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HomeMy WebLinkAbout0075 PINEVIEW DRIVE - Health cotuit TP A = 040 119 -- Y s r IS A c Commonwealth of Massachusetts Title 5 Official Inspection Form- { Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r�7 75 Pineview Drive Property Address .'. Wendy Anderlot Tr Owner Owner's Names information is Cot required for every ✓ Ma 02635 4-21-2020 page. City/Town State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. - 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code yam (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 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. R Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey ,Digitally signed by Brett Hickey 'Date:2020.04.2314:17:08-04'00' 4-21-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwedith of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System"Passes:,.. 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: The system was in working order at the time of inspection. _ z 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 isj metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 k cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name - - information is Cotuit Ma 02635 4-21-2020 required for every State page. City/Town St Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1 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: u t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (; 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 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 i i v cry Commonwealth of Massachusetts I Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coot.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow D' O Required pumping more than 4 times in the last year:NOT due to clogged or obstructed pipe(s). Number of times pumped: . 0 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. ❑ 0 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ a The system fails. I have determined that one or more of the above failure r criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.- 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ,4. El Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pin(;v w Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every 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 EJ El Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ E] Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) 0 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? F-1 ❑ 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? El ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ O Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 M Commonwealth of Massachusetts ,z Title 5 Official Inspection Form ?° i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 2 2 Number of bedrooms (design): Number of bedrooms(actual): 355/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 2 bedrooms allowed with a minimum (330GPD.) design -Number of current residents: 0- Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? ' ' ❑ Yes RI No Seascnaluse? ❑ Yes CE No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: "Broken water meter per Water Department" Sump pump? ❑ Yes X No 4-1-2020 Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive. V� Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: `3 NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ * No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volum6 pumped: r 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 f Commonwealth of Massachusetts �d a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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 j ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): a Approximate age of all components, date installed (if known)and source of information: Plans dated 3-20-13 Were sewage odors detected when arriving at the site? ❑ Yes ❑0 No 5. Building Sewer(locate on site plan): 116" Depth(below grade: feet Material of construction: ❑ cast iron H 40 PVC ❑ other(explain)'- Town water 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 SysterroPage 9 of 18 c Commonwealth of Massachusetts ' �n Title 5 Official Inspection Form ±= w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 75 Pineview Drive u% Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 611 Depth below grade: feet Material of construction: [10-1 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons 811 Sludge depth: (J 28`1 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. l5insp.doc•rev.7/26/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection 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): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA �,. Material of construction: r ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I I c Commonwealth of Massachusetts �m Title 5 Official Inspection Form _ � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 753Pineview Drive V� Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) ..s Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out,of box, etc.): The d-box was in working order at the 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 f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: (20)ARC36 infiltrators n leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ` �n ,ip Title 5 Official Inspection Form i 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive V� Property Address Wendy Anderlot Owner Owner's Name information is Cotuit• Ma 02635 4-21-2020 required for every 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.): The SAS was in working order at the time of inspection and was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts r Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form Not for VoluntaryAs sessments ` 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 1 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Andeelot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately 4h 712020 Assessing As-Built Carols: VIL[.A4t.4.,J.. t..�... [A�SSt.S1tJR T��MnVG Pw1YCF.L 1I_-3 - <f•Tl]CT YR CAYAC:ITY �/ � Ja'`Y-2"v _ f i ttACHR.9 FAC1S ITV:{ry'fr)BZ1J.,CxA�So�wie.+�)�S .,yt aF 3 ' - NU:GP Bft+IitX1M<_1 ��•.•.••.. -.n :•J r'u. . r) nerztw'rt+mt 3✓;'�.L.l..',d-- �.oR4t-�u:cin n::..�r�..�y,,;� : - .. ....27..!. _.:...t— . . - Mne'4bie •h'Nr'R'NI'avll Nicsivli(c'(Irero w<lin :s e5: ......_...Vuet fiCgaurayJ.0- csl�{ Auv(r(fiu�v. .ai::w�l11�n . :Y4V(cea�f eepiug:rx N( - ....... .....T—Pcn _ G (3-( '7Y'7 ' httpsi:IWv.n.bariistBbl�,ma.uslUepartmentslAssessing/F'+ropeny_ValuesiHMUisple�y.asp7mAppar=D4Ol`IA&seq <^,-, � 71t t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts - /p Title 5 Official Inspection Form �_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; l 75 Pineview Drive v Property Address Wendy Anderlot Y Owner Owner's Name information is cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) J 15. Site Exam: Check Slope ❑E Surface water ❑■ Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 132" feet Please indicate all methods used to determine the high ground water elevation: / 0 Obtained from system design plans on record 3-20-13 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) b ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. I _,... Before filing this Inspection Report, please see Report Completeness Checklist on next page.,-, t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Pineview Drive Property Address Wendy Anderlot Owner Owner's Name information is Cotuit Ma 02635 4-21-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: O 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 i oar Town of Barnstable Department of Regulatory Services Public Health Division Date c� 200 Main Street,Hyannis MA 02601 y Date Scheduled �J Time Fee'Pd. Soil Suitability Assessment for Spvage Disposal Performed By: Witnessed By: LOCATION&GENERAL INFORMATION n Location Address Owner's Name r�>�� r\(g Ci:�C�J �l-vV Address "CS- Ep Add c � cam:Lj ziz Assessor's Map/Parcel: aU L/O/ Engineer's Name CS A-") xz Pn4 NEW CONSTRUCTION REPAIR � L_ TelepJhone# s©4- a 7 3.417 Land Use. �� �C1 P f1'�1C.I Slopes(9b) O -S0(b Surface Stones el ALA—ft Distances from: Open Water Bodyft Possible Wet Area Drinking Water Well N IA ft Drainage Way _ft Property Line ___S9 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) Io2\/it=i.) Parent material ) 1(geologic) ` r_1 OWCS� Z�I g Depth to Bedrock Depth to Groundwater. Standing Water in Hole: I Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: __--____- in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: In. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adi,thetor__ Adj.Clmundwater Leye]a„o PERCOLATION TEST Date,. Thne,w._ Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ 0.. 00 . . O0 Time(9"4") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# — Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,Boulders. o is tency.96 Oravel) -3 0�� LsL ie 2j, 3 �I S LJ 3Lq -►3 �� M ��� �o /�. Flo �r^�,��► DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell), Mottling (Structure,Stones,Boulders. Consistency, %Gravel) _ Ls I� s 0 �+ 001. GrAve l DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No V'. Yes Within 100 year flood boundary No..:-T Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? P If not,what is the depth of naturally occurring pervious material? Certification I certify that on DJ. o-(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tr i g,expertise and experience described in 310 CMR 15.017. Signature Date 113 Q:\.S.EMCVERCFORM.DOC TOWN OF BARNSTABLE �^ LOCATION r �i eJ C/;1' 4�'nv SEWAGE#r_�Q/ L3 VILLAGE c, \ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. �sz�.r eAai�✓1-W SEPTIC TANK CAPACITY I<ZXZI d LEACHING FACILITY.(type) A (size) NO.OF BEDROOMS �l r OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 77, 5 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 � G� j�s" d�ttn� a : S7 ° 1p .. G3 t 0 No. 7_0 G--Oq v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPlitation for Mispo8al 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade(,-' Abandon( ) ❑Complete System Plinndividual Components Location Address or Lot No. S 4 '%v.ct��>�s� ems-, Owner's Name,Address, nd Tel.No.'�© �,�'f Y- 17a- L at s ►,�vL u�as-'la Assessor's Map/Parcel �Q 71�- 1�>, _> - � Cj 3 ,- Installer's NaanW,Address,and Tel.No.q, (Z!k`?-7917- C�S Designer's Name,Address,and Tel.No. Sc.S-a 57 fi�.Q©x Ada-i✓s �� Y� r� U 3 6 Type of Building: Dwelling No.of Bedrooms o! Lot Size �3� l sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) o��U gpd Design flow provided S' gpd Plan Date 3 I 'gyp Number of sheets ' Revision Date Title /y Size of Septic Tank OC°» �e_ ovk ypeofS.A.S. S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Q® Lc Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. d Date Y'n�1AX(h, Application Approved by Date 3 2Z Application DisapprovedK Date for the following reasons Permit No. Zp t­ 01 7�- Date Issued 312z- 2,013 -- -- - --- - ��- - --- ----- r. .. R.a a -7 x qe-G��s y ( W o J No. Zo(� ��T Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes — " PUBLIC HEALTH DIVISION'- TOWNS OF BARNSTABLE, MASSACHUSETTS _. application for -Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(V)'Abandon( ) ❑Complete System ['individual Components Location Addressor Lot No. Owner's Name,Address,and Tel.No. 7p3 " Assessor's Map/Parcel �? i Installer's Name Address,and Tel.No. Desi ner'`s Name,Address,an Tel.No.QQfV � 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 0 Title Size of Septic Tank OQ)cn C--k ype of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)`",n E—� At--,c�7 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ed Date �f L o.1�(h n� �VDt3 Application Approved by Date , Application Disapproved Date for the following reasons Permit No.F D I-7 -- Q Date Issued ---------------------- ----------------------------------------------------------------------------'=- ------------------------------ Th G COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(, ) Repaired( Upgraded( " Abandoned( )by at �' �,y',�c. �X'. �odc,'.� has been constructed in accordance with the provisions of Title 5:and the for Disposal System Construction Permit No.7D(3-at} dated Installer �q � 5 c — v.�: Designer Ck LA r #bedrooms Approved design flow 1 0 gpd The issuance of this permit shall not be construed as a guarantee that the system will nctiio `de gne' d. M Date .��_/� /� � Inspector._ - 1 ------------------------------------------------------- ------------------------------------------------------------------- --------= No. - Fee (�oa THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( t,)") Abandon( ) System located at 'I S, i���-e,c In t...+e— 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:Co struction must be completed within three years of the date of this permit Date ?j Z Z. Approved by s 3 Town of Barnstable Regulatory Services Thomas F.Geiler,Director Public Health Division 39. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: Z5Sewage Permit# ,?b 3- b " Assessor's Map/Parcel 0 1 Installer&Designer Certification Form Designer: GIN Gl' l n2xuri n!� Installer: Address: ��_��� �0 3 o Address: '?(!D,`%ZK 2 ff C . • ..,+� •Tee-h c1��4- . M� Q2�3l� �.��z��i��yy�4 �l�/� On 3 0? 3 -i r z was issued a permit to install a (date installer) septic system at S i n w i e is C based on a design drawn by (address CSN ►nue,,r n c, dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required - . ed and the soils were found satisfactory. oa��.4�ti of Mass c q LINDq J. PI (Installer's Signature) Vl b ` o. 6 qv P 61L �Q/S T E G�►�4► s � � � (Designers Signature) (Affix Design ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercer ification forrn.doc 4- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® SEP 1 0 2003 �*i TOWN OF BARNSTABLE ,TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 75 Pineview Drive MAP C) Cotuit PARCELOwner's Name: Barbara Snow ` Owner's Address: LOT Date of Inspection: 8/29/2003 Name of Inspector: (please print) Kevin J.Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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: _ZPasses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: d2�y� y Date: C� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of I I a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. stem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Co itional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or r air,as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the r the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* r the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltrati or tank failure is imminent.System will pass inspection ifthe existing tank is replaced with a complying septic as approved by the Board of Health. 'A metal septic tank will pass inspection if it is s cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old i available. ND explain: Observation of sewage backup or br out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settl or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pum ing more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approv of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 75 Pineview Drive _ Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the d 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 determiu m accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which rotect public health,safety and the environment: _Cesspool or privy is within 50 feet of a su ce water _Cesspool or privy is within 50 feet of a dering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Pu c Water Supplier,if any)determines that the system is functioning in a manner that protects the pub' health,safety and environment: _The system has a septic tank and soil absorptio system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wa supply. _The system has a septic tank and SAS an a SAS is within a Zone 1 of a public water supply. _The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. _The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method ed to determine distance "This system passes if the well r analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compoun indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen an nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A cop of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 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 — _yI'Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool _ "Liquid depth in cesspool is less than 6"below invert or available volume is less than %a day flow — —v�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. _ �y portion of a cesspool or privy is 50 feet of a private water supply well. y 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.] Q00(Yes/No)The system fails. I have determined that one or more of the above 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 most serve a cility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the fol wing: (The following criteria apply to large systems in addi ' n to the criteria above) yes no the system is within 400 feet of a surfs drinking water supply the system is within 200 feet of a to tary to a surface drinking water supply _the system is located in a nitrog sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply ell If you have answered"yes"to any qu on in Section E the system is considered a significant threat,or answered "yes"in Section D above the large as has failed.The owner or operator of any large system considered a significant threat under Section E o failed under Section D shall upgrade the system in accordance with 310 CMR I5 304.The system owner should ntact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? /Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓i 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&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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example,a plan at the Board of Health. _v""_ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):.A_'.1=' Is laundry on a separate sewage system(yes or no):sue?[if yes separate inspection required] Laundry system inspected(yes or no):= Seasonal use:(yes or no): n.Zz> Water meter readings,if available(last 2 years usage(gpd)): t Sump Pump(yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft, c.): Grease trap present(yes or no):_ Industrial waste holding tank prese (yes or no):— Non-sanitary waste discharged to a Title 5 system(yes or no):_ Water meter readings,if availabl : Last date of occupancy/use- OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: C�c�ar•�,1-- - ��,_,,,� � �c�c_� Was system pumped as part of the inspection(yes or no):A_-eD If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ,Z'§eptic tank,distribution box,soil absorption system Single cesspool T_Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):✓_ D Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron PVC other(ex )ain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakafe,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:n crete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: :3 Distance from the top of sludge 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: ' How were dimensions determin �.� `7J Comments(on pumping recommendations,i� nlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ;ram r r- l•¢�+. e� .� c-].r trs:��r,,� e . �.®iC S`.".a<v.:v.-v GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_m tal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to/dations, tee or baffle: Distance from bottom of scum f outlet tee or baffle: Date of last pumping: Comments(on pumping recom inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evideage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 TIGHT or HOLDING TANK: (tank must pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete m 1_fiberglass_polyethylene other(explain): Dimensions: Capacity: gall s Design Flow: g ons/day Alarm present(yes or no): Alarm level: Alarm i orking order(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX: if resent must be o ened locate on site plan) _Z( P P )( P ) Depth of liquid level above outlet invert:Cr Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump cham r,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 SOIL ABSORPTION SYSTEM(SAS):—zloocate on site plan,excavation not required) i If SAS not located explain why: I Type aching pits,number: leaching chambers,number: —leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): •� � I fy �� `�/��y�+�. V�..l��.�� �C3 t/..ic_1 ti— ♦i�i�"�'dF3.1� �\�e V.��a� CESSPOOLS: (cesspool must b pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inve . Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater' flow(yes or no): Comments(note conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,si of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 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 11 supply enters the building. 1 � � O � Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM"INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Pineview Drive Cotuit Owner: Barbara Snow Date of Inspection: 8/29/2003 SITE EXAM Slope Surface water Check cellar-"' Shallow wells Estimated depth to ground water of feet Please indicate(check)all methods used to determine the high ground water elevation: _V�btained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the 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: f� Commonwealth of Massachusetts 8 Executive Office of Environmental Affairs Department of \ Environmental Protection 9 1997 ' M A`( Wllllem F.'Weld TOWN OFP Governor HEAL Trudy Coxe seaelmy,L'01 David B.,Struhs �111111111\\II'r11P1 1 � • SUBSUKI ACL SL WAGL UISI'USAL' SYS 1 LM INSI'LC 1 IUN 1 UKM PART A CERTIFICATION ` Property Address: 75 Pi n vI Drl Ile Ct� "�,�] r :Address of Owner: Date of Inspection: 5 C� (If different) - —Name-ot Inspector. _ r �( r - ra erts Company Name, Address a d Telephone um er: ic �FICATION CE 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-si te sewage disposal systems. The system: 40. Conditionally Passes Needs Further. Evaluation By the Local Approving Authority Fails Inspector's Sig-al— ig — - 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__origmal should be sen; t uu• s stem owner and copies sent to the buyer, if appilcable and the appro�Ing a '"cn INSPECTION SUMMARY: Check A, B, C, or D: A] SYST PASSES: I 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: , -One or more system components need to be replaced or repaired: The system, upon completion of the replacement or repair, passes inspection. Indicate:yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial.infiltration or ex(iltration,.or tank failure is S im.,minent. The system will pass inspection if the existing septic tank is replaced with a:conforming septic tank as r approved by the Board of Health. ' (revised 8/15/951 i One Winter Street • ' Boston,Massachusetts 02108 0 FAX(617)556-1049 • Telephone(617)292-5500 OJ Printed on Recycled Paper L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -7 IF-) n vv C. f u l f owner: M KI IV1 o c Date-'of Inspectio : J l B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) 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 l.eyelled or replaced _ The system required pumping more than four 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 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 the public health, safety and the environment. t) SYSTEM WILI PASS UNLESS BOARD OF HEALTH DETERMINES-THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN VIR0NSiENT: _ I he kvsiem nas a septic tanK anu SOII,ausurpUUll,system anu is wilkii, i Qu icci iu a su.acc i.,jpp:j Gr trlbuia,t' to a surface water supply. The system ha- a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system"and is-within 50 feet of,a private.-water,-.supply well,. . .-..._...-_ The systen, has a septic tank and soil absorption system and is.less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and vofatile 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• DJ SYSTEM FAILS: I have'determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an 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. (revised 8/1'5/5s) 2 t f / N = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address:, 1 n U Owner: M r Y�-'� Date of-Inspection: b1 �1q � D] SYSTEM.FAILS (continued): dStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. �1 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. dRequired 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 Soil Absorption System, cesspool, or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 1001eet of a surface water supply or tributary to a surface water supply. LL Any portion of a cesspool or privy is within a Zoneil,of a public well.. L Any.portion of.a cesspool or,privy is within 50 feet of a private water supply well. y€ 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,;volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater Marge System) and the system is 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 sensitive area (Interim Wellhead Protection Area 0WPA) or a mapped Zone ti of a public water suppiv weli The owner or operator of any such system shall bring the.system and facility into full"compliance-with he•groundwater:,treatrrtent.program.. requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office offfio,Departmenvfor further information. ,:, t r E s • 5 � ' 3 (r evised 8/1 /95 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM`^-,.'y ._ PART B CHECKLIST Property Address: `nf— Owner: Date of Inspection: - - bI81Q Check if thefollowing have been done: / Pumping information was.requested of the owner, occupant, and Board of Health. /None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during,that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. / AA s built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected (or signs of sewage.back•up. The system does not receive.non-sanitar), or industrial waste flow The site was inspected for signs of breakout. .. .. 2AII system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. /The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. . ThE feCi i;� or,.,c ' ' occ�Na a:, if d"?^ro^t fron-. ov.-ner! \"ere provided with information on the proper maintenance•o(Sub- Surface Disposal System. (revised 6 15 95 4 : v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: -7 Owner-- KIM rO M o ors : ... ... .:: ._. ..�...,,., ..k......._... .. .. .. ._.. ....".. Date of Inspecti n: FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents: 3 Garbage grinder (yesl or no):Lll ' Laundry connected to system (yes or no):y Seasonal use (yes or no): Water meter readings, if available: Last date of occupancy: ►:(`F l COMMERCIAUINDUSTRIAL: Type of establishment: . Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: I' Lust date ul occupancy: { OTHER: (Describe) Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: ` System pumped as pan of inspection: (yes or no)._ If yes, volume pornped gallons Reason-.for pumping: TYPE O'POSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow;cesspool . Privy Shared system (yes or no) (if yes, attach previous inspection records, if.any) Other(explain) r a. T. -APPROXIMATE.AGC o(.ill components, date installed (if known)and source of information �d y✓s _.: ,...___ r.... ., _...... S Sewa a odors detected when arriving at the site: (yes or no1/� - it ....,. .. g (revised 8/15/95)` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property�Address: 75 Pi YlC K-CL v I Y-I vC. CJ U t Date of InSpe Sj rc moo ye, SEPTIC TANK: ' I (locate on site plan) --- -Depth below grade:._. Material of construction: V concrete _metal _FRP _other(explain) Dimensions: Sludge depth: 01 s-3`� Distance from top of sludge to bottom of outlet tee or baffle: - 1 Scum thickness: Distance from-top of scum to top of outlet tee or ly�r tt Distance from'bottom of scum to bottom of outlet tee or baffle:3 Comments: (recommendation for pumping, condition of inlet and outlet fees or baffles, depth of liquid level in relation to outlet invert, structural, integrity, evidence of leakage, etc.) c; c,i't'►� �1c1 S �� - i" .1[�`� �f�`�o GREASE TRAP:Ly 4 (locate on site plan) .. __,Depth below grade: ' Material of construction: _concrete _metal =FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee-or baffle:- Distance from bottom ro artim.in hnr!'6r (11 ptl!)?! IPP M ba!ue Comments:' (recommendation for pumping., condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ' I f (revised Bi-'5/95) 6 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address:. n c, v'I �� �)Y i v e .1 T Owner: Mt�rGjY.�� 1"pt out Date of Inspection: JJgIG1 - - r TIGHT OR HOLDING TANK:4-I (locate ,,,on site plan) Depth below grade: i Material of construction: _concrete _metal _FRP_other(explairi) - Dimensions: Capacity:-gal Ions Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Y DISTRIBUTION BOX: (locate on site plan, Depth of liquid level above outlet invert: dn ,��"' Comments: mote ii ievei anu distriuut.uw: > r.tu,', e;.d�nce of su1 u: ca:1)u,e1; evidence of,leakagq._into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95), 7 . � F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T�SYSTEM INFORMATION (continued) Property Address: �lGJ Owner: MarI are; Date of Inspei n: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) is If not determined to be present, explain: I Type: leaching pits, number: teaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) C 00 0 0 c.r n v- V. ,i T k nv�—S CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of,cesspool: _ Materials of construction: - -Indication of ground%cate . ...,.: .., .,m ...._, inflow (cesspool must be pumped as part-of inspection) Comments: (note condition of soli, signs^of.hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: `(locate on site plan) Materials of construction: Dimensions:' Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised;8/15/95) $ i t _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: G q ) n e. e Y l V(? Owner: M U{ e lM U Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or►ienchmarks locate all wells within 100' ` 36 a DEPTH.TO GROUNDWATER Depth to groundwater. feet ( method of determination or approximation:.---) Irti-- '1 CIA (revised 6/15/95) 9 LOCATION SEWAGE PERMIT NO. food(.-24511: L I (?v LACE � 0 - �,ololf " INSTALLER'S NAME i 4DDRESS SQ' go Into Hf9 DIs nn� _ S • '1Armo cf 11 BUILDER OR OWNER S • `IAr�nb� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED , L�_ �� o74� ®FJ Q' �J L'0f S/ .5TV-E t-T J l6. ;• s P,31/3�No.--- .... .._...... Fps..�4 0..�.0.�....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..TOlnIN............................O F......-.....BARNSSABLli--......---------..-.....---...-..-.-......- Appltration for Disposal Works Tonstrurtinn Frrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Drive Pineview-- �-,�,� � -Cgtuit,---MA................. ...............................................51 Location-Address or Lot No. .L).pX jgL.._a , ...Cs�.ns.fwxuctiox�..:�amp�.r�. ----- 4...�x t...�.Qx�.�.:.� i.y� :5.�... �x z�u .Y�.;...BA Owner Address WSPiema...TheAlajaxldls................................................. ......................SaIri@-................................................................. F Installer� Address UType of Building Size Lot-.2.41,25.t.....Sq. feet Dwelling—No. of Bedrooms.......:•.3...............................Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of Building _Re-s P_XkUAiTo. of persons-----------6-.............. Showers ( ) — Cafeteria ( ) Q, Other fixtures ............................................................. W Design Flow............55..........................gallons per person per day. Total daily flow.-..•.._•334:•_---_••-•_-•--.•..•••.•--gallons. WSeptic Tank—Liquid capacit}-•�0�_.0gallons Length_.10_ 6_ Width...... .•.•-. Diameter..............-. Depth...6:.3----- Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed b Norman__Gros sman.......................... Date......8-_3. 8 3 a y.. -----••••• -•-• .....--........... to Test Pit No. i.••:•-2.......minutes per inch Depth of Test Pit---144•-•----- Depth to ground waten.None............ GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ----•--------------------------------------------------------•..-----------..........------------•--......................................................... 0 Description of Soil...... ....................................................................................................... U --•-----------------------------------------------•..-•.•.-.---...-•--•------------..........-------.-....-----------------•----...-•-•-•-------....-.----------------.......-•--------•••••-•••----•-•- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------- -••-••----------- -•---•--------------- *-------------•-----.-----*.............................. ------------------------------------------- •------.------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITiM 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. i ed Gi ............ Approved By............•P11owing •• --- ............................................................. � �- e -'------------•-•- Date Application Disapproved for a reasons: ---••--••- ..--------------------------•----•-•-----•---•-----•--••••-•-•...-....•..••-•--.-.......-•-•-••--•-••-- Date PermitNo.......................................................... Issued....................................................... Date t No......................... Fm$... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TQ f�...........................OF.............B,ARN,S.TAB.Tatra............................................ Appliration for Disposal Works Tonstrnrtiun rrnti# Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: -Pineview Village., Cotuit, MA 51 ......... •------- ........ .... ........................-......................................................................... Location-Address or Lot No. Dennis Star.... ..C—QUIR-a. y.... 24.5 t_.Pond K)ri Ie......5.�._Yar?rK? �... Owner Address a .Spero..T1xP.Qh.4,r;LdjL6................................................ .......................Sam................................................................ Installer Address Type of Building Size Lot.... j 125+_____Sq. feet Dwelling—No. of Bedrooms...........3-.._.__----_-----------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ..Re.Sidentia4o. of persons............6.............. Showers ( ) — Cafeteria ( ) Other fixtures = W Design Flow.............35.............._..._...._.gallons per person per day. Total daily flow-_-_.--_.-330____-_________ _ dons. WSeptic Tank—Liquid*capacityl:.t.®O.�allons Length... a_�. . Width.......5.'.--_ Diameter................ Depth....._..3.___ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_._....._._.........sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area............_.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by......Norman Grossman __ Date.......8/3§ ............... W Test Pit No. 1.......2...___minutes per inch Depth of Test Pit....144" Depth to ground water..None- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------------------------------------------------------•-------•••---.------........................................................ D Description of Soil......Subsoil, medium sand. x _....--•...•-•----•-------------•-••---•-•---•--•--••-------••---------...------•..........--•---.. V .................... •-----•--------•----•----•---•.........-•--••--------------••---........-•--•..........---•-••--------•- W x ....................-................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •-------------------•--------------•------•----------------------.....--------•---------...----.....------.....--------------------------...--------•-------------------......--•---........_.....•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T'L, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed................................................................ ................................ Date ApplicationApproved BY...................•----...••------......_...---....--•--------••-•-•...--•--•-----•--•--•......- Date Application Disapproved for the following reasons:........................................•--......._...........................----......._..........__........_ ----------------------------------------------------•---------•----------.......------------------------•.....-------------------•----------------•-------------•-------------------------------•••.-•--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD_ OF HEALTH ............TOWN..................OF..... ..BARNSTABLE .... ........................................................ Trrtifiratr oaf Toutpliattrr FRS' y T 1d by T •- � eC6ri-c'Ir1 Cif 3 h O he24oI'aL e Se le�u� �7G I,stu L T,tltr a `Ilt�luttl I ' p&ired ( ) ---•---------•------------------------------------------------•--•-•-------._.-----.....-------•--------------------•-----••---------.-----------•--------- Lot 51 Pineview Nk$ , Cotuil,Etalle MA at.................................................................................................- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ..............................! .. ------•-------......... Inspector..........A-`.-I..------.......--------...-----------••--•--....--•--••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................TOWN OF.......BARNS TABLE $4 00 0 No.......................... FEE....-.................... Disposal marks ftstrV ionFrrntiSpero Theohas, Gre Pon Drive, S . Yarm. , MA, Permissioys hereby granted... to Con t n R�Q�it ( dividua ewa Di System �`t .51) �1nOieW �; g. b9tu , atNo. ....... -.. ...............••------•------._-...-------------•--------.-..-------•---------------......-------••------•--------•---....... �r1 ve Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... DATE................................................................................ Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS ` T,ION 1 ���1t_ ®�/� �"' MID 00-410. f re DATE m�. JCANT FEE- lr .ESS ,� , ��sra ' off. °.1` TELEPHONE NO.� (Non-refundable) NEER TELEPHONE NO. SCHEDULED � .® - (Applicant' s gnature ) • o o e • o o • • • m e m o 0 0 • e m e e • m • o o • m o • m • m o o • • o o • o o • e s o 0 0 • o m e a o • • • • • e o o • e o o e o • • o e e o e • o SOIL LOG DIVISION NAME DATE_ TIME ,NSION AREA: YES ENO ENGINEER-)" WATER A,- PRIVATE WELL a- , , ,s� BOARD OF HEALTH EXCAVATOR 'CH: (Street name,etcm.,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: 7-X1 o y -OLATION RATE: t HOLE NO: ELEVATION: TEST HOLE O: ELEVATION: 24 1 . 21. 2 _ 3 3 4 4 5 5 JF 6. 6 7 7 8 8 9 9 10 10 11 11 yy►' 12 1.2 13 13 14 14 15 15 16 16 _ TABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES UITABLE ,-FOR SUB-SURFACE SEWAGE. REASONS: `E : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPL TION GINAL: COMPLETED IN ENTIRETY BY P. E . 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Vt~ 6vILLCG(/S AW Are-':>✓N OEW PA Y PE.Pta�CilThx/ 7 too.I9W.510. 4,r,4CAllV& AX,64 k urtEo *FV etsy COTU 1 T CaAzt-1 STA-BLE ) MASS• ZxAe/,(/A/G / ez4 lZoV/OCo d.i��K..TGIIKiT: EhtQ►l1.tG�Q: - �..- P12OP05E.D LE,ACHIMCG PIT i� ai�l t sr:h� wl°a7. tt/ El3G1N ING I NC• D I S PpS Q• ` 100�'e E x NA rl s o N '? R` ►T �tJ L� D�'11 k: FAlT1-1 H Gad W.�. 1Grq� r SE�c.!>=fZ DES�GIIr.I �,2�r le) 0;: rLc,v� S.Z' 1�lcSVTi-!� Iu[a .f au' �� i+d�4+ J - SIDE\,II�t.L. X Z 5 377 GPfJiu1 r �p�rtidti Art`[ ;, Arm- Q.O Y i/ WD f r BOTTOM •�+GZ EA = ?C �-2 �c 1 o 50 G PP " rPam/ / M A;� t \t 5swlge APPLIC41-M 041 t40' G C.G. �bT,�_ - 4•�7GP© \\\, ;� t �' O*AiN4 6T. +c r r>Ire►: "fro. 25' COTU IT, TOP OF FOUNDATION 24"diameter concrete covers MA EL=5(.O raised to wrthrn 6'of harsh grade 5.0' 5.0' 5.0' 5.0' 5.0' (or as noted) Inspection Port and cap with magnetic marking tape to within 3"of grade 0) N Existing EL=49.3t EL=49.0+ EL=49 O+ 66a 6 - - d7 to 0-Box nj �p o co 48.5+ Existing 48.0+ 46.8 i 3 9 " X Inspection Port(See Note 04) �5tin45.t3� o 47.0� 46.67 N 46.50 46.40 PLAN VIEW (TYP.) ( L OC(fjr �0 Existm EL Gas Baffle 45.50 SCALE: I " = 10' o�effS Roa�y CV Lon est Run TWEIVTY(20)AD5 ARC36HC f3+ g 75lw+ m �} 29' 9' (36/6002)LEACH CHAMBERS/N BED -j Existm 00-6 CONFIGURATION W/TH FOUR(4)ROWS EX/5TlNG /000 GALLON (H-20 Rated) OF F1Vf(5)CHAMBERS 51 T E LO C U 5 5fPT1C TAN' ` D-Bo LEACH C-�AMBERS IEL=38.0+Bottom of Test Hole NOT TO SCALE 0 1 .) Assessor's Map 40 Parcel 1 19 FLOW PROFILE Q 2.) Deed Book 17G89 Page 123 NOT TO SCALE \��\\G�a 3.) Plan Book 282 Page 27 Lot 5 1 CON 5TRU CT I O N NOTES \`(\� 0 Q�b 4.) This property Supply not In a Zone II Of a Public Q pc X. } O Water Supply s� 5.) Flood Zone: C 1 .) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 CMR 1 5.000): oS305` STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND 9° EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT 62 00 AND DISPOSAL OF 5EPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. �25 LEGEND O 2.) ANY SEPTIC 5Y5TEM COMPONENT INSTALLED IN A LOCATION WHERE THERE 15 POTENTIAL FOR VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 Bdrm Living EXISTING SPOT GRADE LOADING. IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. O 24x5 PROPOSED SPOT GRADE 3.)TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS SHALL BE INSTALLED ON A STABLE Garage EXISTING CONTOUR MECHANICALLY-COMPACTED BASE ON 51X INCHES OF CRUSHED STONE. 24- PROPOSED CONTOUR Bdrm Bth Kitchen/Dining W WATER SERVICE LINE 4.)COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX, AND 0 THE 501L ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN G"OF FINAL GRADE. LEACHING p�e\�0"1 N O OVERHEAD UTILITY LINES FIELDS,TRENCHES, AND OTHER 501L ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL \ Ato° U UNDERGROUND UTILITY LINES HAVE AT LEAST ONE(I) INSPECTION PORT CONSISTING OF PERFORATED 4" PVC PIPE PLACED FLOOR PLAN 0 2�Aa�o� �s s G GAS SERVICE LINE VERMARTICALLY KINGTR O, ACCES THE OTTOM SIBLE OFWI�TH WITHIN 3" OF ABSORPTION SYSTEM WITH A GAP,TIED WITH MAGNETIC o� �� o F ° 0 ��� kF° EDGE OF CLEARING 101Oak --�--�- FENCE 5,}PIPING SHALL CONSIST OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A NOT TO SCALE TEST HOLE LOCATION MINIMUM CONTINUOUS GRADE OF NOT LE55 THAN 2% FROM THE BUILDING TO THE SEPTIC TANK, Oeo� i9 ST SE?TIC TANK AND NOT LE55 THAN I%OTHERWISE; a Lot 50 DB DISTRIBUTION BOX G.)DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4" DIAMETER SCHEDULE 40 8" Oak SAS SOIL ABSORPTION SYSTEM PVC(OR EQUWALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED BENCHMARK AT END OR AS NOTED. <<�\� Existing Septic Shed Top Corner Concrete �::'::: EL=50.00(Assumed Datium) Tank to be Utilized 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO(2) FEET BEFORE ........ (See Nate#2 I) I CERTIFY THAT: I AM CURkENTLY APPROVED BY THE PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED TO Existing Leach Pit DEPARTMENT OF ENVIRONMENTAL PROTECTION PURSUANT TO ASSURE EVEN DISTRIBUTION. to be Abandoned 3 10 CMR 1 5.01 7 TO CONDUCT 501L EVALUATIONS AND THAT (See Note#22) S THE SOIL ANALYSIS HAS BEEN PERFORMED BY ME CONSISTENT 8.)GROUT TO BE USED AT ALL POINTS,WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES s f WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE !N ORDER TO PROVIDE A WATERTIGHT SEAL. \_ .��� DESCRIBED IN 3 10 CMR 1 5.01 7. 1 FURTHER CERTIFY THAT THE SYSTEM DESIGN CALCULATIONS 4 Decorative f�f RESULTS OF MY SOIL EVALUATION AS INDICATED ON THE 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE �..,< �1 Tree , ATTACHED 501L EVALUATION FORM, ARE ACCURATE AND IN SEWAGE DESIGN FLOW REQUIRED:2 509M DWELLING(MINIMUM DE5IGN 3 L 8"StumpACCORDANCE WITH 3 10 CMR 15.100 THROUGH 1 5.107 DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. DORM)@ l/0 GPD/BEDROOM=330 GPD REQUIRED 10.) IN ACCORDANCE WITH 3 10 CMR 15.22 1, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH 0.0 MAGNETIC MARKING TAPE. 5EWAG5 D55/GN FLOW PROVIDES TW5NTY(20)ADS UNITS IN BED 8 Stu ," CONFIGURATION IN FOUR(4)ROW5 OF FIVE(5)UNITS EACH. Linda J. Pinto, Certified Soil Evaluator ! 1.)THERE ARE NO KNOWN WELLS WITHIN 1 00' OF THE PROPOSED 501L ABSORPTION SYSTEM. Vt=[(330/0.74)/(4.B FT2/FT)/5.0 LFJ = 15 AD5 UNIT5 2 4 d REQUIRED(20 PROVIDED) �� cPs tH OF O_ 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF fi THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT 355 GPO PROVIDED>330 GPD REQUIRED s o f Swing Set IINDA J. USE Olf THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. s ` Pig SEPTIC TANK CAPACITY REQUIRED.• 330 GPO X 200% =660 CPO REQU/RED V+ 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS G. 10 Pine 0 CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BYTHE 5EPTIC TANK CAPACITYPROVIOED: SXISTING /000 GALLONSEPTIC TANK Q DESIGNER. IST A GARBAGE OOP05AL 15 NOT PERMITTED WITH TH15 DESIGN FLOW 8/�qE Lot 52 3; 14.)THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE Surve Mork by.- AND SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT P TOE APPROVED PLANS. 48 HOURS ADVANCE NOTICE 15 REQUESTED. TEST HOLE LOGS A & M Ladd Services 15.) LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR BIB Route 28, Suite 3 DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO Test Hole#I (EL=49.0±) A'est Yarmouth, JIA 02673 COMMENCEMENT OF ANY WORK. TH15 INCLUDES, BUT 15 NOT LIMITED TO, REQUESTS TO DIG5AFE, Pb. (506) 797'-177'7' Akna l.• eamland0comcest.net ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. Depth Layer Soil CIa55 Soil Color Comments I G.)CONTRACTOR SHALL VERIFY THAT ALL WA5TELINE5 ARE CONNECTED BY WATER TESTING O"-3" O/A Fine Sandy Loam I OYR 211 Prepared for: WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. 3"-G" E Medium Loamy Sand I OYR 5/2 5 00 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY 24"-1 B fine-Medium Sandy Loam I OYR 4/G Z0S?;0 Q� Wendy Anderlot 24"-132' C I Medium Sand I OYR 5/G 20%Gravel SEPTIC SYSTEM COMPONENTS. Perc @ 58" LOT 5 1 6 `' 75 Pineview Dr. Cotuit, MA 02G35 18.) INSTRUMENT SURVEY CONDUCTED FOR PROPOSED WORK ONLY, SITE PLAN SHALL NOT BE Q �a� USED FOR 5TAKING,OR ANY OTHER PURPOSES. Test Hole#2 (EL=49.0±) Area=23, 125 S.F.± \_O Q J�\�G Proposed Sewage Disposal System �p 75 Pineview Dr., Cotult, MA 10.)TH15 PLAN DOES NOT CERTIFY, GUARANTEE OR WARRANTY COMPLIANCE WITH DEEDED OR Depth Layer Soil CIa55 Soil Color Comments ZONING BYLAWS, SPECIFICALLY, BUT NOT LIMITED TO, SIDELINE SETBACKS AND BUILDING HEIGHT Prepared by: RESTRICTIONS. OWNER 15 RESPONSIBLE FOR OBTAINING SUCH A DETERMINATION FROM THE 0"-4" O/A Fine Sandy Loam I OYR 2/1 p y APPROPRIATE AUTHORITY. 4"-G" E Medium Loamy Sand I OYR 5/2 6"-28" B fine-Medium Sandy Loam I OYR 4/G 20.) IF SOILS DIFFER FROM TH05E SHOWN IN THE SOILS LOGS, DE51GN ENGINEER 15 TO INSPECT 28"-1 32" C I Medium Sand I OYR 5/G 20% Gravel THE SOILS PRIOR TO PROCEEDING WITH INSTALLATION. ✓ITE PLAN -1IF SCALE: I" = 20' ����'�� 2 1.} EXISTING 1000 GALLON SEPTIC TANK TO BE UTILIZED. PVC TEES TO BE INSTALLED ON INLET DATE OF TESTING: 03/15/13 P#13888 "' AND OUTLET PIPES IF NECESSARY, AND A GAS BAFFLE INSTALLED IN THE OUTLET TEE. INSPECTION NOTE: 501L EVALUATOR: LINDA J. PINTO, P.E., C5N ENGINEERING 22.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND BOARD OF HEALTH AGENT: DON DESMARAIS, BARNSTABLE HEALTH DEPARTMENT PRIOR TO FINAL INSPECTION BY THE ENGINEER, SYSTEM 0 20 40 60 >! P.O.Box2030 Phone:(508)299-3250 ABANDONED IN PLACE, AREA TO BE COMPACTED TO MINIMIZE SETTLING. PERCOLATION RATE: LE55 THAN 2 MIN/INCH IN "C" LAYER Teaticket,MR 02536 =< Fax:(508)548-5478 NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. SCALE I "=20' NO GROUNDWATER ENCOUNTERED C:\C5N\RR-Pineview\RR-Pineview-Pine Plan.dwg Date:03/20/13 Scale:A5 Shown By: UP Check:MTA Project No. C5N0320