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HomeMy WebLinkAbout0043 POPONESSETT ROAD - Health -------------- 43 POPONESSETT ROAD, COTTTIT A= 035 001 - f; C�1 r!` 1� rt i i v v a S r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9ppf ration for MispoSal 6pstm Construction Vrrmit Application for a Permit to Construct( ) Repair k Upgrade( ) Abandon( ) ❑Complete System Vindi,idual Components Location Address or Lot No. L13 POpcWe5.5 err—t P T> Owner's Name,Address,and Tel.No. Assessor's Map/Parcel p )0 �7 t q 3P0P e� P_t AJjy C 'TU 1.T Installer's Name,Address,and Tel.f,4o.SO 8-47 7"$S-17 Designer's Name,Address,and Tel.No. G4p E�7R�Sc3'M,4SJ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) IV tr gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) New ti—W D�Po�0.51A AT IOd Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. got to Date Issued �� 0� 6 No. Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 'Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RppIication for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair 0() Upgrade( ) Abandon( ) ❑Complete System 5d1ndividual Components Location Address or Lot No. y3 PO'PCk/ESS PT) Owner's Name,Address,and Tel.No. " Assessor's Map/Parcel Q3 O` �?u T ��0 E l V C(27( CT,,, k Installer's Name,Address,and Tel. o.S'0 8'-477"$ST7 Designer's Name,Address,and Tel.No. CAP6W(i5 E NIA CvK.tu Nl l��51E��� Type of Building: ; Dwelling No.of Bedrooms AM� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 44 Design Flow(min.required) IV rr gpd Design flow provided /yngpd 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) N Ew t4--Ao b dBaX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described or-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 90(b Date Issued 1 \ 1_ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS �� Certificate of Compliance t THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( x) Upgraded( ) 1 Abandoned( )by ,M&-QJ(D6 EAJ7EaPAQKC C Ur.at v,2 P D?DAtF_'5'S9—r—j AD <�OTu t= has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No;016-15j dated S-- Installer ago, LLC,. Designer V *4 #bedrooms Approved design flow kv 177 fi gpd The issuance of Is permit shall not be construed as a guarantee that the system will fun ;n signed. Date I t2� b Inspector (n 4er 1 I ' ----------------- --------------------------------------------------------------------- No. � 1 55 ° Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS Disposal &pstem Construction Permit Permission is hereby granted to Construct( ) Repair(A Upgrade( ) Abandon( ) System located at ?)_P OP'D IV e q, ,-&-'T' R 0 f4 o Q pT U 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. Provided:Construction must be completed within three years of the date of this permi? / Date J � '— Yb Approved by AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION y3 /�'�d/^��' ss�f� /�� SEWAGE # VILLAGE Cp!u �/ ASSESSOR'S MAP & LOT . vo INSTALLER'S NAME & PHONE NO. 19, r7 ire SEPTIC TANK CAPACITY /.5-042 LEACHING FACILITY:(type) y�i^vNcAxs (size)29 "X y' x?' NO. OF BEDROOMS PRIVATE WELL ORPUBLIC WATER y BUILDER OR OWNER DATE PERMIT ISSUED: cj��} DATE COMPLIANCE ISSUED: � -3 "/ 7 VARIANCE GRANTED: .Yes No i ��c-a gt A L [j Z- 3q� Ll%L A 3 z 34 0ao 4 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=035001&seq=1 5/16/2016 " 4 • 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 6 4pliLation for Misposal *pstpm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System endividual Components Location Address or Lot No. /35V 5-0150- Owner's Name,Address,and Tel.No. 1 Assessor's Map/Parcel ;f, Q (� /�'�773/V C p'�i Installer's Name,Address,and Tel.No. —d2�f��' Designer's Name,Add less,and Tel.No. s Type of Building: IL 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 Da Title li Size of Septic Tank Type of S.A.S. F 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 afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H th. Si Date /� Z r Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ~�� ��(p Date Issued s - . a No. �«.: ... � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r Yes PUBLIC HEALTH'DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Applitationfor Nsposal 6pstem Construction Permit Application for a Permit to Construct(s) '•Repair( ) Upgrade( ) Abandon( ) ❑Complete System � IIndividual Components Location Address or Lot No. /rW7 5.4AIIV,T-Ne Owner's Name, -Address,and Tel.No; y Assessor's Map/Parcel fl i r— Inssttalller's Name,Address,anJ Tel.No.n61—AXY9/ Designer's Name,Add less,and Tel.No. F 14 / p y j2o Type of Building: G" �71 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 I gpd r Plan Date Number of sheets Revision Da e Title '�t Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) j. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of HealfE) Signe _ Date 5"11-7 Application Approved by Date Application Disapproved by �w ' c r~� ,:� w 4 ,, c F ,R.l f 'c =Date r s -`�. v for the following reasons Permit No. F'���1„ (p L� Date Issued rj ----------------------------------------------------------------------------------------------------------------- --------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of compliance 1 ,�' THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(I.,,) Upgraded( ) Abandoned( )by at I1 =51L=Z I j a — ' 4as been constructed,in accordance with the provisions of Title 5 and the for Disposal System Construction Permit-No.:X/6 1lo ydated S% 7 Z4 Installer Designer #bedrooms �A { ( J� Approved design flow �-�— gpd The issuance of this p/er(mlitE shall not be construed as a guarantee that the system will ncti L de si d. Date �I �r I 1�/ Inspector - ----------- `--------C------------------------------------------- -- No. '_1V1 6o- ` & / Fee J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair(. Upgrade( ) Abandon,( ) System located at i �a"^S 5 �,' %>r t—e u -,ate � C,�.��� all—A and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed w' n/three years of the date of this pe rt. Date ly Approved byT r AsBuilt Page 1 of 1 TO O BARNSTABLE JCATION J S S TUB /I tW i DIrn SEWAGE# VILLAGE C -_u'- ASSESSOR'S MAP&LOT 4'3L DG� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OM r LEACHING FACILrrY:(type) P, T G X 6r (size) NO.OF BEDROOMS a�3 BUILDER OR OWNER C , A I� 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 leac4g facility) Feet Furnished by ni Zf,u V-1 aY a a2: a°1 y 3 3S '/0 y s� Cam- ICI http://issgl2/intranet/propdata/prebuilt.aspx?mappar=024009&seq=1 5/18/2016 k - t t �r4 1 Commonwealth of Massachusetts ail W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M .43 Poponessett Road { Property Address f+ Maureen Dunning Owner Owner's Name ¢y information is It tUO required for every C / MA 02635 5-5-16 page. Cltyfrown State Zip Code Date of Inspection �1 Ja 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, C� / / ���` ��H OF use only the tab 1. :���`�•' • N Inspector: key to move your • •.• '•,yG cursor-do not =�. JAM ES N use the return James D.Sears ;m Name of Inspector Z5; •-a key. *.• :rn Capewide Enterprises, LLC �,• c+ p ' �y Company Name ;' '��`` 0 153 Commercia'J Street �iij �5t 1NSP,EG����`�� Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-7-16 spector'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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0"a VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Conn pass- D Box. The system is a 1500 Gal. Tank D Box and 4-24'x4'x2' leach trenches. 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 ❑ N1 ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 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): need to replace dl box ❑ 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 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in IMMIPM is less than 6" below invert or available volume is less than '/2 day flow J- �1614/.v( t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 43 Pop onessett Road Property Address Maureen Dunning Owner Owner's Name j information is required for every Cotuit { MA 02635 5-5-16 page. Cityrrown I State Zip Code Date of Inspection B. Certificati n (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 y 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 i 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 Sectn 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'"i 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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): 5 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and 4-24'x4'x2' leach trenches. 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 2014-23,000GaIs g ( y g (gpd))� 2015-31,000GaIs Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown 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: 4/11/16 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) 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is Cotuit required for every f MA 02635 5-5-16 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: 1986 Permit l#96-555. f Were sewage od�rs detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): 36" Depth below grade: feet Material of constrIuction: i ❑ 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.): I Pipeing is 4" PVC SCH 40. I f i Septic Tank(locate on site plan): . 611 Depth below grade: fe t I Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ( 1500 Gal. Precast H-10 Sludge depth: 0" t5ins•3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cant.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0" 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 18" How were dimensions determined? Asbuilt-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 at working level. Tank and covers at 26" below grade. In and outlet tee's. 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 Date of last pumping: Date t5ins.•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,a 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown 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 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"x21"-38" below grade w/4 line's out. Need to replace d box. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4@24'x4'x2' ❑ 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 four 24'x4'x2'trenches. Ck D Box and camera out. No sign of over loading or holding water. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. City/Town 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.): i ,,ins•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 GSM , 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 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: [a hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 GAR A � �To 0 3 36 13- 41 -711 i HP Color LaserJet MFP M476nw Fax Confirmation Apr-13-2016 15:54 Job Date Time Type Identification Duration Pages Result 385 4/13/2016 15:53:05 Receive 1:30 13 OK Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 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: 2 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: Abutting property and across street drops off 20'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 43 Poponessett Road Property Address Maureen Dunning Owner Owner's Name information is required for every Cotuit MA 02635 5-5-16 page. Cityrrown 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I CB L�JOpO �O LOT 216 CO. 1 - -_-HSE < o-_ 43. �o LOT 217 �0. / LOT 218 PAR. I PAR. II PAR. III 10,9 37 RE.! ZO,'VE'. "RF" This MORTGAGE INSPECTION Plan is For FLOOD ZONE "C" TOWN: — REGISTRY OWNER: MARGARET TOMILSONFKA MARGARET L CERSTLE DEED RLF: 1407 737 _ —BUYER: IYA$IZ W AfAuFz v F DLZmvj G _ _ DATE: 9i2 Z96_ — PLAN REF: 19 143_ SCALE: l"= 30 FT. I HEREBY CERTIFY TO P41Q(1T�L� TA �QiI�P6�'Y�N — — -- `HOW'S ON THIS -----n--------------------THAT THE BUILDING ,+K�A��-'� n� Maw YANKEE SURVEY PLAN IS LOCATED ON THE GROUND AS PAUL `- , UH01NN AND THAT ITS POSITION DOES CONFORM A. CONSULTANTS TO THE ZONING LAW SETBACK REQUIREMENTS OF THE 17Hr;�J - 40B (SUITE 1 ) ti' OF _ B.4RtVSTABLE `' Tore, _-AND THAT it"'` ;,.�• �'�� ti� INDUSTRY ROAD IT DOES_ NOT ----------- `". LIE WITHIN THE SPECIAL FLOOD HAZARD MARSTONS MILLS, MA. 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED- QV _ 3,'0�.;"•=;,-�? TEL: 428-0055 C o u i t —P a e l .250001 001&' D FAX: 420-5553 __ THIS PLAN NOT MADE FROM AN INSTRUMENT A . ?. E Tr. PL5 SURVEY. NOT TO BE USED FOR FENCES ETC. 10751 DCB „ 777 v .% 3 ( %\ q � a /S &y i G» � I . , : . = I - O 7s H, - ))) . \\ . z \« 7 = y m» \/ { § a )2( #§ 6? §§ ) a \ =© ^ N E W ADDITION FOR: DESIGNED/DRAWN B» � / /$ }) /G c�7BAY�SG, N WARD & RENEE DUNNING a eOw R�&D > 2 \ MAH+E*wn62G p o J 6 )/ /O//ONE/SETT RD. COTU|T, MA ( 08)539-2Bg No. lt'— Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatfon for 0i9;po!5a1 6 enY Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 43 POPPotir-S-s era go. Owner's Name,Address and Tel.No. 'W NP,0/MAtA R_k QP 'Dt tPuinl 4 qt' a-4,35 Assessor'sMap/Parcel L4 Co- uf'r y{, POPporit-sL11 RE) CaTuff Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3O Nl.r A, tALTO �Z��9�►5 15 o vJ AujkA i t\hP-STcos IUS MA Type of Building: PNQ10"_Ti Ll Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder(N9 Other Type of Building E� No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow 3 5 0 gallons per day. Calculated daily flow f`5'0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15-®U Type of S.A.S. Kinc a; Description of Soil few Nature of Repairs or Alterations(Answer when �applicable) L/ 1,-e-06-e �a«s/� 9 ev�}st��.'/�/s 9-- If..�./� f.J U'!! ll.�T G /r�I'%/� �J �y ��T l>P/ Z/ac4 //'1/1 A S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi CY_Z�- SignedL��` /%� Date Id-- 3 Application Approved by Date Application Disapproved for th ollowin reasons Permit No. Date Issued 1 �r r ., .001 . � t • No. �' Fee � t JHE COMMONWEALTH OF MASSACHUSETTS¢ Entered in computer: Yes `PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for 0igpogal *pg em Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) , ❑Complete System ❑Individual Components Location Address or Lot No. 4 3 Pofttje ss L=T1 X0 Owner's Name,Address and Tel.No. WAR0/t-AAt0kiWv-J 1DuNNi�►6t (fi35 Assessor's Map/Parcel Cv`Cu 1 T POPPo,4ttSl.-n?,c> Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,T°M� A. nn_.-r'Q t f I'a 9-59-5 ISt� vJAwtAT I-NAKSTa-AS KUS MA Type of Building: 1OE,-17iAL Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(�l� Other Type of Building Re 3 dom14 l No. of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow SsV gallons per day. Calculated daily flow gallons. Plan Date F`Number of sheets Revision Date Title . i Size of Septic Tank Type of S.A:S. s Description of Soil 5;1.1 i Nature of Repairs or Alterations(Answer when applicable) a'10 3 4 fn L /Ida S�o7�c�i.n�f �/ ll��f ',l Gi ' ✓�' Z1,4 Date last inspected: Agreement: The undersigned agrees to'ensure the construction and maintenance of the afore described on-site sewage disposal system - in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi o d f Health. Signed :/; Date w 3 Application Approved by Date / Application Disapproved for thW0lloA;1W reasons Permit No. 5 -= Date Issued �Y-----------------°---------------- .THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage e Disposal System Constructed( )Repaired (y)Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 arid the for Disposal System Cons Luc tioe Pertmt Ni ` / :-`-�._ dated -- Installer Designer1 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. / Date f - 3 - "! 7 Inspector 7_7 ---/f----✓-------- ----------------- NO. �GO SSJ Fee ®� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligogar *pgtem Construction Permit Permission is hereby granted to Construct( J Repair( Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by �1 j tl ' OF ,0i�%7 � p TOWN O BARNSTABLE LOC ATION �� / �'/� �""� ss� � SEWAGE # VILLAGE col i 7 ASSESSOR'S MAP 6 LOT d� r INSTALLER'S NAME 6i PHONE NO. JOA-n 19, Ito` SEPTIC TANK CAPACITY 00 LEACHING FACILITY:(type) f9 %rPh�rr (size) aY"X y' x; NO. OF BEDROOMS Jr PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ;��' on �- r2- corkyr- 2'34 tz 3 600 \ TOWN OF BARNSTABLE VILLAGE r�� Q ASSESSOR'S MAP & LOT NAME&PHONE NO. SEPTIC TANK CAPACITY /LTD LEACHING FACILITY: (type � (size) NO.OF BEDROOMS BUILDER.OR OWNER, -VlJ�'J <OZ tfift=ATE: COMPLIANCE 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) t Feet Edge of Wetland and Ipaching Facility(If any wed ds exist within 300 f t o acacility) Feet Furnished 1 iia pOPonoe6a* V CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, 06-4 g,,/9a lla , hereby certify that the application for disposal works construction permit signed by me dated /�J^ j— ��. , concerning the property located at ���bh�f sP R� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are nz)variances requested or needed. SIGNED : (/l. DATE: le/ LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. C� DATE: _ 7/30/96 PROPERTY ADDRESS: 13 popnonessett Road Gotuit.,Mass . Cotuit,Mass . 02635 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . _.1 -3 'x4! block grease trap. •2. 1 -61x8l block cesspool 3 . 1 -61x6r block cesspool. Based on my InK:wction, I certify the following conditions: 1 . ' This is not a title five septic-.sy9tem. / .2. this is a sewage system. • 3. The sewage system is in proper working Oder at the present time. SIGNATURE: Name:-J . P . Macomber Jr.. i Com an J P .Macori ber & Son 'Inc . , Address:--B..,,-g6-------I------- Centerville , Mass__02632 Phone:__-50L8,7 —333 -------8 ' I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesupoole-Leschflelds Pumpsd & In:t'alled Town Sewer Connection: P.O. Box 66 ' Centerville, MA 02632-0066 775-3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs ®apartment of Environmental Protection WIIc3ovrr+a F.Weld Trudy Cox* Aryeo Paul Celluccl sor "r u•Go mrnor Davld B.Struhs s Conunhaiarr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 43 Popponessett Road Cotuit Mass Addressofownen.. 3314 P Street N.yJ. Date of Inspection:7/2 3/9 6 (If different) Washington D. C. Name of Inspector..Joseph P.Macomber Jr. Company Name,Address and Telephone Number. 2007 J. P.Macomber & Son INc. Box 66 Centerville ,Mass . 02632 508-775-33338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: „f�Passes _ Conditionally Passes Needs Further Evaluat' n By the Local Approving Authority Fails Inspector's Signature: `y�rQ.c.fj�y Date: 7 %D_ X The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] 9YST'F�1 PASSES: I ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: ti z� One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes,lno, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or exfiltmtion,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponformiag septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 * FAX(617) 556-1049 a Telephone (617)292.SW C Primed on Recycled Paper r i.J CEItTIFICATION (continued) 43 Popponessett Road Cotuit,Mass . Margaret Tomlinson 7/23/96 f'.1y9L'9 (continued) tu.ckup or breakout or h`;h static water level observed in the distribution box is d,ie to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(o) are replaced obstruction is removed distribution box is levelled or replaced c' The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALukTION 19 ]'F..gZU1RED BY THE BOARD OF HEALTH: 41 Coridif.ior.q c ',i ; ' h rrq+ :m further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the envirorunent. 1) SYSTEM WILL P:'ILs:3 UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A hL`•11•'111'== ".".- ',.':IAL PROTECT THE PUBLIC HEALTII AND SAFETY AND THE ENVIRONMENT: ti jJ l;<.-i,—o! v. .aivy is within .0 feet of a surface water Ij i Cosapool cr privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ` The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. L .o The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The ayitem has a septic tank.and soil absorption system and is within 50 feet of a private water supply well. .. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, urdesr a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm 9) onlFil ,4;'' The system consists of two bloc cesspools and one 31X/F1 grAa9A-trap. This is a split system -ceaspoo in driveway, 1 -grease trap and one block cesspool in the back yard . (revised 11/03/45) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 43 Popponessett Road Cotuit ,Mass . owner. Margaret Tomlinson Date of Inspection: 7/23/9 6 D) SYSTEM FAILS: • I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. 'rho Board of Health should be contacted to determine what will be necessary to correct the failure. 4a Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. 4,�' Discharge or ponding of effluent to the surface of ri,e 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 leas than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped �La Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analysed to be acceptable, attach oopy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large oyatems in addition to the criteria above: a The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment:because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply :J) the system is within 200 feet of a tributary to a surface drinking water supply �t,ij the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system&hall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for fluther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: G3 Popp?ness?tt Road Cotuit,Mass . Owner, argare Tom inson Date of Inspeotlon: 7/2 3/9 6 • Check if the following have been done: ` .4-1pumping information was requested of the owner, occupant, and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A'PAa built plans have been obtained and examined. Note if they are not available with N/A The facility or dwelling was inspected for signs of sewage back-up. -The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. ZAll system components, a luding the.Soil Absorption System, have been located on the site. A-'!_C The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZTb1 size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I'rolx•rty 43 Popponessett Road .Cotuit,Mass . o,. Margaret Tomlinson Uutc or 7/23/96 FLOW CONDITIONS RESIDENTIAL: Design flow:0 gallons c Number of bedrooms: Number of current residents: Garbage grinder(yes or no):A.� Laundry connected to sysm(yes or no): 7t Cam" Seasonal use (frog or no):_� Water meter readings, if available: I g !I �nt`t ? �lT� .X 'S Last duto of occupancy:l/2I COMM ERC IAL/I ND USTRIAI: Type of establishment: Design flow: w2d gallons/day Grease trap present: (yua or no),-f4l Industrial Waste Holding Tank present: (yes or no)__4_4 Non-sanitary waste discharged to the Title 5 ayst.em: (yes or no)4"1 Water meter readirtgv, if avni'.able:__ _ 'n Last date of occupancy: 41 OTHER: (Da:.cril.r) hi�i Last date of i:ccu., - GENERAL INFORMATION PUMPING Ri C;'. '­ce of information System pumped as port of inspection: (yes or no) 9 If yes, volume pumped: A� ¢allons TYPE OF SYST=;... A septic tauk' i triLu;:a,i box/soil absorption system Sir+gis _L Q.urcow ccaspoal ..^ Privy sluuryl/ayct::,n (ye-, :a r.) (if y attach previous,inspection records, if any) otlwt ...l;onents, date irstulled (if known) and source of information: f- \'zo Sewage odory datectud wl,en arriving at the site: (yea or no) (revised 11/03/95) 6 P.C.,DOX ss `-y p�1�Q�Q y 5V161 02 Ua9F1`Gv'4�" v Lynch, John 43 Popponesset . Road Cotuit, Mass . 02635 1/25/79-Pumping-$30.00-1 ._'grease trap-Pd- /jam I i 5 1O1a9/qy 5L , Cl id,d no f . need fo be- pomped �s-. 415W . .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C• SYSTEM INFORMATION (continued) Property Address, / 3 Popponessett Road Cotuit,Mass . Owntr: Margaret Tomlinson Date of Inspection: 7/23/96 SEPTIC TANK:.A�t v_ • (locate on site plan) Depth below grade:_Azj Material of construction:,gr/toncrete _metal _FRP —other(explain) Dimensions: Sludge depth; AJ Distance from top of sludge to bottom of outlet tee or baffle:." Scum thickness:_ A"r� Distance from top of scum to top of outlet tee or baffler_ Distance from bottom of scum to bottom of outlet tee or baffle.. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level in relation to outlet invert, structural eyi ence of leakage, etc.) �'a GREASE TRAP. (locate on site plan) Depth below grade:,5«r-(%`A Material o consinlrtion-,l':oncrete metal FRP j other(explain) Dimensions• 'X Scum thickness:•_ �-.;-jk (".— Distance from top ur scum to top of outlet tee or baffle:_ -1.4C_ Distance from bottom of srum f- bottom of outlet tee or bafUe,:7x_ G. _ Comments: (recommendation for pumping, condi—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, et _^1.(✓.Z� y11/,ir,Uvr (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddres.: 43 Popponessett Road Cotuit,Mass . Owner. Margaret Tomlinson Date of Inipeotion:')'/2 3/9 6 TIGHT OR HOLDING TANK"1V1'E; (locate on site plan) s Depth below grader Material of construction:4-�iconrrete_metal_FRP--other(explain) - A_!A Dimensions:_ Capacity: tid vallons Design flOW: 0n8/day Alarm level: Af Comments: (condition of inlet tee, condition of alarm and float switches, etc.) —d.1A t�/1i�1klf'<S DISTRIBUTION BOX:dj'tL,'C, (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if leve�and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) A Comments: (note condi In of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 43 Popponessett Road Cotuit,Mass . Owner. Margaret Tomlinson Date of Inspeotion: 7/2 3/9 6 ' SOIL ABSORPTION SYSTEM (SAS): (locate on she plan,if po"DAe;excavation not required,but may be approximated by non-intrualve methods) If not determined to be present, explain: e Type: leaching pits,number. leaching chamber/,number leaching galleried,number. leaching trenches, number,length: Q leaching fields,number,dimensions overflow cesspool, number: Comz�ents: to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetatlon,etc.), J CESSPOOLS: (locate on site plan) Number and configuration: I DePth-top of liquid to inlet invert: Depth of solids layer. ' Depth of scum layer, Dimensions of cesspool: .1�) I Y , Materials of construction: Indication of groundwater: 4 r'A (. inflow(oesapool must be pumped as part of inspection) d//•V Comments: (note condition of soil,s of lydraulic failure Is el of Pon ' n. do ) Medium to fine sans -No signs of '�lydrau�ic 'ai° ue o' ponding; Al ve e a ion s norma . PRIVY: ,l 6 l (locate on site plan) Materials of construction: A ! Dimensions:Depth of solids: II;'i) ` . Comments: (pots condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION •FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L :SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100 ' Cotuit Water Company 428-2687 -- --- .L'�. - r c j 1 DEPTH TO GROUNDWATER 241 + depth to groundwater - - method o.f determination or approximati•on: i alley ` , .s.te�ms..-at�211F. 2.59 T.g whter .ej(o`untered at . 121 All property on •h round - ' - SbIV 3r�1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTIO BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. June 8. 1995 Acting Director of4the ' of Water Pollution Contr i •nr.nr+-rtr—.-rT -'^r-.—•rr-rr_-rr..r...r-.r.-:mersrr:-rr-a..-irsi..is*rrmrnR- .. _ -. **Trr,'c**=trn-rrr-r-^r-`- �- TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �/ F.•••�.•,.T••.••.. —�.tl�-'.�T.T�1•R:TITtr.�[T. TRTT1`T—t•iT{VTR't'RRTI�TTTfT'wlCl'�/nrMAHlTrR71 nnnn++mmm.nn�rn.�r�n•mrrr-•r-•-., -TYPE OR PRINT CI.EARLY'- PROPERTY INSPECTED STREET ADDRESS /L3 Popponessett Road Cotuit,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME MsgrgAret. TAml i nson PART D - CERTIFICATION I NAME OF INSPECTOR Tnseph P_ Macomber Jr. . COMPANY NAME J. P.Macomber & Son In,5. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 _ 3338 RAX ( 508 ) 790 - 1 578 CEwri FICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : XXXXXXXXX System PASSED The inspection which I have conducted has not found any information which indicates that the syste►n fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , '3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . �/ Inspector Signature 1 i Y /i(// Date _ 8/2/96 One copy of this certification must be provided to the OWNER, the BUYER( where applicable ) and the DOARD OF 11RAL1'll. * If the inspection FAILED, the owner or"operator shall u within one year of the date of the inspection , unless allowed dortrequi.redm otherwise as provided in 310 CMR 15 , 305 , partd .doc DATE: . 7/30/96 - PROPERTY ADDRESS: P;; r�o �F�ss�tt Road Gotuit,Mass . Cotui t ,.Mass . "y ,y 2, On the above date, I Inspected the s 'tic system at the above address.I This system consists of the following. 1 . ..1 •-3 ' x4' block grease tra r) . 2 . 1 -61x8l block cesspool_ 3 . 1 -61x6 ' block cesspool , Based on my InKnectlon, I certify the following conditions: 1 . This is not a tl.tle .Dep"'-.c system . / 2 . this i s a sewage syst:;•!, . 3 . The sewage system _,_ ._r =, r working oiler at t}7e present t1irip, SIGNATUR7: Name :_J_P . M Ic-_) ber Jr' - -- - - - - Company:_J • P ,1H�.1:Oi ber & Son Inc Address: _-o-x-") -- Centervi.11.eLhlas.s02632 Phone:---5p1 '..7.ZL _��38 --- -- - THIS CERT1F1C.',Y" " DOES NOT CONSTITUTE A GUARANTY OR WARRANTY I R4 r:'�' 'Z.FPH P. MACOMBER & SON, INC. Txinki•Cestpools Le:chflelds Purnpad InstYII6d Town Sewer Connections P.O. Do.. 56 ' Centerville, MA 02632-0066 775-3338 775-6412 Commonweafth of Massachusetts Executive Office of Environmental Affairs epartment of Environmental Protection William F.Weld Trudy Cox* Gawrnor Aryeo Paul Ceiluocl David B.Struhs LL Gowrnor Cornmfs�r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddresa: 43 Popponessett Road Cotuit Mass AddreasofOwner 3314 P Street N.y . Date of Inspection:7/2 3/9 6 (if different) Washington D. C. Name of Inspector.Joseph P.Macomber Jr. Company Name,Address and Telephone Number. 2007 J.P.Macomber & Son INc . Box 66 Centerville ,Mass . 02632 508-775-33338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the.proper function and maintenance of on-site sewage disposal systems. The system: /Passes _ Conditionally Passes _ _ Needs Further Evaluat' n By the Local Approving Authority _ Fails Inspector's Signature: �. / Date: i� t The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYS TIEM PASSES: I have not found anyinfor mation rmation which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.$03. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: AOne or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Wlnter Street a Boston,Massachusetts 02108 a FAX(617) 556-1049 a Telephone(617)292-55W C� Printed on R"Ied Paper A CEl(TIFICATION (uontinued) 43 Popponessett Road Cotuit,Mass . Margaret Tomlinson 7/23/96 �::oe tr.ckuY or breakout or high static water level observed in the distribution box is d.,e to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system requirad pumping wore than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION Is REQUIRED 11Y THE HOARD OF HEALTH: _ 4L1i re!L:.'^ fist?cr eva.lu.t.ion by the Board of Health in order to determine if the system is failing to protect the public health, safety and the envirorsnent. 1) SYSTE:ii ';'i:,L PAL-3 UNLESS BO UlD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A I'I:CTECT THE PUBLIC IIEALTII AND SAFETY XND THE EWIRONME". Q. .,rivy in within t 0 ft:et of a surface water _42f) Cesspool cr privy is within 50 Net of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: &LV The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The syatem has a septic tank and soil absorption system and is within a Zone I of a public water supply well. n The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unle." a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER The system consists of two bloc. cesspools and one txL� ► grease trap, This is a split system -cesspoo in driveway, 1 -grease trap and one block cesspool in the back yard. (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 43 Popponessett Road Cotuit,Mass . Owner: Margaret Tomlinson Date of Inspection: 7/2 3/9 6 D) SYSTEM FAILS: • _fI I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. A& Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of Uie 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: A4 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment.because one or more of the following conditions exist: 40 the system is within 400 foet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply till the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/11) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddr•em 43 Popponessett Road Cotuit,Mass . Owner. Margaret Tomlinson 'l Date of Inspeotion: 7/2 3/9 6 • Check if the following have been done: ` ,Pumping information was requested of the owner, occupaut,and Board of Health. Zone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Al2U built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for sigma of breakout. _All system components,444cluding the Soil Absorption System, have been located on the site. /✓VC-The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. zThe sue and location of the Soil Absorption System on the site Y has been determined based on existing information or prozimated by non-intrusive methods. _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pruparty ';:.. . 43 Popponessett Road Cotuit,Mass . OU-11er: Margaret Tomlinson ' Date of 7/23/96 FLOW CONDITIONS RESIDENTIAL• Design flow:-0_,�allons o Number of bedrooms: Number of current residents:Q Garbage grinder(yes or no):&6 `l Laundry connected to, n(yes or no): 7�C� Seasonal use (yes or no): 'M Water meter readings, if available: 19 9r d?,ode) w r►.. D Last date of occupancy:u-y•e�. COMMERCIAL/I N'DUSTRIAL: Type of establiahmeat: Design flow: wy� gallon/day Grease trap present: (yea or no)-Ae�Q Industrial Waste Holding Tank present: (yes or no)_444 Non-sanitary waste discharged to the Title 5 system: (yes or no)All Water meter read np, if available:__ AV Last date of occupancy: *1 OTHEM (Descrit.a) Last date of ....A.0 GENERAL INFORMATION PUMPING REC Iz' '. ume cf information: ZL 50 1 System pumped as part of inspection: (yes or no) �'� It yes,volume pumpcxi: 4W gallons Reason fcr oe_nhi TYPE OF SYST""i,' ' _ Septic taiWdiAribuUua box/soil absorption system Single oau .ol .Overflow ccwspogl gz'o_ Privy i SharcJ syttosn (YW or no) (if y attach previous inspection records,�f any) f SP i�iQ✓✓ �i+ �iC'eldS �1 i91/Q/ /� /. J'� Lo �ti T� APPRO)UMA._._. _..: ...._ ,...:.loneuts, date ir:stulled(if• own) and source of information: Sewage odors datected when arriving at the site: (yes or no) (revised 11/03/95) 6 JOSMRNWONBM&Box,Imam P.P�®��.p-B�I�O1X 66 q pp �y��pp Na.'1bS�dSt�Siiye�AMA 026E UM i Lynch John 3 .Popponesset. Road._.. . Cotuit, _M4ss._._02635 - ---- _. -------_ . - - ----------. - -- --- 1/25/79-Pumping-$30.00,7 1 .,.__.,grease_- trap_ 0 - � -�2)m G% �.0. ._....... - ivla9/ y_-..__5�,.- 1:c1_no-f -n -�►- - b --PUmpecP_-��-- !�/S1 W.---- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. • - SYSTEM INFORMATION (continued) Property Address: 43 Popponessett Road Cotuit,Mass . 1 Ownttrr: Margaret Tomlinson Date of Inspection: 7/23/96 SEPTIC TANK: (locate on site plan) Depth below grade:_419 Material of construction:/concrete _metal _FRP —other(explain) Dimensions: Sludge depth: ' Al Distance from top of sludge to bottom of outlet tee or baffle:,&*_ Scum thickness:_ Distance from top of scum to top of outlet tee or baKle:__&t _ Distance from bottom of scum to bottom of outlet tee or baffle._ Aa Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level in relation to outlet invert, structural evi ence of leakage, etc.) . . r GREASE TRAP. (locate on site plan) Depth below grade:,Jumr-,�K'v au've Material o constninion;Y'oncrete _metal _FRP other(explain) � y� 9 , Dimensions• iX Scum thickness:', Distance from top of scum to top of outlet tee or baffle: l ei Distance from bottom nt crurn to bonnet of outlet tee or 6(le;. Comments: (recommendation for pumping, condil—rl o;! inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc�/��lrlf,0 d&e2,i-6 22iw r:... • s„, (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 43 Popponessett Road Cotuit,Mass . Owner. Margaret Tomlinson , Date of Inspection:']/23/9 6 TIGHT OR HOLDING TANK"e, (locate on site plan) Depth below grade:La Material of construction:. concrete_metal_FRP—other(explain) - Dimensions: Capacity: t/!f gallons Design flow: gallons/day Alarm level: Comments: (condition of��•nlet tee,condition of alarm and float switches, etc.) W4 C'e.s��r7 Q�r�TS DISTRIBUTION BOX APVe, (locate on site plan) Depth of liquid level above outlet invert; Comments: (note if lees and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:Ai�VQ_ (locate on site plan) Pumps in working orOer:(yes or no) Comments: (note condi ' n of pump chamber;condition of pumps and appurtenances,etc.) i D (revised 11/03/95) ,:,,f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontlnuod) Prop,ertyAddresx 43 Popponessett Road Cotuit,Mass .. Owner. Margaret Tomlinson , Date of Iniprootlon: 7/2 3/9 6. i SOIL ABSORPTION SYSTEM(SAS)'-Z (locate on site plan,if possible;szcavation not required,but may be approximated by non•intrusive methods) If not determined to be present,explain: e Type: leaching pits,number..], . leaching chambers,number. 1 leaching galleries,number._0 leaching trenches,number,length: t7 leaching fields,number, ns — overilow cesspool,cumber Comments: to condition of so' signs of hydraulic failure,level of ponding,condition of vegetation,etc.) I'm ki4441) CESSPOOLS: (locate on site plan) I� Number and configuration: l Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Materials of construction: -& Indication of groundwater: BUG'&,,,C inflow(oeaspool must be pumped as part of inspection) Comments:(note condition of soil, of hydraulic failure ls el of Medium to fine sans sr.-No signs o '�ydr�au�ic' 'ai1uvef ont p)onding; A vee a ion is normal. PRIVY: (locate oil site plan) 1 Materials of construction:— Depth of so": Commentsi condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART B SYSTEM INFORMATION continued SKETCH -OF 'SEWAGE L :SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100 ' Cotuit Water Company 428-2687 i 1 DEPTH TO GROUNDWATER 241 + depth-to---groundwater ---- Mthod of determinesion or approximation: w _..�, , testa: l.le ':;systems::a "21.18cr 2�9 :fox utteF encountered at 121 All property on hh ground a r J ' THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' ' 'ion of Water Pollution Control 1 ' Y T:T:1'{rlrrti'f4TT�STirTJI'+I'rrifRrtCTT:itT.riT.T:•.TT:4frlTrRtr'IRr1 t.i lttiTrt'RrLT.rs'frt T7r•.TT�.T1'Rm�..�.T••} TOWN OF Barnstable BOARD OF HEALTH \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `/' h•••rrt-r••.-::T--err.^.ern:nrm•rt:rsnrnrss+rr+rnn'.-ti+-svrm•rarnmr-rn+mR.enrns+vmnsss-mew esmn+*err•ins+v+*r.err•nnv+-rrrr�•sr•�r+r•� —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS _Z.3 Pobnonessett Road Cotuit,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Margarat. T64mlin4on —o PART' D - CERTIFICATION Y NAME OF INSPECTOR Tnsp h P_ Macomber -Jr. COMPANY NAME J.P.Macomber & Son Int94. ' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Tows, or City State LIP COMPANY TELEPHONE ( 508 I 775 _ 3338 RAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time (.,inspection . The inspection was performed . and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXXXXXXXX System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or tfle environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to . protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 8 2 6 % One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the- inspection FAILED, the owner or�`O`perator shall upgrade ' the system. within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 . ChIR 16 , 305 ,