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Home My WebLink About0087 PINEVIEW DRIVE - Health 87 PINEVIEW DRIVE COTUIT A = 040 118 w N Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co uteri Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLation for Mispo8al *pstrm Construction i9ermlt Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No.,,!5�p xo- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �o7k�<l' i67 u�✓, Installer's Name,Address,and Tel.No. T75=za�5— Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ?6�� 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) eA<;,� 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 Healt Signe Date Application Approved by Date / Application Disapproved by Date for the following reasons Permit No. Date Issued , z a¢ g Y NI90�� f - i" ;•fir t. ;.. Fee ,.Iro THE COMMONWEALTH OF MASSACHUSETTS Entered in co�uter: Y r, Yes .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,.MASSACHUSETTS 0(ppfitaition for Dis'posal *pstrm'Construction Permit Application fora Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ' Individual Components Location Address or Lot No..� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel f'of��/`" p i67 s uli Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 3y� .i��•�d i3`: lzi,F� Cook„s"c+�?C „5'�uc+� 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) !?mod gpd Design flow provided gpd Plan Date Number of sheets Revision Date j Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,dt,•� �' ., ,, �t:'%/ �l �, " Date last inspected: t :a Agreement: S 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. ^ - s - - .. -.,•—J-- _i. Signecd`' -- mac_ "..-- ,:,s �_"r-.cis-. -- - - Date- i✓.z °/ �_"/.. - '=., �- -�-Y.. -_ Application Approved by W Date f�? Application Disapproved by e2 Date for the following reasons. B / � Permit,Nb''` e. ® Date Issued 9 f THE COMMONWEALTH;OYMASSACHUSETTS k 7U k BARNSTABLE MASSACHUSETTS certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4,-')/ Upgraded( ) Abandoned( ')by�/-:�./ c.. :� / �.%' /, �.✓'� S' -�,= caorP s -. at ,��.�� *mil has beeri'constructed in accordance p p ,.S :• a 6 n I dated 1,D)17/ with the provisions of Title 5 and the for Disposal System.Const ction Permit Na; Installer Designer #bedrooms Z Approved design flow l\ gpd The issuance of this jermit hall not be construed as a guarantee that the system will Rbt ed. (�r Date Inspector tf e -------------- ---- --- — ---- - - -- - ---- ---- ------------- ------- - - -- ___ __ ----- --- ----- --- No. �-+y AA j " I LP " - --- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Nsposal bpstem Construction Permit Permission is hereby granted to Construct( ) Repair(6111/ Upgrade( ) Abandon( ) System located at �7 f/�' /"/;Ce ��.;,,,/i /" r'in,.�s.•7`-- and as described in the above'Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must/be completed within three years of the date of this permit. Date / /��/ c�}C7 Approved by� �c-AA _ '•" �.. c aitvty Assessing As-Built Cards TOWN OF BARNSTABLE G h�— LOCATION O 7R-I&e I/rN& DR SEWAGE fl.2OdI�q� VII,LAGE C'r� fi i�' ASSESSOR'S MAP&LOT CP INSTALLER'S NAME&PHONE N0. T p MAC o SEPTIC TANK CAPACITY /.o 9a, r PlT o L L7 LEACHING FACILITY:(rype)x La eNAM ?2 S' (size) A QQ NO.OF BEDROOMS 13p ) BUILDER OR OWNER 17fv ti 1e, PERMITDATE: Z r7/ COMPLIANCE DATE: 't/�Z0 I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fat Private Water Supply Well and Leaching Facility (If any welts 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 . r d/u:Y`f " o � r https://townofbarnstable.us/Departments/Assessing/Property_yalues/HMdisplay.asp?mappar=040118&seq=1 1/2 C . Health MaSc.r fetnll ��x Qi OpenGw � ., x 1 P M L. 4artefs ,x:� � M.�sh Master tkYap X �} ' F � C Q ti itsgidb.to:vn.barnsiable.ma.usS43?;Healtlltdas[erDEtatl.aspx?rD-27153rmp U4U71& reaIth ast r Paf ; ions Rcp Nt &h kfv s acttire # C. 1 r1�lpllcatt�h:s 'aNa r pjt' ti. AM A! Parcel:040:118 Location:87 PINEVIEW DRIVE,totuif 9v:ner.BRBNPELL,RDBERT G bR JOAN P Septic 7,.12/17/2020 Septic t 4J 7J2001yNew SeptlC_ M ; Permit number: 20204 0 1 ! Permit type:I Repa r �. wCamplete'system i Issue date:T211712020 - Complete date: 122212020 r Septic tank size: 1500 ! Type/Size of SAS: � I, Installer: Martin,Paul C.,Cape Cod Septic Services T � Card on file:0 r Innovative/Alternative Technology e: k, i I/A service type:.Select service v !SelectAt�l _..... ^^» �� Variance date: Abandon complete date Abandon permit number: k Repair deadline date: rJ+ Repair notification date: i Key vord r - � Comments: ._ ...__...— .... .. _:..... .._ �_ .... _ it iseptic tank repair ��- Delete Septic i I ' Number Inspection Date Inspector - z, i Result ~� I i�15090 !72/92D2D rell M Stone,Dar C �' pe Cod Septrc inspection CP Condit onal,passl l� i Received Date Comments A . 121312020 � n Delete inspeciwn !i, Save Septic.Changes-] Rdturnito Lookup. " IC°StaK �I� f � P,9 0) Friday,Jan 08,2021 03:36 PM Town of Barnstable • t + BARNS[ABM ' b� ,�� Inspectional Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 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 ❑ 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 ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below thAigh groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located 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 facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) ER c 1 V�-tQ�/'� (%✓��2� +Qe ` SPAI 'CG. ��`nC� .St'pT7 L '�G✓7IC . Repair deadline: 1 o r Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc I i c Commonwealth of Massachusettsb' �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Pine View Dr Property Address i•w Robert Brunzell Owner Owner's Nary information is Cotuit MA 02635 12-9-2020 required for every St page. Cityfrown ate 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. inspector Information SI 160 14 filling out forms on the computer, Darrell Stone use only the tab key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return Company Name key. P.O. Box 1466 re6 Company Address Harwich Ma 02645 City/Town State Zip Code (508)240-2500 S14995 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the pro address listed above; the information reported below is true, accurate and complete as of t Ime of my inspection; and the inspection was performed based on my training and exp ce in the proper function and maintenance of on-site sewage disposal systems. After conductin inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs F he Evaluation the cal Approving Authority 4. ❑ Fails 12-11-2020 Inspector Sign re Date The syst m 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 f Commonwealth of Massachusetts (e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l e 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is required for every Cotuit MA 02635 12-9-2020 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: 2) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally_sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. (Explain ElY ❑ N El ND (Exp a below): The septic tank is leaking and needs to be resealed The septic tank outlet tee is cracked and needs replacement t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .............. � J 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to'broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the,Yoard of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): f� r' 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is.failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is required for every Cotuit MA 02635 12-9-2020 page. City/Town State Zip Code Date of Inspection Co 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tsinsp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 it i Commonwealth of Massachusetts r= Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.'A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the,system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Ia Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is COtUIt_ MA 02635 12-9-2020 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 ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts ► Title 5 official Inspection Form f' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 2 bedroom residential dwelling 0 Number of current residents: Does iresidence have a garbage grinder? ❑ Yes Z No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump,pump? ❑ Yes ® No 9-2020 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 Title 5 official Inspection Fora I� o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Unknown Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page B of 18 c Commonwealth of Massachusetts r= Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank and pit 1980+/- , chambers and d-box 2001 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 24" +/- Depth below grade: 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.): Apparent good condition t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every Zip Code Date of Inspection page. City/Town State D. System Information (cont.) 6. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gallon Dimensions: 14" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 18" 1/2" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" Sludge Judge 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.): Low liquid level Concrete outlet tee cracked Recommended next maintenance pumping within 1 year_ Recommended maintenance pumping every 2-3 years t5inso.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every Zip Code Date of Inspection page. Cityrrown State D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .............. � 87 Pine View Dr Property Address p Y Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): IGrade to box 24" OK condition 2 outlets with equal flow Normal liquid level No scum No sign of leakage No sign of failure t5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * if pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 1 ® leaching pits number: 2 ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 4 Commonwealth of Massachusetts �n (P Title 5 Official Inspection Form ' Il� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is required for every Cotuit MA 02635 12-9-2020 page. Cityfrown 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.): 1 pit with stone Grade to SAS 20 Bottom 101 Ponding 1 Previously overloaded 2 (500 gallon) chambers with 4'stone Grade to chamber 36" Cover 11" Bottom 65" Dry Staining 4"from bottom No sign of hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): c5inso.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1a • Commonwealth of Massachusetts p Title 5 official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is COtUIt required for every MA 02635 12-9-2020, page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts lip Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y/ c� J 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is Cotuit MA 02635 12-9-2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A REAR r- t $ shed O 3 SAS �. o ® SAS 2 A 2 26- 10 1 a- 10 3 31- A 1 4 I 40 - 2 i aS- 6 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts n F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is COtUIt required for every MA 02635 12-9-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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: See Below You must describe how you established the high ground water elevation: Elevations from USGS maps are approximate Property ELV. 69.0 Bottom of Pit ELV. 60.59 Bottom of Chamber ELV. 63.59 GW ELV. 37.0 Separation >5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 87 Pine View Dr Property Address Robert Brunzell Owner Owner's Name information is required for every Cotuit MA 02635 12-9-2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i €5insp.doc-rev.7/26/2018 Title.5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE � LOCATION '8-7R1 e V/e& 04 SEWAGE # Q0 Z 2 VILLAG ASSESSOR'S MAP & LOT 'I INSTALLER'S NAME&PHONE NO. M A C ®/M d Cyr' I- S G,el SEPTIC TANK CAPACITY Z o ao t" /02T 0- LEACHING FACILITY: (type).`t._A O cry C AA4 l9 CIE S (size) S-00 NO.OF BEDROOMS BUILDER OR OWNER ►��+ In ZPi G PERMIT DATE:_ Z 0 I COMPLIANCE DATE: `�� 1ZO Separation Distance Between the: Maximum Adjusted.Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r I - - stir, a �? . , � 0 `�'' _� �' - � • � 0 _ o / �� - � I t,, No: = z�yFee$ 50. 0 00 7T�THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Migool *potem� Construction Permit Application for a Permit to Construct( )RepaijKX4 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 87 P i n e v i ew Drive Owner's Name,Address and Tel.No. � t M Robert G. Brunzell Assessors aza s. 02635��0 �� 87 Pineview Drive Cotuit,Mass. Installer's Name,Address,and'Tel.No. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass.02632 Box 66 Centerville Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S: Description of Soil Loamy sand to--sanr Nature of Repairs or Alterations(Answer when applicable) Adding two 500 ga 1 1 nn leaching chambers packer] in 4 ' of 1�_stone 25 'X1 3 'X2 ' Existing 1 000 ' gallon tank Di sfri hni-inn anra 1 -1e0� CIR I I��p ___t leaching 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 Certifi- cate of Compliance has been issued by thi B and o Heal Signed a 0, Date3/9/ Application Approved by Date Application Disapproved for the following reasons Permit No. % Date Issued $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZippYication for )Digpogal 6potem Construction Permit Application for a Permit to Construct( )Repairr(XX)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 1 ri e V 1 e w D r 1 V e Owner's Name,Address and Tel.No. Robert G. Brunzell Cotuit,Mass.02635 Assessor's Map/Parcel , 87 Pineview Drive Cotuit,Mass. G, �( f � 02635 Installer's Name,Address,and Tel.No. 5 0 8—8 7 5:3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass.02632 Box 66 Centerville,Mass. 02632 Type of Building: _. Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons I Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to sand Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon 1 ea r h i n a chambers packedti'.ri At of 1A" Rtone_ 25 'X13 'X2 ' Existing 10000 gallon tank,Distribtltion and 1 -10n gaab n precast jeaehing _it. 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 Certifi- cate of Compliance has been issu 9f Healt . 3/9/o Signed _ A4 O o 1 Date Application Approved by _ L l3 ��` Date Application Disapproved for the following reasons Permit No. • '� r Date Issued 4Y A /� 1 �--- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Cote liance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )RepaireX(XX)Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc. at 87 Pineview Drive Cotuit b. en constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N . B/dated Installer J.P.Macomber & Son Inc. Designer J.P• co'ml;ek A Son Inc. The issuance of this per t shall not be construed as a guarantee that the system mill fu -on/ s d esigned. Date /Y G/ Inspector _ --�— / —�; ------------------------- $ ill-IT -- 50. 00 No. / J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwiopooar 6potem Congtruction Permit Permission is hereb granted to Construct( )Repair��X)Upgrade( )Abandon( ) System located at �J Pineview Drive,.�70tuit,Mass. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. . Provided:Construction must be completed within three years of the date o Sper/mit. i Date: Approved b r � PP Y � 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. 1 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) Joseph P.Macomber Jr., hereby certify that the application for disposal works construction permit signed by me dated 3/9/01 concerning the property located at 87 Pineview Drive Cotuit,Mass. meets all of the following criteria: e_ The failed system is connected to a residential dwelling only. There are no commercial or business / uses associated with the dwelling. V The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system / l ✓ There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. y The bottom of the proposed leaching facility will not located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor /method when applicable) Y If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will tM be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation '✓� r1 +the MAX. High G.W. Adjustment .7 DI1TERENCE BETWEEN A and B SIGNED : JV' DATE:3/9/01 (Sketch posed plan of system on back). q:huhh folds.ccn F 2-500 gallon leaching chamber r Q Existing 1000 gallon packed in 4 ' of precast leaching pit.. 112" stone. 25 'X13 'X2 ' Existing distribution box. Existing 1000 gallon septic tank. a 3y TOWN OF BARNSTABLE LOCATION --?:7R1,41e ill Al SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. MAC nzmdpri i- g 0'e SEPTIC TANK CAPACITY 1600, —0 Z LEACHING FACILITY: (type) (size) Cct9 N06 OF BEDROOMS BUILDER OR OWNER In tell PERMITDATE: COMPLIANCE DATE: 3 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Peet. Furnished by R Q ce< .1,0I lynl Co=onweaiih of Massachuseiis Executive Office of Environmental Affairs �tsadment of ' nvironmental Protection W1111am F.Weld Trudy Coxe S.c.aay,fou I 350 MAIN . YA UTH Dav1d B. Sbuhs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO OIR 2 )� '? PART A TOM OF B l` MAP#040 CERTIFICATION PAR# 118 PROPERTY ADDRESS: 8 Pine View Dr. Cotuit ADDRESS OF O Z DATE OF INSPECTION Apnl 4, 1997 Preston, Susan NAME OF INSPECTOR James D. Sears COMPANY NAME, ADDRESS AND TELEPHONE NUMBER: A&B CANCO, 350 MAIN STREET, WEST YARMOUTH, MA 02673 (508)775-2800 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS Inspector's Signature: Date: April 8, 1997 Note: This is an inspect non the system. Inspecton`is based on condition of system at the time of inspection. No guarantee on life.of the system. 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 and copies sent to the buyer,'if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, or C A] SYSTEM PASSES: X 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: N/A 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 NO). 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 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 the Board of Health. (REVISED 11-03-95) One Winter Street Boston, Massachusetts 02108 Fax(617)556-1049 Phone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 B] SYSTEM CONDITIONALLY PASSES (continued) _N/A_ 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 leveled or replaced _N/A_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: _N/A_ 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. 1) SYSTEM WILL 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: _N_Cesspool or privy is within 50 feet of a surface water _N_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 ENVIRONMENT: _N_The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _N_The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _N_The system has a septic tank and soil absorption within 50 feet of a private water supply well. _N_The system 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 bacterial 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. 3) OTHER 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 D] SYSTEM FAILS: N 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. N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N Any portion of a cesspool or privy is within a Zone I of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply well. N 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: N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exits: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to 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) 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 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. X 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 X As built plans have been obtained and examined. Note if they are not available with N/A X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site. X 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. X 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. X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 87 Pine View Dr. Cotuit Owner: Preston,Susan Date of Inspection: April 7, 1997 FLOW CONDITIONS RESIDENTIAL: Design Flow: gallons Number of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no): YES Laundry connected to system (yes or no): YES Seasonal use (yes or no): NO Water meter readings, if available N/A Last date occupancy: N/A COMMERCIAL/INDUSTRIAL: Type of establishment: N/A Design flow: gallons/day Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharge to the Title 5 system:(yes or no) Water meter readings, if available: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A , System pumped as part of inspection:(yes or no) NO If yes, volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection recods, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 1984 PERMIT# 83-1135 Sewage odors detected when arriving at the site:(yes or no) NO 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 SEPTIC TANK:_.X_ (locate on site plan) Depth below grade: 16" Material of construction: X concrete metal FRP other(explain) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: 1 Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A 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.) TANK AT WORKING LEVEL INLET BAFFLE, COVER 16" BELOW GRADE, COULD NOT OPEN OUTLET COVER. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construciton: concrete metal FRP 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: 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.) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 TIGHT OR HOLDING TANK:- N/A-(locate on site plan) Depth below grade: Material of construciton: concrete metal FRP other(explain Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_X_ (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) BOX IS 16"X16", 28" BELOW GRADE, ONE PIPE IN, ONE PIPE OUT, BOX IS CLEAN AND NEW. PUMP CHAMBER: N/A' (locate on site plan) Pumps in working order:(yes or no) (note condition of pump chamber condition of pumps and appurtenances, etc.) 7 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 SOIL ABSORPTION SYSTEM (SAS):_N/A_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 1 leaching chambers, number: leaching galleys, 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.) 1,000 GALLON PRE CAST, PIT IS 20" BELOW GRADE, PIT IS 6' DEEP, HAS LESS THAN X OF WATER AND RECEIVING NORMAL FLOW. CESSPOOLS: N/A (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 cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil, signs of hydraulic faiure, level of ponding, condition of vegetation, etc) PRIVY:_N/A (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.) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 87 Pine View Dr. Cotuit Owner: Preston, Susan Date of Inspection: April 7, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' � FAR as ' :3 O DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: LOT HIGH, NO SIGNS OF GROUND WATER PROBLEMS. BASEMENT DRY, NO PUMP. 9 PERMIT NUMBER DATE COMPLETED BY HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 87 Pine View Drive, Cotuit Lot No. Owner: Preston, Susan Address: Contractor: Address: Notes: Figure 13--Reproducible comutation form. 10 S LOCATION SEWAGE PERMIT NO. oT `�rlo PING yicw y g 4ftll..� VILLAGE INSTA LER'S NAME i ADDRESS ® U I L D E R OR OWNER /R)-W 0 Ll // D.A T E PERMIT I S S V E D DATE COMPLIANCE ISSUED / � '3 d 5rtEcr THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................TQW.N.....OF......BARNS TABLE Xpp iraftou for DisVosal Works Tonotrnrtion ramit Application is.hereby made for a Permit to Construct (g ) or Repair ( ) an Individual Sewage Disposal -� System at: N.LA..--•.................. Location-Address or Lot No. . o... St7_UQti.Qn...Conp.any......1=.......... 2.......... Qxi ,.YYarmQUt 1...MA Owner Address aS.pero.... heah-asidis................................................ Same.......----•-.................. Installer Address d Type of Building Size Lot...23.,125±_;._..S . feet U Dwelling No. of Bedrooms...................a......................Ex Expansion Attic g— p ( ) Garbage Grinder ( ) aOther—Type of Building of persons............6.............. Showers ( ) — Cafeteria ( ) dOther fixtures --------------•-•-------------------•-------•----------------•----------------------------------..................................................... WDesign Flow.............5`..5.........................gallons per person per day. Total daily flow............:..3-3.0....................gallons. WSeptic Tank—Liquid capacit ...O QQgallons Length...1Q....F.. Width....`5........... Diameter................ Depth.....:..�..... i 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 ( ) aPercolation Test Results Performed by.....ROY?P_ .t_._E.,._..RA.y.JQ4?.d.................... Date....1Q 6,(8 ................ Test Pit No. 1....... --.....minutes per inch Depth of Test Pit....114"____. Depth to ground water None.......... Gro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------------------------------------------------------•....------.........----•---•--------•.............................................................. O Description of Soil......Subsgil...... edllltt___Sand........................................................................................................ U ---------------------------•----------...............------------------------------•-----------------------------------------------•------------•------------........---•-•.....------------------------ 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 TIT I.;. 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 and f health. igne ------ .-- ---- ------ Q --------------- ----- - ------ ............ ,f Application Approve ---- -- ----------------------------•-•----------••-------------------------..........-• — . Date Application Disapprove r e following reasons:.............................................................................................................. ' rt- ' ............................................. ... ---------- ----- ----- -----------------•----•---•-•••-------••--....-------••-------............------------------............------............-•-•-------Date PermitNo......................................................... Issued....................................................... Date No......................_ FEs.......0 .0 0...... THE COMMONWEALTH OF MASSACHUSETTS � ^ BOARD OF HEALTH .........................TOWN.................OF......BARNSTABLE .................................................................... ApplirFation for Biiposaal Works Tonstrurtion rratti# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: .Pineview Drive, Cotuitl__ ...................... 50 --. ...... .. - --.......----------------------- L cation-Address or jot No. •Theo Construction Company ,Inc . _ 24 Great Pond Drive s. S . Yarmouth_ MA .... ..... Owner Address Spero_Tl?eoharidis --------................................. .............................................Same...............................•......... pq Installer Address V Type of Building Size Lot... ....Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ResidentialNo. of persons...........60............. Showers ( ) — Cafeteria ( ) Otherfixtures .----•------------------------------------------------••----------•--••-------•-••-•---------------------••-•-•---•-------...- W Design Flow.............55............._._.....___gallons per person_per day. Total day flow........... 330 ........gallons. WSeptic Tank—Liquid capaci. .. ..�.Qgallons Length.._10.`6.. 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 ( ) aPercolation Test Results Performed by....-Robert E . Raymond Date_._.10/6/83 04 Test Pit No. I................minutes per inch Depth of Test Pit ..z�4........ Depth to ground water None 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pd 0 Subs' oiT;...meclium san x d. Description of Soil............................................................................................................•-------....-------------------..........-•----.........--_. W ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- V 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 1- p 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........................................................... ..................... .....................0.......... Date ApplicationApproved By...................................•...........................-..................0--------------- ------------------------............... Date Application Disapproved for the following reasons:--------•...................•--------------------...----------•-....-------------•--------------...------•...._ ..---•...................•--••---------------------•---------------------.....------....---...---...------•-•----------------.....-----------------•----•--------------•-----•-------.................. Date PermitNo........... ....................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN BARNSTABLE ..........................................OF.......I............................................................................. Trrtifirtttj� of TontpliFanrr C h t h n'� 'dual S a e oral Sys c str cted X or aired O 3 �24 `` ieat Vo�dD 'rive I ou i armo�tt�h I ,, by------------------------------------------------------------------------•--.-..-..-.-....----------------------------•--..-..-•-----•--..-.-•----..--.-._..--...----------------------------- at ... ....._ Lot 50 Pineview Drive, Cotuit,Inf4,%sachusetts , ........................•-------.....-•--••---..........._....-----•--------- 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 ISSIJ,ANPE OF THIS CERTIFICATE SHALT. NOT BE CONSTRII D AS A GUARANTEE THAT THE SYSTEM I l/..... TION SATISFACTORY. �tor DATE... Insp .. .................................................................--•---•--- ... THE C COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN BARNSTABLE ...........................................OF.....................................--•---...---................---........0........ $40 .00 No......................... FEE................... llisv aalIRA& �x at ra i n �e atti�per ari is , re On Drive, S . Yarm. , MA, Permissiois hereby granted.........................-......................................................... . ----................-----..........------•-•-_.... to Con4&ILt P1.&jtajre(.j b f.!j_Jjadivi6&�&vtage&Vosal System atNo...............•-----•----•----------•....-•---•--.....---•---•-•---....---..................... ...... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ------------••-•.............................•-•---------------•--------•---...------•••--........----._ Board of Health DATE................................................................................ - FORM 1255 HOBBS & WARREN. INC„ PUBLISHERS op _ ,i�, �o�Al g 7,t, Z tii ............. 1,ij 3jl i� q xe o ici. I,- SiI te 4�, it, -74 r-, J� t ic> r-18,v_ ,in, XA— J� o Lt)"c S 77� Z :,t me :A��" ID z -A-CC-09 lcw��C W M-4, 7r IT Z)4 ie-fA 7� 7TY -ST OOCP, �46 0 SC�* Cle4lEb P17*�� 77 -Y`A�4S Q9(UF;O�Vv,:T"rebLl-,40i i w1ke Al CA01-A rl-O Act-- 2A L- ,e W . ..... 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