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HomeMy WebLinkAbout0125 PINEY ROAD - Health 125PINEY A = 020 082 i I i I 1 f r pao Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane ' Property Address d- r.: Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every State Zip Code Date of Inspection r page- Citylrown t 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 I#W 10519-0 filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma _ 02632 Cityrrown State zip Code 774-248-4850 smjonesbtle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was.performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2/24/2021 Inspector's Signatu 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.7l28/Zo18 rdle 5 official Inspection Form:Subst0ace Sewage Disposal System•Page 1 of 18 1 Commonwealth of Massachusetts vTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments loe 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every State Zip Code Date of Inspection page. City/Town 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 property located at 125 piney Lane Cotuit is served by a Title V septic system consisting of a 1560 gallon septic tank, distribution box and 5 Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional by Pass"section need to b replaced or repaired.The system, upon completion of the replacement or repair, as approvedy the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound,.exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection,if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Title 5 Official inspection Form:Subsurraoe Sewage Disposal System•Page 2 of 18 t5insp.doc•rev.7/26/2018 4 t c Commonwealth of Massachusetts MIEN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every state Zip Code Date of Inspection page Cityfrown 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- El 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 0 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. 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: t5lnsp.doc•rev.712812018 Title 5 Official Inspection Forth:Subsaface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name Ma information i §t s Cotuit 2/24/2021 required for every cityrrown State Zi Ep p Code Date of Inspection page. s 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: [I 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic 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 nitratehe a nitrogen is sis mustl to or less than 5 ppm, provided that no other failure criteria are triggered. A copy y 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 Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool ® Discharge or ponding of efflue El Discharge to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Titte 5 official inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 t5insp.doc•rev.7126=18 Commonwealth of Massachusetts Title 5 official Inspection Foy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every lown State Zip Code Date of Inspection page. C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 %day flow ❑ ® Required pumping1 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- 'El10,000 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 Forth:Subsurface sewage Disposal System-Page 5 of 16 Commo nwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Ma 02635 2/24/2021 required for every -67dyfown State Zip Code Date of Inspection page. CitylT 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)] i Tale s official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 tsinsp.doc•rev.7n62018 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owners Name information is Cotuit Ma 02635 2/24/2021 required for every State Zip Code Date of Inspection page. C'ItylTown D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 2 Number of current residents: _• ❑ Yes 0 No Does residence have a garbage grinder? 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? El Yes No ® Yes Not. Seasonal use? ❑ Water meter readings, if available(last 2 years usage(gpd)): Detail: *"irrigation system ❑ Yes ® No Sump pump? current Last date of occupancy: Date Tide 5 officiai Inspection Form:subsurface sewage Disposal System•Page 7 of 18 t5insp.doc-.rev.7 26=18 c Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma _ 02635 2/24/2021 required for every State Zip Code Date of inspection page City/Town D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: MR 15.203 w based on 310 C ) ins r day d Design flow( Gab per Y(gP 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 Q No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons Now was quantity pumped determined? Reason for pumping: Mnsp.doc•rev.7/AM18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every Cityrrown State Zip Code Date of Inspection page. D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool' El Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Altemative technology. Attach a copy of the current operation and ❑: of latest maintenance contract(to be obtained from system owner)and a copy inspection of the I/A system by system operator under contract f , ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: original system installed 1999 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 2 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.)- Joints in good condition, no leakage,vented through roof. Title 5 Ofrt 4 Inspection Form:Subswface Sewage Disposal System'Page 9 of 18 t5msp,doc•rev.7I rWl8 I Commonwealth.of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney1ane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) 6. Septic Tank(locate on site plan): 1.5 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 Dimensions: 1500 gallons 5" Sludge depth: 31 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness Distance from top of scum to top of outlet tee or baffle 711 10" Distance from bottom of scum to bottom of outlet tee or baffle Opened covers and took How were dimensions determined? measurements ' Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet cover is on a riser t5lnsp.aoc•rev.7IE MIS Title 6 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form IFJO Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every city/Town State Zip Code Date of Inspection page. D. System Information (cunt.) 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 Tale 5 Official Inspection Form:Subsurface sewage Disposal system•Page 11 of 18 t5insp.doc•rev.71282018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 125 Pinej Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every City/Town State Zip Code Date of Inspection page. 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): 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.): Distribution box was level and in good condition with no rot.Water level was even with outlet invert with no signs of past backup. Cover is on a riser Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 18 t5insp.doc-rev.7r4ffi )18 i Commonwealth of Massachusetts Title 5 Official In Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owners Name information is Cotuit Ma 02635 2/24/2021 required for every page Cityrrown 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.): *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: t ' Type: ❑ leaching pits number: ® 5 Infiltrators leaching chambers number. ❑ leaching galleries number: ❑ Teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7Q612018 Title 5 official Inspection Forth:subseace Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) condition of soil si ns of hydraulic failure, level of ponding, damp soil, condi tion of Comments note 9 vegetation, etc.): s.a.s. consists of 5 Infiltrators in a 38'x11'x11"trench. Leacjing facility was video inspected from d-box and was found dry with no signs of past overloading. 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.): t5insp.doc-rev.712612018 \ Tale 6 Official Inspection Form:Subsurface sewage Disposal System-Page 14 of 10 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2t24/2021 required for every City/Town State Zip Code Date of I'nspedion page. D. System Information (cont.) 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.): f &,sp.doc•rev.7Yzimi a Title 5 Official Inspection Form:Substufaee Sewage Disposal System•Page 15 of 18 L Commonwealth of Massachusetts.. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Cotuit Ma 02635 2/24/2021 required for every Cityffown State Zip Code Date of Inspection page. 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 ithin 100 feet. Locate where public water supply ers landmarks or benchmarks. Locate all wells w the building. Chec k one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately L 00 AZ '3 30 `6 � Idle 5 official inspection Form.Subsurface Sewage Disposal System•Page 16 of 1e t5insp.doc•rev.UNM18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Pi -ney Lane Property Address Albert Brunett Owner Ownees Name information is Cotuit Ma 02635 2/24/2021 required for every City/Town State Zip Code Date of Inspection page- D. System Information (cunt.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar . ❑ Shallow wells 12,+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t5insp.doc-rev.7/2812018 1 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Lane Property Address Albert Brunett Owner Owner's Name information is Ma ' 02635 2/24/2021 required for every COtUIt page. CityJTown 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. Z 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 t5aup.doc•rev.7126=18 Title 5 Official Inspection Farm:Su&A facs Sewage Disposal System•Page 1a of 18 No. Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS 9ppfiration for Misposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair k/ upgrade( ) Abandon( ) ❑Complete System E�Kndividual Components Location Address or Lot No. S 1� �1~C� Owner's Name,Address,and Tel.No. Assessors MaI el c1i Vi All kA QCVP\�e_ Installe`s Name,Address,and Tel.No�.� cI 0(®� Designer's Name,Address,and Tel.No. 1 rtµlti� l �M� Type of Building: Dwelling .No.of Bedrooms fjA. 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 A)' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �.Q,JJ� L_ .-e�'( S1!` 9 S`�r ��6 l 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 Health. S ign Date/ Application Approved by v Date Application Disapproved by Date . for the following reasons Permit No. Z B Date Issued Zj No. ! 6 Fee THE COMMONWEALTH OF.MASSACHUSETTS,, Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for 33isposal 6pstrut Construction 3Perltttt Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Ulndividual Components Location Address or Lot No. / ,� A, _y j {r,, Owner's Name,Address,and Tel:No. Assessors ap L't U t'{' Installer's Name,Address,and Tel.No.._, Q�!1 Designer's Name,Address,and Tel.No. 311i .,'ISpe of milding: Dwelling.- No.of Bedrooms Lot Size sq.ft. Garbage Grinder Others Type of Building No.of Persons Showers( ) Cafeteria , . Other Fixtures Design Flow(min.required) A J1A•. gpd Design flow,provided y gpd I ri.- Plan Date Number of sheets 1 Revision Date Title—-'! Size of SeptickTar Type of S.A.S. t Description of Soil - -•- Nature of Repairs or Alterations(Answer when applicable) al c C# L y t.j it/" �; t S+r-C( U }i t(A. • Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in k 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. t Signed'"_) 7''. ,� ,,..'.� Date Application Approved by ' w,.w f - _ •-Date��r ' -�."��r�•'=- �, Application Disapproved by r '' Date for the following reasons ` Permit No. .7 c)y g ` � Date Issued 11 r 7 7 l�24,! V, _ - - - - ------------------ -- -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by S C. 0 14 AA. at } L.c,,, c U-++ has been-constructed in accordance —with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer 4-j ,t'v� �r.c ,,.a►,,bl(__ Designer + / #bedrooms ~ v apX Approved design flow .,..� gpd The issuance of this permit shall not be construed as a guarantee that the system will functiio designed. Date P f 3elt 8 Inspector -� 5 V_ i -_----7 - -. _- . . -.- _ =_ - - _ - :. - - - -- ---------------------------- No. — :-. Fee v7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposaf *pstrnt Construction i3ermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at�/ �" p► n 4 t�•En�'' t� }�J t -+l 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. ram" Provided:Construction must be completed within three years of the date of this permi. ,;. Date / Z2.J ZU I Approved by — �� I /1 v a Va Town of Barnstable Barnstable " cacayRegulato�3 Services Department Z BARNSTABLE. 1 1 M MAM 039. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 9231. October 15, 2018 BRUNETT, ALBERT J ET AL 125 PINEY ROAD COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 125 Piney Road, Cotuit, MA was inspected on 09/21/2018 by Michael J. DeCosta, Jr., certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Pce an, R. ., C H 0 Agent of the Board of Health I Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\125 Piney Road Cotuit.doc THE t Town of Barnstable M . Regulatory Services Department fD µp`l Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director - Thomas A.McKean CHO FAX: 508 790 6304 , Feb 6, 2007 Rev. 5/11/16 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 ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool • Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion.of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool KAny"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) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 1' Commonwealth of Massachusetts ,p Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 e � 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is /it MA 02635 t ou 0921/2018 r required for every C � page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information sly 1335 filling out forms on the computer, use only the tab Michael J. DeCosta, Jr. key to move your Name of Inspector cursor-do not Wind River Environmental use the return Company Name key. 46a e Drive � Company Address Marlborough MA 01752 City/Town State Zip Code r (508)400-8083 SI 13230 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 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. El Passes 2. Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails s ect r'p o s Sign to 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 E_ i c Commonwealth of Massachusetts �d Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Piney Road v Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 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. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Piney Road v Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA_ 02635 09/21/2018 page. Cityrrown 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): 2 outlet D-box has extensive deterioration and must be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage bisposal System•Page 3 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 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 ❑ ® 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 r c Commonwealth of Massachusetts r, Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow El ® 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 . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < � 125 Piney Road v Property Address Albert Brunett. Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 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)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i I Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Piney Road L — Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 319gpd 9 ( Y 9 (gpd)): Detail: 2016- 120,000gallons 2017- 110,000 gallons Total -230,000 gallons 230,000/24 Months =9,583GPM/30 days = 319 gpd Sump pump? ❑ Yes E No Last date of occupancy: Current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. City/Town 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: Source of information: Wind River Environmental -See attached record. Was system,pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? The quantity was measured by the pump truck. Reason for pumping: To check the structural integrity of the septic tank. t5insp.doc•rev..712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 18 f Work Order# 0217067572 Cust# 1464908 Customer Since: 2 011 Tax: 6 .2 5 0 0 Job Comments Tech Comments 09/21/2018 Title 5 Inspection / 1000 gallons / will have Cover(s) secured. Start 9/13/18 after745am. Ticket - diagram and water / 1000 gallons % Home CC on File / bd 20183700609. cancel not getting T5/pumping yet (as) Cover(s) secured. Start 8/24/18 after Sam. 20183403735. 08/28/2018 pump 1000 tank located in front some digging cc on file ct System Owner System Location Albert Brunett Primary Home 125 Piney Road 125 Piney Road Cotuit, MA 02635 Cotuit, MA 02635 (508) 314-3239 AL BURNETT : (508) 314-3239 Service Date: FRI 09/21/2018 os:oo AM Frequency: Call to Confirm: Service Type: Standard Previous Service: 09/10/2018 Approx. Gals: o CCLS: Location Details: Depth Below Grade:0 Custom Clean ._ . 'Wo Cust Home: YES Filter •• .. Township: nspecti'on1T5'— County Barnstable Build lJp v ¢ ¢ . Inspection Title 5 (not 6 incudsngpumpang� 1 0 $ 365. 0000 $ 35 OQ Inspection (Labor/Expo""",re F eprhr� �0 40 $ 784.9990 '0 00 Fuel / Energy Recovery 1 0U $ 6511Q5 •$ 65 11 Inspection Title 5 BOH`Fees ��1�OQ$ 25_:00D4� 2,5 04 Pumping 1000 1.00 $ 255 0956 $ 255.10 � . P � t (03'�is/ an wY z i We suggest these 3 keys steps to keep ' �sobt Drat y`$-, '710.21 �� Y P p your system healthy: Tax $ 0.00 • Regular servicing • Use CCLS bacteria additive rotat $ 710.21 . Use a filter Disposal Site: Disposal Volume: Payment Detail: Waste Code : 0.0000 Discover xxxxxxxxxx7904 05/2021 Sales Rep : CSR : Barbara Decosta Due on Receipt Truck : Technician : Michael Decosta Jr. On Site : 09:24 AM P 0 Number: Tech Notes : System Operating Fine. Normal water level. Moderate top solids. Moderate bottom .sludge. Outlet baffles are intact. Main line Clear. No filter is present on the tank; current tank can be outfitted with a filter. Recommended Installing a filter,Installing a riser. Cover(s) secured. Repairs needed: 2 outlet dbox has extensive deterioration must be replaced 181, bg 2 outlets, schedule 40 pvc X quoted 2700$ plus permit. Title 5 inspection conditional pass, 2 outlet dbox has extensive deterioration and must be replaced, full report will be emailed Customer Signature to customer, tech to pump later today 1000gals. All set thank you. ENVIRONMENTAL Remit payment to 46 Lizotte Dr Suite 1000,Marlborough,MA 01752 l . i Commonwealth of Massachusetts Title 5 ,Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Piney Road u - Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 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: 1998, per plans. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"_ feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 0" n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints sealed. No leaks. Vent on roof. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �y ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 5' Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 36" 611 Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): All covers are 1' below grade. Good tees, no filter installed on the outlet. Liquid level normal with moderate solids and sludge. Tank appears to be structurally sound and not leaking. Recommend installing a filter and riser on outlet cover.Tank should be pumped annually. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 L c Commonwealth of Massachusetts j1p Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /n 125 Piney Road L Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. City/Town State Zip Code Date of Inspection 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i c Commonwealth of Massachusetts _ ,p Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Piney Road V� Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA . 02635 09/21/2018 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): 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.): D-box is 18" below grade. Box size is 12'x 12". Box has two outlets accepting equal flow. Liquid level normal with minimal carryover into box. Box has extensive deterioration and must be replaced. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f . Commonwealth of Massachusetts �ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !/ 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 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.): * 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: 5 @ 1 V x 38' ❑ 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 Commonwealth of Massachusetts r- Title 5 Official Inspection Form )1% Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Piney Road v Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. Cityrrown 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.): Dry, sandy soil. No ponding. Showing no signs of hydraulic failure. Vegetation is normal. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c � Commonwealth of Massachusetts ,p Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is Cotuit MA 02635 09/21/2018 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 Housf `3 l _'DE cv- I a Z t R 2= 7-1.41 'E5 bZ 3(.•4' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts 1n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Piney Road v Property Address Albert Brunett Owner Owner's Name information is Cotuit MA 02635 09/21/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check celllar ® Shallow wells Estimated depth to high ground water: 144"/ 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: November 1998 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained from original design records. 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 125 Piney Road Property Address Albert Brunett Owner Owner's Name information is required for every Cotuit MA 02635 09/21/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included ` t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 l COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form b Not for Voluntary Assessments y0 Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 6C2 pga 1. Property Information: MAP 0202—PARC 082 125 PINEY ROAD — COTUIT, MA 02635 � Property Address BOYNTON, DONALD & SUSAN Owner's Name 125 PINEY ROAD Owner's Address COTUIT MA 02635 City/Town State Zip Code FEBRUARY 21, 2007 ' Date i 2. Inspector: JAMES D. SEARS `1 fYy ' Name of Inspector A & B CANCO Company Name Cn 350 MAIN STREET Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2800 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The System: ® Passes Conditionally Passes Fails ❑ N eds Further Ev uation by the Local Approving Authority Inspect;r's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 r ` COMMONWEALTH OF MASSACHUSETTS iy 'Title 5 Official Inspection Form ye v`0� Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 125 PINEY ROAD Owner's Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007! Date of inspection Inspection Summary: Check A, B, C, D or E/always complete all of Section D A) System Passes: ✓ ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CHAR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: N/A ❑ 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. Answer yes, no or not determined (Y, N, ND)in the M 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. ND Explain: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d " Not for Voluntary Assessments S Subsurface Sewage Disposal System Form B. Certification (cont.) 125 PINEY ROAD Owner's Address COTUIT MA 02635 CitylTown State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection B) System Conditionally Passes (cont.): N/A Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced I obstruction is removed ND Explain: 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 public health, safety or the environment. 1.System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1) (b)that the system is not functioning in a manner which will protect public health,safety and environment: ElCesspool 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS F W Title 5 Official Inspection Form 'e w Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 125 PINEY ROAD Owner's Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection C) Further evaluation is required by the Board of Health (cont.): N/A 2.System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ' ❑ The system has a septic tank and SAS and the SAS is less than 1.00 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments /^M SJpv Subsurface Sewage Disposal System Form B. Certification (cont.) 125 PINEY ROAD Owner's Address COTUIT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in leaching is less than 6" below invert or available volume is less than '/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 surface water elevation. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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.] YES No The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd. Yes No ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will 7 be necessary to correct the failure. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 I COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection E) N/A-Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply ® ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 125 PINEY ROAD Property Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection 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? QHas 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, including 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: ® 0 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 r COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 125 PINEY ROAD Property Address COTUIT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Residential Flow Conditions: if Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ® Yes No Is laundry on a separate sewage system?[if yes separate inspection is required] Yes ® No Laundry system inspected? Yes No Seasonal use? ® Yes No Water meter readings, if available(last 2 years usage(gpd)): 2006-86,000 GAL. 2005- 117,000 GAL. Sump pump? Yes ® No Last date of occupancy: PRESENT Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,_etc.) Grease trap present? Yes ® No Industrial waste holding tank present? Yes ® No Non-sanitary waste discharged to the Title 5 system? Yes ❑ No Water meter readings if available: Last date of occupancy/use: Date Other(describe): - t Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS a v Title 5 Official Inspection Fora d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection General Information Pumping Records: Source of Information: N/A Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank.Attach a copy of the DEP approval. ® Other(describe): Approximate age of all components, date installed(if known)and source of information: 1999—PERMIT#98-714 Were sewage odors detected when arriving at the site? ® Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 COMMONWEALTH OF MASSACHUSETTS' d Title 5 Official Inspection Form Not for Voluntary Assessments 41 V0� Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Building Sewer(locate on site plan): ✓ Depth below grade: 14" feet Material of construction: ❑ cast iron 13 40 PVC ❑ other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): GOOD - CLEAN Septic Tank(locate on site plan): ✓ Depth below grade: 161, feet Material of construction: concrete ❑ metal ❑ fiberglass polyethylene other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500,GALLON PRE CAST. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum Thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 151, How were dimensions determined? ASBUILT—TAPE&SLUDGE JUDGE. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS A Title 5 Official Inspection Form is d 0� Not for Voluntary Assessments 41 yev Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTUIT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK AT WORKING LEVEL, TANK & COVERS AT 16" BELOW GRADE. INLET TEE — OUTLET TEE. NO SIGN OF LEAKAGE OR OVERLOADING. NOTE: MAINTENANCE PUMP AFTER INSPECTION. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: El concrete1:1 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: 0 concrete ® metal ❑ fiberglass polyethylene ❑ other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form o Not for Voluntary Assessments a� rev Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Tight or Holding Tank (cont.) N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ® Yes ® No Alarm Level: Alarm in working order: ® Yes ® No Date of last pumping: Date Comments(condition of;alarm and float switches, etc.): I *Attach a copy of current pumping contract(required). Is copy attached? Yes No Distribution Box (if present must be opened) (locate on site plan): ✓ Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS 16" X 16" — 18" BELOW GRADE, ONE LINE IN —TWO LINES OUT. BOX IS CLEAN & SOLID. NO SIGN OF OVERLOADING OR SOLID CARRY OVER. Pump Chamber(locate on site plan): N/A Pumps in working order: Yes No Alarms in working order: Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 COMMONWEALTH OF MASSACHUSETTS U Title 5 Official Inspection Form Not for Voluntary Assessments } Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 Cityrrown State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: a Type: ® leaching pits number: leaching chambers number: 5 leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: ® overflow cesspool number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACHING IS FIVE INFILTRATORS WITH 4' STONE 1 V X 38'. LEACHING IS DAMP — NO SIGN OF OVERLOADING. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 Cityrrown State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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, damp soil, condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 COMMONWEALTH OF MASSACHUSETTS 'r Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635 City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I ' 33` o Title 5 Official Inspection Form:Sutuurface Sewage Disposal System Page 15 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 125 PINEY ROAD Property Address COTU IT MA 02635' City/Town State Zip Code BOYNTON, DONALD & SUSAN Owner's Name FEBRUARY 21, 2007 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to NO ground water: 12' Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavators, installers—(attach documentation) Accessed USGS database—explain: You must describe how you established the high ground water elevation: DESIGN PLAN 3-98, NO GROUND WATER AT 12'. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 00 YOU WISH TO OPEN A BUSINESS? , For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1 FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: DZ4p`J Fill in please: r APPLICANT'S YOUR NAME: DOAfpELD At 130c Aj, 01V BUSINESS YOUR HOM ADDRESS:_?0 5 o X r;o( Scrd TELEPHONE # Home Telephone Number St'Ss-4 2jr- NAME OF NEW BUSINESS. Fi�lF TYPE OF BUSINESS .f '. E &1_ ;2 . IS THIS A HOME OCCUPATION?— L--*- VES NO Have you been.given approval from the building division? YES NO ADDRESS OF:BUSINESS -zs i C 07Lu MAP/PARCEL NUMBER 0Z ®d8 Z When starting a new business there are several things you must do in order to be in compliance with the rules-and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd.&Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO NER'S OFFICE This indivi ual h s n infor of any permit requirements that pertain to this type of business. Author' ed S* tur COMMENTS I i—nr) 49 rytApIqees 2. BO ARD OF HEALTH This individual ha n info of t e pprmi irements that pertain to this type of business. Authorized nature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: �/ r BUSINESS LOCATION: .2'� ~ - MAILINGADDRESS: `o l' 1a oX o i Mail To: TELEPHONE NUMBER: .5_02 " 36�—/3`i 6 �✓ ZS Board of Health /CONTACTPERSON: ' Town of Barnstable � ?��c.% %�� t��.i`�� P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: T=/A-:- Z�� �5 Hyannis, MA 02601 TYPEOFBUSINESS: i �l,e i /� 1i��/3�t/elr-*�+1 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO ✓�A This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUND/herbicides, Quantity Quantity Antifreeze(for gasoline or coolant systems) Daners NEW USED Cl cleaners Automatic transmission fluid Dnts Engine and-radiator flushes Rlt ( ite) Hydraulic fluid (including brake fluid) R s Motor oils Ps NEW USED ( es, herbicides, rodenticides) Gasoline, Jet Fuel Pmicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers a a�' Lye or caustic soda Car wash detergents Y"- Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, es PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW U D (inc. carbon tetrachloride) Paint & varnish r overs, deglossers Any other products with "poison" labels Paint brush cl aners (including chloroform, formaldeh de, Floor & fur iture strippers hydrochloric acid, other acids) Metal lishes La dry soil & stain removers Other products no listed wh' you feel including bleach) f ay b xi or/'� zardou ( I ase list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS c � TOWN OF BARNSTABLE . . u LOCATION t SEWAGE# �y/ VILLAGE Cod J r.L ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.Sr_,Q'�K TrakV_ S b 0 0 4 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 1�t NO.OF BEDROOMS OWNER PERMIT DATE: h` as d0 Q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ce �rcv vc taw 4 S r i TOWN OF OF BARNSTABLE I:OCATION £ / /� SEWAGE# 'VILLAGE C a7-& 1 7- ASSESSOR'S MAP&LOT 0 P;SwAik7FR'S NAME&PHONE NO. SEPTIC TANK CAPACITY •5 PT/C /ti LEACHING FACILITY.(type) (size) NO.OF BEDROOMS v �°— BUILDER OR OWNER PERMIT DATE: G%94I WE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,3 � �o T 7 OF BARNSTABLE LOCATION SEWAGE # VILLAGE 0l ASSESSOR'S MAP & LOT C-2 6 07 Z.,' INSTALLER'S NAME&PHONE NO.¢� ae oleo 3 SEPTIC TANK CAPACITY v 15)LEACHING FACILITY: (type),�_ 117 tRQ�y�'S (size)!5 61r% l�S' ,a NO.OF BEDROOMS 3_y X s �� '-BUILDER OR OWNER Pov 0 i h O ki PERMTr DATE: 0 OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water.Supply.Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -�� d �� �_ -/ '� C t t ` �,1 +�.�__ No. %aa' - _ FEE Board of Health, i ,rVt�'`"'�' �`e" MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) - ❑Complete System �dividual Components Location E A661 CLty, Owner's Name 7ovu,(b 130)fV-'OfU S Map/Parcel# Q 2% 0- Q Address Lot# Telephone# q2-9- 6SS"V Installer's Name Designer's Name i4 Nk'elc Sci vn C onju f-fA I-JS Address f.FJ1 5-{- AZ K4 Address L/0 13 ZfvbuS 6 Hlas Telephone# 7 7 - Z 9-0 1) Telephone# Type of Building R.e$ • 9 D USA 4- fi o o0 PV Ain-&e Lot Size � U©O- sq.ft. Dwelling-No.of Bedrooms J Garbage grinder NO Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) 'Other Fixtures Design Flow(min.'required) '3 0 gpd Calculated design flow 3 3O Design flow provided Q 1q gpd Plan: Date �r' Ll_ Number of sheets Revision Date ._Tide+ 5 ii-e t Segh C h4 p . Description of Soils) See p pp Soil Evaluator Form No.(p r a. Name of Soil Evaluato�P0-,C6 1 u61P1YV ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees o not tto ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreeso pl the system' operation until a Certificate of Compliance has been issued by the Board of Health. Signed 7 Date Inspections if � No. ' R-, » .ry �� /7� 8, a FEE Board of Health, I --) 'I Vt If f MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT e Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑Complete System �dividual Components Location 19 �A O b�.( C v� Owner's Name 7Urnac?� 130y�v7b�V Map/Parcel# a1 d— Q Z Address �/ C W � I Lot# Telephone# Installer's Name Designer's Name ANV-ee- G 6onjullAW-IS r Address w,Q 5,+ „ i0kli W Address 90 3 T f4b0 s tv R L� 14 A R Sb uS / Il GGS,M 11 Telephone# 7 7S— Z 10 0 Telephone# 'jab-00 Type of Building Res • 1�'!01M t wo oo .PY!qyK e Lot Size �S�U 00-+ sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder V�D Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) • t Other Fixtures ^� ? �7 Design Flow (min.required) 33 o gpd Calculated design flow J3� Design flow provided J� 1 gpd Plan: Date 41— Cy 6 Number of sheets Revision Date Title t SeptI C Description of Soil(s) See p Soil Evaluator Form No / Name of Soil Evaluato l�C�T.M URP���/` ate of Evaluation 3—A(--J/8 DESCRIPTION OF REPAIRS OR ALTERATIONS l The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE75 and further agrees o not to pl the system operation until a Certificate of Compliance has been issued by the Board of Health. Signed ' ,Date -� - V: f Inspections ;;r z No. FEE COMMONWEALT14 OF } .� Board of Health, IJa ����� `�lP MA. IQ CERTIFICATE Of COMPLIANCE Description of Work: O.Individual Component(s) &-Complete System The undersigned hereby certify thatAj e Sewage DisposlalJSystem;)Constructed (-)—,Repaired ( ),Upgraded ( );Abandoned ( ) by: ,' at L07 P I N Q�y K 0A1 Cc�u has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. / 7 Y dated Approved Design Flow,3(07.1 (gpd) Installer A ,1 / Designer: Nl�:fe SQ I of 6,ASV6-tAN Inspector: i�/I 66 p 11,VWN( ate: ' The issuance of this permit shaVnot be construed as a guarantee that the system function as designed. No. If` '17 FEE COMMONWEALTH OF MASSACHUSETTS,. Board of Health, &(A 0" )'e ' , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct() Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at c� as described in the application for Disposal System Construction Permit No. V—7/`r, dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health ry V ' i T OF BARNSTABLE LOCATION SEWAGE # .2 Z Lz VILLAGE ASSESSOR'S MAP & LOT O 6 © Z INSTALLER'S NAME&PHONE NO.,� ZaC '<f Q� O 3 ,°" SEPTIC TANK CAPACITY v "N �5 LEACHING FACILITY: (type),�_— /� �2u�o✓5 (size)/ 5A/f Los t,1 .1 NO.OF BEDROOMS { BUILDER OR OWNER o ► h 0 k1 r I PERMIT DATE:�` /� OMPLIANCE DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ;I i x gor S 61Z S � 4,) F7-c Lj I L-y- i 1 ! i ! I Q�c 1 1 I � PI' P' 4! ,it o' c b'-u` a''�/' I '•U \�j--.__ I'l'•0". y 5'-'1'" 0.4 e�_9::0�.__. � �'' '�;. ,,-,' +� 1- l 5 I �` _ V I I n t 1 .= .— rJ4 - XT ij: III•�,. 41,Ij' Town of Barnstable P a f�- "� / Department of Health,Safety,and Environmental Services V � 3Z Public Health Division DateD � g 367 Main Street,Hyannis MA 02601 IARNEMABIA KAM 'r ►�� Date Scheduled --a= - Time' HAA44 Fee Pd. p Soil Suitability Assessment for Sewage Disposal Performed By: I Sy-0C e �' �°10R R' °' " Witnessed By; ���'r� 1J�3✓��t`^G LOCATION & GENERAL INFORMATION Location Address Owner's Name �7 too0AC\1 �d� rt�ur, s t ✓1 �--� IZ Oo Address CUB, 4- Cf_4w4_0ra.-R.1A_, Assessor's Map/Parcel: En ineer's Name NEW CONSTRUCTION REPAIR lephone g, Land Use t.�p�C�� Slopes(%) T Surface Stones Distances from: Open Water Body�� ' ft Possible Wet Area ff-A- ft Drinking Water Well ft 1'Ow ' Drainage Way 6' ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) � � I . IDS Parent material(geologic) C-AT VP(Z° Depth to Bedrock �— Depth to Groundwater: Standing Water in Hole: /— ' Weeping from Pit Face Estimated Seasonal High Groundwater DETERMYNA'T IbN'FO0R SEASONAI, H G]4 vVA 1 ED T ADLE 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 N Reading Date: 1 eVxI Adj.factor Adj.Groundwater Level— PERCOLATION TEST Hate 3 � '; Time Observation Hole N Time at 9" �L a Depth of Perc Time at 6" Start Pre-soak Time® Time(9%6") End Pre-soak /D'S(� All �n y01,a ' Rate Min./Inch Site Suitability Assessment: Site Passed�_ Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back-� Copy: Applicant DEEP OBSERVATION HOLE LOG Hole # 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other -Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. Consistency.0 S.4VA y to 7Rse I 38 i3 Lc,cow.y o 1 YR -S pe O DEEP OBSERVATION HOLE LOG Hole# a Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % -$ O rpv�11 i DEEP OBSERVATION HOLE LOG Hole Depth from Soil klorizon Soil"Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell). Mottling Structure,Stones,Boulderes. % ---------------------- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil'iwure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 0 DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % • 3ARNSTABLE ASSESSORS LOT 83 � � C(JTUIT Jo ' � EXISTING A,SPHAL T DRI V �Y° 200. 00 I - i I .� �,E LOCO Z �4 N85 °52'00 'lp h a BAYT \ ASSESSORS LOT 82 p \\ AREA— 25, 000 f S. F. \ \ , / _ I LOCUS MAP o p \ \ 46. 0 r O 97. 6'� o rn 5. c' TP 0 17 0, j o II ASSESSORS MAP.- 20 o 11. 0 I 11. 0 �28 7 __ _ _ 1 n' 'b I O ►� PLAN REF. 319/64 -I O 1 FLOOD ZONE C wF PROPOSED I I RES. ZONE.• "RF" W r 7 I p HOUSE C4 I yv W I SETBACKS. 30-15-15 \ \ EL. = 102 1 138.5 11. 3 _ �� �I � I I I oOp• 1 00 O GARAGE o \ \ O to, .990 TP 2 \ � , /� � I ' L J I \ \ oo 24. 0 i ED 1i BENCHMARK "PK" NAIL J \ PROPOS EL. - 98. 5 \ ► 23, 0; �p 0 CLAMSHELL �I �\ 1 VENT , DRIVE WA Y � / � _ - SITE AND SEPTIC PLAN •� 1 PROJEC T L OCA TION PINEY ROAD — LOT 82 C� c COTUIT, MA. 0 02635 o � 1 00. 00 APPLICANT' N85 ,52'00 "E► ASSESSORS LOT 88-11 DONALD A. BOYNTON, JR ' YAWEE SUR I/EY CONSUL TANTS OF �� '�' P.O. BOX 265 ASSESSORS LOT 126BRUCE �4 .c G. PAUL �J UNIT 1, 40B INDUSTRY ROAD MURPHY A- MARSTONS MILLS, MA. 02648 No.749 +� }; o MPEA11THEW PH.(508)428-0055 — FAX(508)420-5553 c , , No. 32W8 �GIS`T§. SCALE- 1" = 20' DA TE.• 11104198 `°"tia•.,v.t+`'': p, REV IRE1. JOB NO. 51533 SHEET 1 OF 2 EL. =_102 719P OF FOUNDATION ! '20' MIN. 10' MIN. CONCRETE COVERS 4" SCHEDULE 40 P. VC MIN. PITCH 1/8 PER FT. 2"LA YER OF VENT 118"-1/2" 6" MArl —� / / . . . CONCRETE COVER WASHED S719NE EL=99.5 EL=100.5 4" CAST IRON PIPE (OR EQUAL) MINIMUM PITCH 1/4 PER FT. CLEAN SAND 9" LOW LINE MIN. INVERT " 14" EL=96.5 — 98.5 MIN EL.—_�-- g INVERT �6 SUM LEVEL c c °°° °°°c°° INVERT EL.= 97. 75' INVERT INVERT °o c° °°° ° EL.= 98.0' EL.=_97.25 EL.= 97.0 _ °°° ° ° EL.=95.0 (70 BE PLACED ON FIRM BASE) DISTRIBUTION MECHANICALLY COMPACTED OR 6" OF STONE �' BOX 1500__GALLONS TO BE WATER TESTED Il' X 38' TRENCH FORMATION SEPTIC TANK IF MORE THAN ONE OUTLET PLACE ON 6 STONE 3�4" 7Y1 1-1/2" SOIL ABSORPTION PROFILE OF A'ASHED S7YINE S YSTEM (SAS) SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. =_87 75 NOT TO SCALE NO OBSERVED WATER TABLE (03126198) ELEV= 87 75_ OBSERVATION HOLE 1 ELEV=_ 100.5 PERCOLATION RATE �5 _ MIN./ INCH AT —3d" INCHES OBSERVATION HOLE 2 ELEV.=— 99. 75 Y DEPTH HORIZ TEXTURE COLOR MO TT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER O"-8" A SANDY LOAM 10YR5/1 0"-6 " A SANDY LOAM IOYRS/1 8"-38" B LOAMY SAND 10YR6/8 8"-38" -B LOAMY SAND 10YR6/8 GENERAL NOTES 38"-144 Cl MEDIUM SAND 10YR6/4 PERC 38"-144 ' Cl MEDIUM SAND 10YR6/4 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF _BQRl1/SL4B_LE____ RULES AND NO WATER ENCOUNTERED NO WATER ENCOUNTERED REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO SOIL TEST SOIL TEST WITHIN 6" OF FINISHED GRADE" OTHERS WITHIN 12" DATE OF S 0 yL TEST 3/26/98 SOIL TEST DONE BY BRUCE G. MURPHY, R.S. 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITNESSED ;BY: JERRY DUNNING, B.O.H. DESIGN CALCULATIONS.' WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN , 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. P weu NUMBER OF BEDROOMS . . . . . . . . 3 4) ANY MASONARY UNITS USED TO BRING CO VERS TO GRADE SHALL i GARBAGE DISPOSAL . . . . . . . . . NO BE MORTERED IN PLACE. TOTAL ESTIMATED FLOW 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH ( 110_—GAL/BR./DAY x 3___ BR.) 330 GAL/DA Y DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO TO. ' LOAD REQUIRED SEPTIC TANK CAPACITY 1500 GAL OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 5 INFILTRATORS TORS WITH STONE SOIL CLASSIFICA TION . 1 c1 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR 11' X 38' IS TO CALL "DIG— SAFE" AT 1—800—322—4844 AT LEAST 72 HOURS DESIGN PERCOLATION RATE . . . . . < 5 MIN./IN. PRIOR TO COMMENCING WORK ON SITE. EFFLUENT LOADING RATE . . . . . 74 GAL/DA Y/S.F. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS LEACHING CAPACITY (AREA X RATE) 369 GAL/DAY SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. RESERVE LEACHING CAPACITY . . . 369 GAL/DAY 8) PARCEL IS IN FLOOD ZONE___"C" . (38 X 11 X . 74)+(38+38+11+11 X .833 X . 74) 9) LOT IS SHOWN ON ASSESSORS MAP 20 _ AS PARCEL SHEET 2 OF 2 JOB NUtYIBER____51533 _____