7 Co TveT IFl5TA LLER'S � NA ME ADDRESS — 57�� R UILDER DR OWNER �o J NE y !/��✓SanJ -------------- DATE PERMIT ISSUED 3— DATE COMPLIANCE ISSUED SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. • SYSTEM INFORMATION (continued) Property Address: 82 Pineridge Road Cotuit,Mass . 02635 Owner: William F. Tripp Date of Inspection: 11 /6/96 SEPTIC TANK: (locate on site plan) Depth below grade:& Material of construction: �ncrete _metal _FRP —other(explain) Dimensions: Sludge depth: /V' �r Distance from top-.of stud a to bottom of outlet tee or baffle: _ 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.0 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle depth of liquid level in relation to outlet invert, structural rity, evidence of leakage, etc.) . Pump tank .eve^ry_ two to three years : Inlet & outlet tees are in place ;Liquid level tt k shows GREASE TRAP. /lit7i C (locate on site pian) Depth below grade:X4 Material of consinirtion,,V/ zoncrete _!metal _FRP —other(explain) Dimensions Scum thickness:_ .. Distance from top W1 scum to top of outlet tee or baffle:_.-V/1 Distance from bottom nl ftim to honnm of outlet tee or 6h1e:1f& Comments: (recommendation for pumping, condi—rl of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (:raa as t.rAn i a nni'. nracan+. z s (revised 8/1S/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 82 Pineridge Road Cotuit,Mass . 02635 Owner. William F. Tripp Date of Inspection: 11 /6/96 TIGHT OR HOLDING TANK:,,12v.(1� (locate on site plan) • Depth below grade. AM Material of construction:t!�6onuvts_metal_FRP_other(esplain) - .7A Na Dimensions: AJA Capacity: AIA gallons Design flow: li}f1 aaIIons/day Alarm level VA_ i comments: (0° 0i"9�al`ore'�°ioa�ing a�an�are`not'present at this location. Not needed DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert: Rua Comments: (note if level and n is eq evidence lids over,• Usuoe of 1 into or out of . e .) Box is level with one flow line. No evidence of soics carry o , No evidence oTr ieakage in or ouz ol zne-Fo-x. 140 rP=a; rg nPaciPr3 at PUMP CRAM BER: drVe> (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pum chamber;, condition of pumps and appurtenances, etc.) Pump chamber is not present. Not needed at this iocation. ;, .:. fir: i• .i,i (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) p,o;4AyAdd. 82 Pineridge Road Cotuit,Mass . 02635 Owner. William F. Tripp Date of Inspection: 1 1 /6/96 SOIL ABSORPTION SYSTEM (SAS$ (locate an site plan,it possil ;excavation not sequirad,but may be appraaimated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: leschh, chambers,nnmbar j leaching galleries,number. leachimg trenches,number,langth: leaching fields, number,dimeq{ions. overflow cesspool, number. (J Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,stc.) Medium sand to fine sand;No signs of Hydraulin failure or ponding. All vegetatinn i4 nnrmal _ Nn renairn nP.Pritmd at „ ±.he prPsPnt. time_ CESSPOOLS:_&L4Ve (locate on site plan) Number and configuration: 424 Depth-tap of liquid to inlet invert:— Depth of solids layer: A))1 Depth of scum layer:_ A A Dimensions of oeaspool: A919 Materials of construction: Indication of groundwater AM inflow(cesspool must be pumped as part of inspection) AM AA Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) C'ea4nnn1 a are nnt, nreaPnt at. thi a 1 nnnti nn _ PRIVY:2VJ,0,6 (locate on site plan) Matarials of .1//� Dimensions: ,-411_ Depth of solidsds is Comments:(note condition of soil,signs of hydraulic failure, level of pon&ng,condition of vegetation,etc.) Privies are not present at this location (revised 11/03/95) 8 i �J.�,JUIIUACE SEWAGE DISPOSAL SYSTEM INSPECTION ,PQI,. i PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE [ :SPOSAL .SYSTEM« I include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Cotuit�, Water Company 428-2687 0 0 Jn i i I DEPTH TO GROUNDWATER 1.61 + depth to groundwater Method of determinesion or approximation: . Insti�1-1e:d' Stem -de—i L.© zibrldh Road. Qo . J t- Nn wAtpr ancountpred t _ W � b THE .COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control ` �I ` •nrnr�•-rt,r��-rrrnrmr•ntrr.re+rt awnrr•�r:-.�r+:�rrirn•+enm+rer:tia*�•�nmsrn .rrrrrr-�r—r-...--.r...) 1 TOWN OF Barnstable BOARD OF 11EALTII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `� �^•T•`1�T••.".:T—T.t11�.�lTTT:'1.1-R.TlfTT4T.fT'.�fT1:T.•.-1r{VTTtf...1Rr�T.Rl�RTO�Rr10T..�+r1tT7 itl.. .,fir T'."•1• �•.^ -TYPL OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS 82 Pineridge Road Cotuit.Mass . 02635 ASSESSORS MAP, BLOCK AND PARCEL i _18 lot 17 OWNER' s NAME William F.• Tripp PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Maco#er & Scf4 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578 A 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 : -.XXXXXX= System-PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLf1 or Lhe environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . -Inspector Signatu Date 7—c One copy of t)ii rtification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or"'o` orator shall up grade pgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 , partd -doc LO C. ATION aEWAGE PERMIT No. 3 0 to 4 (1 4c_ el-oge 8 !Y VILLAGE Ca?v1T INSTALLER'S NAME �Z ADDRESS .._ —u ! LDER DR awoER DAT E P IT ISSUED DATE C 0 M P L I A N C E ISSUED l e �a a1 yN A01 /On T No... Fss. .._....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF......../ .2�v ST�4►3C E--------.............--.........••--- ApplirFa#inn for Disposal Works Tonstrur#ion jrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -��-........ ... .-----,...._ ....... d................ .. - l f� -Location-Address or Lot No. ................�__!4i�?- o'`�=...................................................... ................-----------•-------••---... --....... ....----------......-----....... Owner Address .................... ...................... •--........................................ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.......:................................Expansion Attic ( ) Garbage Grinder ( ) Other'—Type T e of Building No. of persons............................ Showers Pa YP g ---------------------------- P ( ) — Cafeteria ( ) a d Other fixtures -----•--------------------------------•-----...-------.-•-----•---•--------------------- -•-•--------------•--------•-----------...._.........-•-----• W Design Flow..........5S..........................gallons per person per day. Total daily flow...... 0.........................gallons. WSeptic Tank—Liquid capacityl©�?..gallons Length._J.O......... Width-5. ........ Diameter..............•. Depth_.S.-........ x Disposal Trench—No..................... Width........ Total Length.................... Total leaching area.................... ft. Seepage Pit No........,.... ...... Diameter...`8........... Depth below inlet.._..W-�.....__.. Total leaching area..s�2=�� q. ft. Z ' Other Distribution•box ( Dosing tank ( ) aPercolation Test Results Z Performed bY.......................................................................... Date........................................ Test Pit No. 1..._.---_•---___minutes per inch Depth of Test Pit.13............ Depth.to ground water........................ Test Pit No. 2.."7'_..minutes per inch Depth of Test Pit----ta........... Depth to ground water........................ x ..........--•-•••-:-•••-•-•••-•-•-•--•-••-----•.....--••-----••-.....-•--••••--.........•--------•--...••----•-----••-•---•.................................. 0 Description of Soil.............. ' ...........pl0` ------•-------------------------------------•-•...........•-•••.---• x r, ---------------•---................. ---....-------------------....... -.------•------------------------------------------------------•-------•-----------..--------------------- .... W •----...---•---------------•--------•-----------•--------------•-•--....---...-------------------••--••--••-.-••-••. --•-•••------•-----•-•---•-•••......-•-•-•-•••--•-•-••---••--•••-•-••-••--.--.... U Nature of Re a'rs or Alterations—Answer when applicable....•- 1 1.� 7— 1. f.... .R Agreement: 71T—y �'�'� The iindersigned agrees to install the aforedescribed Individual Sewage isposal System in accordance with Gr the provisions of iITi 12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in r operation until a Certificate of Compliance has b en iss bythtb ealth. JZ Signed _..._ .-- . (t? —� Date Application Approved By.. =� !`---- .._. r-G ate Application Disapproved for the following reasons------------------------------------------------------------•---------•--------------•-......••--............---- ..----------•.......................................••---•---•-----•-------•--•.........•-------•._......................-----------••--•--•-••----••••-••••-•••-•--•-----•-••-....--••---•-••---•------- Date Permit No......... s.r...--..t.�l7------------ Issued.....................................................-- Date A j r CZ f - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---.1...a ..................OF....... . Applilcn#ion for Disposal Works Tons#rnr#ion rami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal t System at: Ck alit �., U/ lA 7 f RS 0✓15- _»»»»_-•--- »-...._. --- .......... ........... . . .. - .1...........----....»� --.......... Location-Address •or Lot No. ................»....»»»W....•l.»__..........•............-•---^............^--------------- �(,'�" Owner / Addr ess .......... ............................... ......:.......................................................................................... Installer Address a' Type of Buildings ', Size Lot............................Sq. feet Vs Dwelling,—No. of Bedrooms..............1 Expansion Attic G g P ( ) Garbage Grinder ( ) a ` Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 0 Other fixtures .............................................................. .......................... Design'Flow......._..:5..........................gallons per person per day—Total Total daily flow... 33 ........................ gallons. Septic Tank—Liquid capacityld�?p..gallons Length._P c!....._.. Width..:_.......... Diameter................Depth..5.......... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft: Seepage Pit No............ ...... Diameter...Z421.......... Depth below inlet.....!-.......... Total leaching area..:5A9.8sq. ft. Z Other Distribution'box Dosing tank ( ) `.• Percolation Test Results �- Performed by.......................................................................... Date.................................... Test Pit No. I...'G.�_.minutes per inch Depth of Test Pit...L r�....._.. Depth to ground water........................ L4 Test Pit No. 2-_�_�r-...minutes per inch Depth of Test Pit.... 3.._........ Depth to ground water........................ a .......---•----•---•........................•--•-•-••••-.......•••••••..................••...---••-.................................. O Description.of Soil................ P-f.•........... ------- --------------------------------------------------------------------------------------------•-••................_.. x x ....--- .........................,��;.. ...: ..... .........••••-. ......--•-••....-•-•...•. •----••-•••.......... U Nature(o�f Repairs or Alterations—Answer when applicable Agreement: � � f ,�The_undersigned_ agrees to install the aforedescribed Individual Sewage Disposal System in accordance with C�'. the provisions of TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in Aaa?me . + J tjA ftj operation until a Certificate of Compliance has b en iss d by � t the �Realth. Signed. ------ •• •.• .:boa ? ate Application Approved r / :_. T ate Application Disapproved for the following reasons:--•----------------------------------------------------------------------------------•---------------•---.--••- --•---•---•-•---.......--•-----•-----•--...----•----•---------------•--------------.....----•----...............----.........--•-------------------------------------------------------------------.---_. Date PermitNo............. G -- d I----------- issued.................. ---................................ Date THE COMMONWEALTH OF MASSACHUSETTS lie� BOARD OF HEALTH .....O F...........: .......................:....... ::...................-:............................................ ' Tntif irtt#r of Tontphatt r THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) at .(° .1---.....•..-------•-----------------------------------•-------••--•-•-•--••-••-••••-••••••••••-••••••••••-•-......•-••••••----.._........-•••••......•---•- has been installed in accordance with the provisions of T -" '`'" 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. G..----i.-!-(- 7._____..... dated.....i. ;;�/ 6--.._--_---_-_...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ._ DATE................ �:�.I..f.I e& Inspector--•-•-•...! r ,•.... .... .--- < ------------- -----------------------•---•----•---..-.--- THE COMMONWEALTH OF MASSACHUSETTS r{ gj"._-. IGmoo c� BOARD OF HEALTH �✓"" ►r as a moei.� 10 No.......... .."'L.�C ..........................................OF._................ FEs: ......... Disposal Works Tons#rnr#ion Vernfit 7-11-1--A Permission is hereby granted............ --- -L.......... I................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Di s oral System at No...•.... I=�1 "^C_... 4.. s r ...e = (�/� ............................................................... -Street Z� L;7 as shown on the application for Disposal Works Construction Permit No ____ `( / C... DATE.. ISu1n1 of� - Health 1` --��- --�---'------- ---•------------------------------- LOW & WELLER, INC. "Fiddler's Green Plaza" 774 Main Street, P.O. Box 119 Yarmouth Pbrt, Massachusetts 02675 362-6868 362-8131 Registered: George Low, Jr., R.L.S. Land Surveyors A. Paul Simard, P.E. Professional Engineers William G. Weller, Consultant December 12, 1986 BOARD OF HEALTH Town of Barnstable 367 Main Street Hyannis; MA 02601 RE: Lots 46 & 47 Pine Ridge Road Cotuit Dear Sirs: Please be advised that we have supervised and inspected the installation and construction of the new sewage system for the above referenced location. We find that the system has been installed and completed in accordance with the approved plan. If you have any questions, please do not hesitate to contact US. i Very truly yours, Wil iam G. Weller WGW:kew - - SID VOT& k40)2/Z. SC,9LC- : -� — - proPvsed c�rovnd Pr-ofi leOF P. V. C. ©.2 _ - ---- �Ldw - ------_ SCHED. 40 E � -,Co GQ Ui9L TC� $EP T/C rnu�r r r nr rn per Yi 7ANk' - Y` /000 G,,gz-. SE PT/C TFiA-/+e 3/4 o a t �astied stone } ° s # ° a a a _ a r t ALE A,. - / L0- F'! 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