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Home My WebLink About0276 POPONESSETT ROAD - Health I� 276 Pop onesse �� r Cotuit \ A= 019-062 1 / 1 / 1 DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sign item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse ddressee so that we can return the card to you. B. Received by(PAf Name) Dat of Delivery ■ Attach this card to the back of the mailpiece, { or on the front if space permits. JZ& D. Is delivery address r fere t from it ❑Yes 1.,Article Addressed to: If YES,enter delivery address below: ❑No Ellen F. Mycock PO Box 955 Cotuit, MA 02635 CJ'G, pews- 3. Service Type 0(dertified Mail ❑Express Mail �U ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number — (Transfer from service label) 7 015.`17 3 0 000114990 4827 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-Z UNITED STATES1P,@9TXt 8i— ai •E First-Class Mail `'°� i Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • 1 r Town of Barnstable I pu..hlic..Health Division C200 Main Street Hyannis, MA 02601 I - � I Fj��'�!!i!�Filli�r�'1 rl lull Fr Fiar F�.f!i:•?!j:?�J r/�Fi`i ii rl�?lr I f%- e. e ru Q' Certified Mail Fee Er $ C7 M Extra Services&Fees(check box,add fee as appropriate) /,� ` 0 ❑Return Receipt(hardcopy) $ r3 ❑Return Receipt(electronic) $ />� Postmark c 0 ❑Certified Mail Restricted Delivery $ •, - p []Adult Signature Required $ []Adult Signature Restricted Delivery$ o Postage 73 m $ � Total Postage and Fees { Ln Sent To' Ellen F. Mycock Sfreef e �. . PO Box 955 �iry'Sri Cotuit, MA 02635 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail labe for an electronic return receipt,see a retail m A unique identifier for your mailpiece.s L associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this. delivery. USPS®-postmarked Certified Mail receipt to the 4 ■A record of delivery(including the recipients retail associate. —� signature)that is retained by the Postal Service- Restricted delivery service,which provides •T for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent. Important Reminders. Adult signature service,Which requires the ;, ■You may purchase Certified Mail service with signee to be at least 21 years of age(not — First-Class Mail®,First-Class Package Se,ices, '-available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavallable for requires the signee to be at least 21 years of age, international mail. and provides delivery to the addressee specified ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent With Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is .Insurance coverage automatically included with accepted as legal proof of mailing,R should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on f ■For an additional fee,and with a proper this Certified Mail receipt,please present your —1 endorsement on the mailpiece,you may request Certified Mail item at a Post Office—for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion w of delivery(including the recipients signature). of this label,affix it to the mailpiece,apply -. You can request a hardcepy return receipt or an appropriate postage,and deposit the mailpiece.r,_(— electronic version.For a hardcepy return receipt, complete PS Form 3811,Domestic Return Receipt attach PS Form 3811 to your mailplece; IMPOKAN7:Saxe this recelpt for your records. Ps Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: (��J key to move your cursor-do not Sean M. Jones use the return Name of Inspector ` key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 ; Cityfrown State Zip Code 774-248-4850 smjonestitle5@gmaii.com S14522 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 a 8/23/2014' Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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: s ace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is Cotuit Ma 02635 8/23/2014 required for every page. CitylTown 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: The dwelling located at 276 Popponesset Rd Cotuit is served by a septic system consisting of a cesspool with a cesspool overflow. The system was found to be in proper working condition at the time of inspection. 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): r , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is Cotuit Ma - 02635 8/23/2014 required for every 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 ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 page. Cityrown 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: R *"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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the°surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 '/2 day flow t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is Cotuit Ma 02635 8/23/2014 required for every page. Cityrrown 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. J ❑ ® 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- 1 0,000g pd. . I ❑ ® 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-3113 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 GSM 5 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 page. Cityrrown 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? El ® Have large volumes of water been introduce_d 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): Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3113 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 '( 276 Popponesset Rd Property Address Steve Maderios Owner Owners Name information is required for every Cotuit Ma 02635 8/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage(gpd)): Detail: 2012= 13,000 total = 36 gpd 2013 = 9,000 total=25 gpd Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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-3113 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 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 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: Was system pumped as part of the inspection? ❑ Yes ®< No If yes, volume pumped: galfons- How was quantity pumped determined? Reason for pumping: Type of System ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ®, Overflow cesspool ❑ Privy .t ❑ 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 Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system 1950 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is Cotuit Ma 02635 8/23/2014' required for every page. Citylrown 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 scum of to to of outlet tee or baffle P Distance from bottom of scum to bottom of outlet tee or baffle f Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 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 . t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 276 Popponesset Rd Property Address j Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 page. Cityfrown 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 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.): 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: F . ' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owners Name information is required for every Cotuit Ma 02635 8/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): overflow cesspool was video inspected and was found to be dry with no signs of past hydraulic overloading. Cesspool was structurally sound. Cesspools (cesspool must be pumped as part'of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert dry Y Depth of solids layer Depth of scum layer Dimensions of cesspool 6'x9' Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t r Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is Cotuit Ma 02635 8/23/2014 required for every 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.): Cesspool was dry at time of inspection. cesspool was structurally sound, blocks were solid. Pipe to overflow was video inspected and found to be in good condition. Outlet tee was.intact. 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-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 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 A.2 f t5ins•3113 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 276 Popponesset Rd Property Address Steve Maderios Owner Owner's Name information is required for every Cotuit Ma 02635 8/23/2014 page. CityrFown 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: 12'+ feet ee Please indicate all methods used to determine the high groundwater elevation:, ❑ Obtained from system design plans on'record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•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 276 Popponesset Rd Property Address Steve Maderios ' Owner Owner's Name information is required for every Cotuit Ma 02635 .8/23/2014 page. Cityrfown 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 r I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION - SEWAGE PERMIT NO Y I�jl LEA G E /J INS L L E R I S NAME Z ADDRESS Lg� /(�, , 2&, It U,I.L D E OR OWN R J DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� -.- --�r N Y� 1 ^l' � v ��