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Home My WebLink About0030 POINT ISABELLA ROAD - Health :rT- T FF30 POINT ISABELLA ROAD otuit A = 074 - 016 No. Fee k90-- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for bisposal 6pstem Construction 3pPrmit Application for a Permit to Construct pat ( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. 3� � Owner's Name,Address,and Tel No. Assessor's Map/Parcel p-741,_ p� Installer's N Address,and Tel.No. Designer's Name, ddress,and Tel.No. Type of Building Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 6D Nature of Repairs or Alterations(Answer when applicable) Date last inspected:--(/� `LS. $s'`� `�.• �t;, � _41/— 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 th' oa�Health. e - Date ^� • Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued R No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -:TOWN OF BARNSTABLE,,,MASSACHUSETTS Yes 2pplicatlon for Disposal *pstettt Construction Permit Application for a Permit to Construct Upgrade( ) Abandon( ) ❑Complete System ndividual Com onents P Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel CO T.-�— p\gyp p` n I taller's Na a Address,and Tel.No. 'e Z. . Designer's Name, ddress,and Tel.No. , l Type of Building: Dwelling No.of Bedrooms � � Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. .•Description of Soil Nature of Repairs or Alterations(Answer when applicable)�.� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the escr'be&on-s f ewage disposal system in accordance with the provisionsiof Title the Environrrentalt,Code and not to place the system in operation until a Certificate of Compliance has been issued byi B ard of Health. /Sjjtne . Date ` Application Approved by / / .� Date r Application Disapproved by/ Date / for the following reasons Permit No. U Date Issued w --- _-- - -' -- -- - .. t - Z,N, THE COMMONWEALTH.OF MASSACHUSETTS Nv� BARNSTABLE,,MASSACHUSETTS y \ Certificate of Cotnoltin.ce THIS IS TO CEERTIFY that the On- ite ewage Dispo al.system,Constructeda( )'y Repaired(X Upgraded( ) ' Abandoned( by at �. c D has been constructed'n a rd" ce with the provisions of Title 5 and the for Disposal System Construction'Permit No. ~ 'fated y Installer Designer #bedrooms Approved designJlQw'' gpd The issuance of this permit shall of be o strue as a guarantee that the system will f Ui n d pi dDate Inspector11 ------ = " No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Co L ns• ct�( ) Re air( Up ade( Ab lion System located at PO t r. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with fi Title 5 and the following -localP' revisions orspecial conditions. R � Provided Coti§hucf on 'ust be c W ted within three years of the date of this permit. rLs Date � '" Approved by Commonwealth of Mas$adhusefts ~�^".�R�� w��"�~~��8 N��b��~�� 0~8�� Title �� yNN ��wmU Inspection N—�rmmuw Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments VARA HENRY D JR&VIRGINIA A TRS Property Address 30 POINT |SABELLAROAD Owner Owner's Name information is required for every �8TU[T _N_A_ O2835 � � nos'. cuy[rown State Zip Code Date mInspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100hamt. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below Fj dre ~ing attached separately FRoNT- t5ia^3n3 Title o Official Inspection Form:Subsurface Sewage Disposal System'Page 15wn | 'w Shay Perry From: Shay Perry [shay.perry@cavossa.com] Sent: Wednesday, October 29, 2014 10:16 AM To: Shay Perry Subject: IMG_5252.jpeg ANX 4 Y'' tDr b , i } # 4 F Shay A. Perry Sent from mobil device M#:508-274-8012 0#:508-563-5530 x18 1 r Shay Perry From: Shay Perry.Ishay.perry@cavossa.com] Sent: Wednesday, October 29, 2014 10:16 AM To: Shay Perry Subject: IMG_2690.jpeg r i r > a �x-,'s p��"�i '^ •'�4.� $ �3'f *. asp �4' I Shay A. Perry Sent from mobil device M#:508-274-8012 0#:508-563-5530 x18 i Shay Perry Front,: Shay Perry[shay.perry@cavossa.com] Sent: Wednesday, October 29, 2014 10:16 AM To: Shay Perry Subject: IMG_1038.jpeg I > a; r tl�II, i M1 4 F - s+h Shay A. Perry Sent from mobil device M#:508-274-8012 0#:508-563-5530 x18 i . a Shay Perry From: Shay Perry[shay.perry@cavossa.com] Sent: Wednesday, October 29, 2014 10:17 AM To: Shay Perry Subject: IMG_5659.jpeg h r } z r y NM i 6 Shay A. Perry Sent from mobil device Lit M#:508-274-8012 0#:508-563-5530 x18 1 i TOWN,, or b� i ,k { et`! (U., J0 Town of Barnstable t3a111Stabl2 \��F Tk1E j o{y\ �FrAItt�IC2 C[ty Regulatory Services Department r® ( l � QARNSTABLE„ i Public Health Division �' MASS. 1 _ 3 /� 2007 Argo MAC a`� .200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0185. September 17, 2014 Mr. and Mrs. Henry D. Vara, Jr. % Point Realty Trust 350 Chestnut Street Newton, MA 02465-2951 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 30 Point Isabella Road, Cotuit, MA. was last inspected on August 22, 2014 by James D. Sears, certified septic inspector for the State.of _ Massachusetts. According to the private septic system inspector, the system"Conditionally Passes" due to the following: • Need to replace Distribution-box. • Need to replace piping into and out of Distribution-Box. • Need to replace both tank covers. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification: Failure to repair/replace the septic system within the deadline period may result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH mas McKean, R.S., CHO Agent of the Board of Health 0:\SEPTIC\Conditionally Passes Ltr\30 Point Isabella-Rd Cot 2014.doc ep 0414 09:24a p.1 ` Commonwealth of Massachusetts im Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Point Isabella Road , Property Address Henry Vara - Owner Owner's Name information is Cotuit required for every MA 02635 8-22-14 page- Cityfrown Slate Zip Code Date of Inspection Inspection results must be submitted on this form.-Inspection forms may-not be altered in any way_Please see completeness checklist at the end of the form.- Important:When filling oul forms A. General information on the computer, 603� `� OF �gSuse only the tab `,\� 1. Inspector: `� ' sv key to move your o? cursor-do not James D.Sears = JAMES N use the return = :m key- Name of Inspector ? c Ca ideEnt ewerprises,LLCt * o Company Name �' �� - 153 Commercial Street '��,,�s iNSQ��'��`�� Company Address - nnNu Mashpee MA 02649 City/Town — State Zip Code - 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ®' Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-3-14 pectors 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 desig n,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. 15ins•3/13 - • I � ' Tit'se 5 e ec6on Form SubsAface a Dist sal System• e P 9 h ys Page 1 or 17 Sep 0414 09:24a p.2 Commonwealth of Massachusetts a . Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Point Isabella Road Property Address — Henry Vara Owner Owner's Name inlorrequired ation a Cotuit MA 02636 B-22-14 required for every page. City(Town State Zip Code Date of Inspection B. Certification (cunt.) 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 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: rs The system is a 1500 Gal.Tank D Box and Pit. Need to replace D Box,. Need to replace pipeing in to and out of D Box. - B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the.replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements.If'not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved 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): t5ire-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Sep 0414 09:24a p.3 Commonwealth of Massachusetts _ Title 5 Official Inspection Forma a` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information required for every Cotuit MA 02635 8-22-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.):., ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ® broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ .N ❑ ND(Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N 0 ND (Explain below): Need to replace D Box. Need to change pipeing into and out of D Box. Need to replace both covers on tank. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y' ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which_ will protect public health, safety and the environment:. ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 or 17 Sep 0414 09:25a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form i= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is required for every Cotuit MA 02635 `8-22-14 page. City[Town State Zip Code Date of Inspection B. Certification (cont.), , 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply_ ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**_ Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. „ 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 4® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool a ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in ee2spaM is less than 6' below invert or available volume is less than day flow /o/T 15ms•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 a'17 Sep 0414 09:25a p.5 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owners Name information required for every Cotuit MA 02635 8-22-14 page. City/Town - State Zip Code Dale of Inspection B. Certification (cont.) Yes No ❑ ® Required pumpirig more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or-privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10.000gpd_ , . The system fails. I have determined that one or more of the above failure El ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes'or"no"to each ofthe 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. 15irls•3113 - Tille 5 Official h Vecilon Form:Subsurface Sewage Disposal System•Page 5 of 17 Sep 0414 09:25a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ol 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is Cotuit MA 02635 8-22-14 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes".or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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. El ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x'#of bedrooms): 550 t5ins•3113 Title 5 Olfiael hspeaon Form:Subsurface Sewage Disposal System.Page Gof 17 s Sep 0414 09:26a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is required for every Cotuit MA 02635 8-22-14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D. Box and Pit 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No 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 years usage (gpd)): 2013-50,000G 2014-50,OOOGa l's s Detail: Sump pump? ❑ Yes No- , NA Last date of occupancy: Date CommerciallIndustrialFlow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? a . ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? 1 ❑ Yes ❑ No Water meter readings, if available: — Dins•3113 Tale 5 OlBcal Inspection Form Subsurlace Sewage Disposal System•Page 7 of 17 Sep 0414 09:26a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is Cotuit _MA 026351 8-22-14 required for every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: , Source of information: NA 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: , k ® 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): Mire-3M 3 Title 5 Official I:speation Ferm:Subsurface Sewage Disposal System-Page 8 of 17 Sep 04 14 09:26a p.9 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name reformation foration is required for every Cotuit MA ' 02635 8-22-14 page. Citylrown state Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components,date installed (if known)and source of information: 1978 Permit # 78- 137. Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 30" 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.): Pipeing House to tank 4" PVC SCH 40. Pipeing in and out of D Box is 4" PVC SCH 20. Septic Tank(locate on site plan): 16„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years s Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal.Precast H-20 Sludge depth: 2" t5tns•3113 Tee 5 Offida'Inspection Fomc Subsurface Sewage Disposd System•Page S of 17 Sep 041409:27a p,10 Commonwealth of Massachusetts Title 5 Official Inspection Form a1 Subsurface Sewage Disposal System Form-Notfor.Voluntary Assessments r 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is required for every Cotuit MA 02635 8-22-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle IT, How were dimensions determined? Plan Tape Sludge Judge 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 and cover's at 16" below grade, cover's broken. Need to replace both covers. Two inlet tees,outlet baffle. No sign of leakage or over loading. 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 ti Date-of last pumping: Date 15ins•3/13 Title 5Offidal Inspection Form:'SuDsurface Sewage Disposal System•Page 10 of 17 Sep 0414 09:27a p.11 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara - Owner Owneis Name information is (',ptuit MA 02635 8-22-14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 5 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . - a 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: T gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: 4 Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract (required)_ Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 t]Rdal Inspection Form:Subsurface Sewage oisposal System•Page 1.or 17 Sep 0414 09:27a '' fl p.12 Commonwealth of Massachusetts .- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Point Isabella Road ` Property Address Henry Vera Owner Owner's Name information is required for every Cotuit " MA 02635 8-22-14 ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate-on site plan)_ w Depth of liquid level above outlet:invert - ` "` ^ 0 F 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"x21"-32 below grade. Wall's are gone. Need to replace.Box. One line out. Pump Chamber(locate on site.plan): Pumps in working order.' Q Yes El No* Alarms in working order. ,Yes ❑ No* Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): { T * If pumps or alarms are not in working order, system is a conditional pass.,' .°. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 _ Title 5 Official Inspecllon Form:Subsurface Sewage Disposal System Pege 12 0`17 s v " Sep 0414 09:28a p.13 Commonwealth of Massachusetts - - Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is required for every Cotuit MA 02635 8-22-14 page. Cityrrown state Zip Code Date of Inspection D. System Information'(cont.) Type: ® leaching pits number 1 ❑ leaching chambers number: ❑ leaching galleries number: '. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:' ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal Pre cast Pit w/2'.:stone. Pit at 43" below grade w/cover at 16". Pit is dry w/stain line at 1'. No sign of over loading. No high stain line. 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 r Indication of groundwater inflow ❑ Yes ❑'No , Mns•3r93 Title 5 CMciat inspection Form;Smsurface Sewage Disposal System•Page 13 of 17 ISep 0414 09:28a p.14 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is required for every Cotuit MA 02635 8-22-14 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids --- -- -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Tice 5 Ofrdal Insusc6on Form Subsurface Sewaae Dispasal System•Pepe 14 cf 17 Sep 0414 09:28a p.15 Commonwealth of Massachusetts PP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is Cotuit MA 02635 8-22-14 required for every page_ Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in,the area below ❑ drawing attached separately �R __J A t /4 -3-:36` ,�o�, 19 ,6- y= 38' t5ins%3113 Title 5 Offxief Inspection Form:Subsurface Sewage Disposal System•Page 15 of'T Sep 04 14 09:29a p.16 Commonwealth of Massachusetts ---- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name information is required for every COtUIt MA 02635 8-22-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water b ❑ Check cellar ❑ Shallow wells IV Estimated depth to igh ground water12' -- feet , Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 3-9-78 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: T.H. on design plan 3-9-78 no G.W. at 12'. Bottom of pit at 9'below grade. Bottom of pit at T above T.H. Depth. Before-filing this Inspection Report,please see Report Completeness Checklist on next page. (Sins-3113 Title S Ofriclal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Sep 0414 09:29a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- ° 30 Point Isabella Road Property Address Henry Vara Owner Owner's Name required fo is Cotuit MA 02635 8-22-14 required for every page. CitylTown State 'Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)-completed ® System Information- Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t [Sins•3013 Tift 5 Official Inspection Form:Subsaface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector._ "I key to move your cursor-do not JOHN GRACI use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC „� Company Name PO BOX 2119 Company Address r TEATICKET MA 02536 City/Town State Zip Code 508-641-6694 S 1468 Telephone Number License Number B. Certification I certify that'l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes . ❑ Fails ❑ Needs Furth valuation by the Local Approving Authority 09/27/2014 Inspector's Signatur Date The system insp or shall submit a copy of this inspection report to the Approving Authority(Board of Health or DE ithin 30 days of completing this inspection. If the system is a shared system or has a design flo of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the app priate 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. t5ins•3113 Title 5 Official Inspection m: bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora ri Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. Cityffown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUCTIONING PROPERLY AT TIME OF INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. RECOMMEND RAISING ALL COVERS. 13) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): NA ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): NA C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � M VARA HENRY D JR&VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: NA D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 H-20 GALLON SEPTIC TANK H-20 DISTRIBUTION BOX 1000 GALLON LEACH PIT Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gp ))� Detail 2012 50,000 2013 50,000 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'4 Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC 40 PVC ® other(explain): Distance from private water supply well or suction line: GREATER THAN 10+ FEET feet Comments(on condition of joints, venting, evidence of leakage, etc.): TWO INLET PIPES Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: (4) FOUR INCHES t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014. page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle (30)THIRTY INCHES Scum thickness (1) ONE INCHES Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK HAS TWO INLET PIPES SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY RECOMMED PUMPING EVERY TWO YEARS. RECOMMEND RAISING COVERS. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping, recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping:. NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert BOTTOM OF PIPE Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSEPCTION Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1000 GALLON LEACH PIT WITH NO VISABLE STAIN LINES COVER IS (1) ONE FOOT TO GRADE. LEACH PIT APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M VARA HENRY D JR&VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately FRoN� 8 0.,;,A(Z A B O U c 15606AL S r4Ptt G T�tN{L AA I-I BA 1153 /+C 364 B- 24 o 140 gfo(o SP 88 c� 396 1OH P' ` CO 487 cc5q &M G D(P7,3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M VARA HENRY D JR &VIRGINIA A TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: GREATER THE 10+ FEET 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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , VARA HENRY D JR &VIRGINIAA TRS Property Address 30 POINT ISABELLA ROAD Owner Owner's Name information is required for every COTUIT MA 02635 09/27/2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LTOWN OF BARNSTABLE LOCATION �u��"1 ZeUl(h SEWAGE # 7 k,"1 3 7 VILLAGE ��'�✓� ASSESSOR'S MAP&LOT07-(-4/d INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) I (size) 1,10.OF BEDROOMS to o C4 S ) e( BUILDER OR OWNER PERMITDATE: 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 TEST MADE ON •rem/ s ie�'' f 36 el AM�arvt-�f'/' 30 1 Tct Iron Pipe, F' ag ( 30 xe; ` a z. th garbage,4'�, �r�, . C yal, 2)MI.aI/aivaLA da, y , ,s sysfe/j7 l5: 185E x2,509vd/ = 470 gyp/ �"Y ` for 79 r >,00 = T9 n r 3 po _ o -549 _ ti ✓�,; W. No.......... - .-.. L Fxs.... C2 ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...----.r)1�I1..................... OF.........8 M5..�.ble....................._.:.......-..-..... ApOiration for Diapas al Works Towitrurtion ramit Application is hereby made for a Permit to Construct (k/ or Repair ( ) an Individual Sewage Disposal System at: ••- Location-Address t No H�+ 1..IRS....��i�.. w.....---�....::.��:? _A�r� tim4SS...... _ Address T r Installer V Address < Type of Building Size Lot..... i. 16.....Sq. feet U Dwelling—No. of Bedrooms.._._.................................Expansion Attic ( ) Garbage Grinder ( ' Other—Type of Building ............................ No. of persons...__._.._.____._._..__.__.. Showers:( Cafeteria a' Other fixtures ------------------------b---• •-- 4,4 Design Flow.............. ......gallons per pefeen per d4. ay. Total daily flow__._..........._�3.0..............gallons. WSeptic Tank—Liquid*capacity.1.6M.gallons Length__tQ. _._ Width...' .. Diameter................ De th. =............ Disposal Trench—No..................... Width__................. Total Length._......_ Total leaching area..'... ... ft. x p , ` �'... T Seepage Pit No.......'............ Diameter......I " ._. Depth below mlet...�.— ._.____ Total leaching area..................sq. ft. Z Other Distribution box (`iY Dosin� tank ( ) M `-' Percolation Test Results Performed by_._. � - r�. ,< i_.__.____ Date_.._.,3r�±4. j7 ,:. �a Test Pit No. lVt .Z.minutes per inch Depth of Test Pit----lt.:" .._. Depth to ground water .eA.C.1_.__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground ................ �/ .. ._ 61 O Description of Soil. .11 � 1'�Y.! �' ��----- �' -----•.. ' } P u y r n �� DART ---- i� W ---- U Nature of Repairs or Alterations—Answer when applicabl :nn�cFcti,v1E - No.14704 e________________________________________________ _� ........_....�Q. ...... ...................................... -••----------•-•----•--------------------------......--•--•------.......----•--------- . Agreement: N t The,undersigned agrees to install the aforedescribed Individual Sewage"Disposal,System 1 ante with the provisions of iIT 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. . ,` • i- Sig d + GG � % � Dat Application Approved BY / :a......% Date .. t Application Disapproved for the following reasons:.......................................................................... .. Date Permit No......................................................... Issued.tL-15 ` Date i - No........../.3 _ Fps.... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ....................OF:....... h/01............................................. , ppliratiun for M-4posa1 Works Ton$trnr#ion ramit Application is hereby made for a Permit to Construct (L/j or Repair ( .) an Individual Sewage Disposal System at: t k6l,............................... ... .... ........................................................... -^•- • ------,Location-Address t Noy _----�� ..l..S -it�?�? .(Z-----. t! ............ Owner Address . .._.�l .U_.....75................................................... .... .............. 9 S.�i..............._.._._..... PQ Installer Address U Type of Building Size Lot.....3.1r�,3•�44....Sq. feet Dwelling—No. of Bedrooms...... ................................Expansion Attic ( ) Garbage Grinder (k-r P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures ..................................... db&owf _------------------------------------------ Design Flow.............. ..1_�0......gallons per percrm per day. Total daily flow.................330..............gallons. W If Septic Tank—Liquid capacity.1,.5 gallons Length..10...0. Width...*•'4`' Diameter_______________ De th-A-'Di!- x Disposal Trench—No..................... Width.................... Total Length.........e_._.! .. Total leaching area....... 7...sq. ft. Seepage Pit No........I........... Diameter....... Depth below inlet...6-0...... Total leaching area..................sq. ft. Z Other Distr'bution box ( '' Dosing tank ( ) Percolation Test Results Performed by..c ..�r. '� ' _ Ctt �� !t'� ,�... Date.. t�d`c ..}_� .. a Test Pit No. 1 6JOYI minutes per inch Depth of Test Pit.....it_.a.. Depth to ground water.t�_...�/zCa.... fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground ................ .- �... .. .--- .................. �.. ..F Mgs��c --------- x . Description o�Soil...(_ ?[�r .�1 =�----� � •• 13 �''.. �N LL fJ� _•7]J�}(�1�/ //] //f�/j//jam ...._._._L:,............. ..... -.:�.X`:V_ _ .i_._._GO......Asy....._.____.�.__....J. __J.._�_ .•_..__.1 `%Ye%�? _ .Qv. ........ `/ W -- --••-----------------------------------•.........--••-•---------•------•------•----••---••-----•----•-•-•----•-----------•------•-••---••-•---•_........ ..lu1CKECHNIE._..t—'o .... U Nature of Repairs or Alterations—Answer when applicable................................................. �9��No.147�� . p�e --•---....-•------------------------------------------•--------------------............._..-•-•---••--•-----••---------------------•---•-------.--- 4 k. .. •. Agreement: o The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in dance with the provisions of TITL 2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ---•-•----•----------------------------•-••-•---••--•---•-----• .......................... J Date Application Approved B ...!! .._..,.. .__... Date-•--•- PP PP Y fie d{-_4 Date ' Application Disapproved for the following reasons---------------------•-•-----•---------------------------------...._..--•--•--•--•---•-----• •--•••............. ..........................................•--••-•-•----------...----.....-•----------..........-----•------------...........----•--•------•----:......_..------------•---------...----••-•---•-••------ Date PermitNo......................................................... Issued_..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF............/.. ....:...................... Tatifiratr of Tompliana THIS I6 TO CERTIFY, Th IndividgaySewage Disposal System constructed ( or Repaired ( ) by.. - _ .4 mod . / stall/In al / at I. ...... It ''?Y �Y.IkS... ..u��.......L....!' has been installed in accordance with the provisions of TIT_�F �5 of The State 'Sanitary Code as described in the application for Disposal Works Construction Permit No.___{ :22.___�s ............ dated_ :.............. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......-�. 2 -..1. ... ................................. Inspector....•. •----•----............. -............... ............................ , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H, p7c�- - q � �..............0 F............. lX �............................. FEE..... vd No.. ` / ... 2.5....... Diuvoug1 ork Tons n ami# r Permission is hereby granted._._` ........ . ._... L� .... to Construct (%�)jor Repair n In vii 1 Sem ispos st at No...- .bg � :.��1•-•--� ';.%""'e`�l '�''�,r�c......... .. -- Ud Street as shown on the application for Disposal Works Construction Permit _________________�jated..... ........... �'✓��'��- __..-------------------------- �j a Board o Health DATE--- ---^•-..................................................................... - FORM 1255 HOBBS & WARREN. INC., PUBLISHERS o �«a• $O i L LOG - _ / = 2".PEASTONE �• LOAM & FILL: 12"NAx, L•--,Oc' p,,,." __�___vvi • �° a of tads rG Z7. 3 0 • e e U° °I (min) Box I; �� a �D°•I MIN. 1 500 i 0 vlN.e �cPGG Z 7•� 1000— GAL. a °e� _ GAL. _ °i �• PRECAST OR SEPTIC .6l00�•�, BLOCK a° °°DI 07ia' TA``�IK ,'. ° e SEEPAGE PIT n > 20' MINIMUM ;o°• ,o Tatat 0 Zo''�F b ; FOUNDATION I 1 YS' WASHED STONE I SCALE: I"= 4' ELEVATION SKETCH 10' PRIM RATE s Q..••oee aw••wlrN�N SCALE I�'= 4' TEST BY : eeu J srw6/"h/�n/rcr�a !d.✓ TOWN INSPECTOR: "�a eN-lef e BACKHOE OPERATOR ' TEST MADE ON M f \/ oo bG s�2. A 'rb� #ram pipe, 3x �? `__ 4`��a y p-df. (Wi c�jrbage l.?r), /, Septi- 4�, 41 Wr�' stdew%t'hs' 1 88 sf x 2,srrs qp'r�/.�-= 4 70 a�.l ,,.�`. ��' r �-•' - ' 9 L4- . ,. t ' GGFf ►ZS o'7' S1.7 a�ua 319/"i i UI rr ELEVATION SCHEDULE PROPOSED SITE PLAN I. INV. AT FOUNDATION = U90 �,� � SEWAGE SYSTEM DESIGN 2. INV. INTO SEPTIC TANK = IN 3. 1 NV. OUT OF SEPTIC TANK = Z140 A ,' T'/ L CO7-Ul )j IAS1 4. INV. INTO DLSTRIBUTION BOX = 2i.'1" }_ SCALE I�_ �� fF0�.1%' ''�,/ • 19 5. 1 NV. OUT OF DISTRIBUTION BOX = C- G50 6. INV INTO SEEPAGE PIT = " CAPE COD SURVEY CONSULTANTS ROUTE 132 7. BOTTOM OF PIT = 2LOO HYANNIS, MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. 8. BOTTOM OF STONE LAYER =