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HomeMy WebLinkAbout0096 PRUDENCE LANE - Health 96 PRUDENCE LANE, COTUIT A= 040 049 I • � Commonwealth of Massachusetts ' • - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 1 of 2) Property Address _ Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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. A. General Information is 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr = Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number Certification •x �ilcertify that I have personally inspected the sewage disposal system at this address and that the «� Liinformation 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 g Title 5 (3"1q0,'CMR 15.000).The system:' Zz C . ® Passes ❑ Conditionally Passes ❑ _Fails ❑ Needs Further Eval ation by the Local Approving Authority l 10-31-12 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit - MA 02635 10-31-12 page. City/Town State Zip Code Date of Inspection B. Certification (cons) ; y 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: System is in good working order with no sign of failure. 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): - w t5ins-11/10 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments;, 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 , - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ; 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 El",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 16.303(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 r ❑ - Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City(rown 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. > -.r D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No Elr ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 t Commonwealth of Massachusetts r 'R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments,, r , 96 Prudence Ln (System 1 of 2) - Property Address r.. Karen Moksvold Owner Owner's Name r- information is required for every Cotuit:. MA 02635 10-31-121%, page. City/Town„ A State ,Zip Code Date of Inspection r B. Certification (cost.) Yes No . . ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: a ❑ ® - Any portion of the SAS, cesspool or privy is below high ground water elevation. Y,.. ,fir.: •.r. •. 1t r :,1�•. i 1L r t .1 „w, ❑ ® 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. El ® 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 y and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd.• The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303,therefore the system fails. The - system owner,should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system-the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. r ' 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 r , 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"Jo any question in Section E the system•is considered a significant threat,- F 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 r regional office of the Department. t5ins•-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City/Town State Zip Code Date of Inspection C. Checklist t 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) ® ,E] Was the facility or dwelling inspected for signs of sewage back up? ® ❑ -.' Was the site inspected for signs of breakout? ® '❑ 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? 7 Was the facility owner(and occupants if different from owner) provided with ® ,El' 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: - a ® ❑ 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): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x,#of bedrooms): 660 t5ins•11110 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; 96 Prudence Ln (System 1 of 2) Property Address v , Karen Moksvold • Owner Owner's Name , information is required for every Cotuit t MA 02635 >. 10-31-12 page. City/Town _ 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes E No Seasonal use? r ,. ❑-Yes ® No Water meter readings, if available (last 2 years usage (gpd)):t , Detail: • • Sump pump? "4 Yes ® No Last date of occupancy: 10-2012 „ Date Commercial/Industrial Flow Conditions: -....- Type of Establishment: Design flow(based on 310 CMR 15.203): `canons per day(gpd) Basis of design flow(seats/pe`rsons/sq.ft., etc.): Grease trap presents ❑-' Yes ❑ No Industrial waste holding tank present? El Yes, ❑ No , Non-sanitary waste discharged to the Title 5 system? ❑. Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System-Page 7 of 17 . A I Commonwealth of Massachusetts ` Title 5 Official Inspection form' " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments', " 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit _ MA •,02635 10-31-12' page. City/Town' State Zip Code Date of Inspection D. System Information (cont.) F Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: p g Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy r ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official. Inspection Form. ;,t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 1 of 2) q Property Address - Karen Moksvold ; Owner Owner's Name , information is it MA 02635 t Cou 10-31-12 required for every � 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 i6formation: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3. Depth below grade: a - 48" feet Material of construction: ❑ cast iron k.® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: : . feet Comments (oncondition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate;on site plan): �. •Depth below grade: R 4011 feet Material of construction: ® concrete ❑ metal. ❑ fiberglass .❑ polyethylene- ❑ other(explain) , , V If tank is metal, list age: years Is age confirmed by.a Certificate of Compliance? (attach as copy of certificate) ❑',Yes ❑ No Dimensions: 1000,gal + • Sludge depth: 12' t5ins•11t10„ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form-Not for.Voluntary Assessments 96 Prudence Ln (System 1 of 2) Property Address t „ Karen Moksvold f Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 2011 Distance from top of sludge to bottom of outlet tee or baffle- Scum thickness = i. 1 Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 1611 How were dimensions determined? Tape 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 is in'good condition with baffles installed and no sign of leakage. t Grease Trap (locate on site plan): Depth below grade: feet . r ' Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explainj: t Dimensions: Scum thickness - f 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection ForMr . Subsurface Sewage Disposal System,Form -Not for.Voluntary Assessments - 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold ; Owner Owner's Name information is r ;r required for every Cotuit, MA 02635 10-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,-etc.):' Tight or Holding Tank (tank must be pumped of time of inspection) (locate on site plan): ' Depth below grade: . Material of construction: ' w ❑ concrete. ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): r 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•11/10, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 P 9 Commonwealth of Massachusetts Title 5 Official Inspection Form,.p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 1 of 2) =F Y Property Address Karen Moksvold ' Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site'plan): .4 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. : Good condition with water at working level and no sign of back-up. , Pump Chamber(locate on site plan): Pumps in working order: u ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 l Commonwealth of Massachusetts Title 5 Official 'I nspection form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments 96 Prudence Ln (System 1 of 2) + ; Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 - page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ 'leaching galleries number: - ❑ leaching trenches number, length: r ❑ 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 d vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 36" below inlet invert. 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•11110. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17" Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' . 96 Prudence Ln (System 1 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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.): t5ins-11/10 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 96 Prudence Ln (System 1 of 2) i Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) v 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 K IT-K- 36' 4 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 iL i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments 96 Prudence Ln (System 1 of 2) f Property Address Karen Moksvold Owner Owner's Name information is Cotuit MA 02635 10-31-12 - required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' Site Exam: ❑ Check Slope . ❑ Surface water a ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 1 of 2) - Property Address Karen Moksvold i Owner Owner's Name information is required for every Cotuit, MA 02635 10-31-12 - page. City/Town State Zip Code` •> Date of Inspection E. Report Completeness Checklist - ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file. 7 - t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 ` / °`' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments °( 96 Prudence Ln (System 2 of 2) � 555 Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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. A. General Information 1. Inspector: Shawn Mcelroy ' Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr , Company Address E. Falmouth MA 02536' City/Town State Zip Code 1-508-495-0905 S13971' Telephone Number License Number B. Certification p I ekertify that I have personally inspected the sewage disposal system at this address and that the formation reported below is true, accurate and complete as of the time of the inspection.The inspection was perfoNmed based on my training and experience in the proper function and maintenance of on site 1-sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3�Oyw�CMR 15.000).The system: ' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev luation by the Local.Approving Authority ,,• . , 10-31-12 a 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts ' Title 5, Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Svey`mv 96 Prudence Ln (System 2 of 2) ` `•`' Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City/Town 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: ` System is in good working order with no sign of failure. 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): , t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts A Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 2 of 2) , Property Address Karen Moksvold - Owner Owner's Name information is required for every Cotult MA - 02635 10-31-12 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) ' 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 r ❑ 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 31.6 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold ` Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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 aseptic 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.,. 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 '/z day flow 7 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts vvTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form,-,Not for Voluntary Assessments 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold Owner Owner's Name. _ information is required for every Cotuit t MA 02635 10-31-12. page. '-City/Town , : _ State Zip Code Date of Inspection B. Certification (cont.) F 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. E Any portion of a cesspool.or privy is within 50 feet.of a private water supply well. �.f ® 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 .. k •,. ;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..) 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 Y. necessary to correct the'failure; t 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. fi p.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 Ell" ❑ '° Area—IWPA) or a mapped Zone ll 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System t Page 5 of 17; Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold { Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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? 411 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'ihe,Board of Health. ® El approximation 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 Flown Conditions: Number of bedrooms (design): r 6 . Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 rq ` `,` t5ins•11/10 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 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold , Owner, Owner's Name information is required for every Cotuit MA 02635 10-31-12 `:, page. City/Town State Zip Code Date of Inspection D.System Information C. Description: Number of current residents: 0 Does residence have a,garbage grinder? ❑ Yes ® No Is laundry on a se arate.sewage system? [if yes separate inspection required]] El Yes ® No , Laundry system inspected? A - : ��.k ❑ Yes ® No - Seasonal use? {- ❑' Yes ® No Water meter readings, if available (last 2 years usage (gpd)): �, b Detail: " ., - ° . •.a}•'. fit, ^ Sump pump? t ❑ Yes ® No 10-2012 Last date of occupancy: °. ., c :-.t 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 R Industrial.waste holdingitank present? „ ,, ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? •' ❑ Yes ❑ No Water.meter readings, if available: t5ins-11110 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 ,M 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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: N/A Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason,for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool - r f 1, ' ❑ Overflow cesspool a • ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 F Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 96 Prudence Ln (System 2 of 2) - Property Address Karen Moksvold Owner Owner's Name information is Cotuit MA 02635 10-31-12 . required for every 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: 1995 Were sewage odors detected'when arriving at the site? - ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12°, - 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.): . Good condition. , Septic Tank(locate on site plan): Depth below grade: ` • feet Material of construction: t ,. ® concrete ❑ metal ❑.fib'erglass, ❑ polyethylene• ❑ other(explain) If tank is metal, list age: years Is age confirmed by Certificate of Compliance? (attach,a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 12@1 Sludge depth: r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.). Distance from top of sludge to bottom of outlet tee or baffle 2011 . Scum thickness 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? ^Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: g r;• 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: .r Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts I� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form :Not for Voluntary,Assessments 96 Prudence Ln (System 2 of 2) ,w Property Address Karen Moksvold Owner Owner's Name information is required for every COtult, MA 02635 10-31-12 i .. s°';° page. City/Town State Zip Code Date of Inspection ' D. System Information'(cont.) w 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 of time of.inspection) (locate on site plan): Depth below grade: f 1 Material of construction: ❑ concrete .❑ metal;. ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: a gallons, ' Design Flow: gallons per day Alarm present: ,. ❑ Yes ❑,_No Alarm level: Alarm in working order:, ,. ❑ Yes ❑ No Date of last pumping: r Date Comments.(condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 ,. 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 96 Prudence Ln (System 2 of 2) E Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) .f 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,aany evidence of solids carryover, any evidence of leakage into or out of box, etc.): 11 Good condition with water at working level and no sign of back-up. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: , ' .. •of t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Prudence Ln (System 2 of 2) k 4 ..,t Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit t MA 02635 10-31-12, page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® " leaching chambers number: 3-330 f t Rechargers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number; dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: , Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers in good condition with no sign of back-up into d-box or surrounding stone. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts { v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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.): t �I t5ins-11/10 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 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold Owner Owner's Name information required for every ormation is Cotuit - MA 02635 10-31-12 page. City/Town 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 to ja - J J 6ri A r .�o��p e r`- 31 _ _ '2 x-, : PC K- 73' 13-K- 3�• t5ins-11/10 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 96 Prudence Ln (System 2 of 2) Property Address Karen Moksvold Owner Owner's Name information is required for every Cotuit MA 02635 10-31-12 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: 20 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: USGS and town maps show groundwater at greater than 20'. . Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 Prudence Ln (System 2 of 2) - Property Address , Karen Moksvold Owner Owner's Name information is r equired for every Cotuit MA 02635 10-31-12 _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary': A, B, C,'D, or E checked ® Inspection Summary,D (System Failure.Criteria Applicable to All Systems)'completed ® System information-Estimated depth to high groundwater ~.t ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f ' AIL, hid. } ..• F , . - _ � , - _ f r • 1. y - tiims•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 E ,PROPERTY ADDRESS:_ 96 Prudence Lane Cotuit,Mass . .© ------------------------ 026 N0� ------35---------------- � 9 1996 On the above date, I inspected the septic system at the above addt This system consists of the following: I_1688 a��oon an ehtsi eerear. S 3. 1-1000 gallon tank. Front yard. 4. 1-1000 gallon leaching pit. Front yard. 0 Based on my inspection, I certify the following conditions: 1 . 1500 gallon tank is a holding tank. No leaching facility. Must be one. 2. 1 -1000 gallon tank left rear is a holiding tank. No leaching facility Must be one . 3. 1 -1000 gallon tank and 1 -1000 gallon -leaching pit in the front yard. This is atitle five septic system. This system is in failure and must be upgraded with a leaching trench. 4. Distribution box must also be installed. SIGNATURE:— Name:_p5_eph_p, Macomber Jr. _ Company:J_P_Macomber_&_Son INc. Address: Box 66 — ------------- k 6 _ Centerville ,Mass__02632 PAM ta.,.,` Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-teachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 .775.3338 775-6412 ,f Al t • � i c r ♦ - . r y Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld e aowmu • Trudy Coxe �' Srcr�luy,60EA David S.struhs conwwwonsr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 96 Prudence Lane Cotuit,Mass . Address of Owner: Date of Inspection:) 1 /2 0/9 5 (If different) Name of Inspector: Joseph P. Macomber Jr. Company Name, Address and Telephone Number: 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 Evaluation By the Local Approving Authority -IC Fails _ Inspector's Signature: Date: 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: AJ SYSTEM PASSES: Ak I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired, The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or 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 6/i5/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 96 Prudence Lane Cotuit,Mass . Owner: Edwin J. PIna Jr. Date of Inspectional 1 /2 0/9 5 BI SYSTEM CONDITIONALLY PASSES (continued) 44 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 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 CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: VO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A& Cesspool or privy is within 50 feet of a surface water Q/f/ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF. HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIROkMENT: The system nds a septic tdok inu wii dbsurptiun systen', ar.ii li v,'thln 100 feet tG a surfacc Suppl)'G.uiuuta j tG a surface water supply. AD The system has a septic tank and sbil absorption system and is within a Zone I of a public water supply well. AD The system has a septic tank and soil absorption system and.is within 50 feet of a private water supply well. &0 The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform 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. DI SYSTEM FAILS: Ye—4 1 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. Board Of Health Has Ben Contacted. d2 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Q� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15195) 2 U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property.Address: 96Prudence Lane Cotuit,Mass. Owner: f&i_ In 'J.` P i7na Jr. . Date of Inspection.11 /2 0/9 5 • D)SYSTEM FAILS (continued): • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS.or cesspool. �,BncR tP�� Liquid depth in cesspool Is less than 6" below invert or available volume is less than 1/2 day Clow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped jo Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. AM Any portion of a cesspool or privy is within a Zone I of.a public well. NA Any portion of a cesspool or privy is within SO feet of a private water supply well. 6lA Any portion of a cesspool or privy-is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: PJAI The design flow of system is 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 the system is within 200 feet of a tributary to a surface drinking water supply 6W 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ropertyAddress: 96 Prudence Lane .Cotuit;Mass caner: Edwin J. Pina Jr. . . ate of Inspection: 1 1 /2 0/9 5 heck if the following have been done: ipumping information was requested of the owner, occupant, and Board of Health. d�Yy None of the system components have been pumped for at least two weeks and the system has been regeiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 2As 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 IThe site was inspected for signs of breakout. i 2AII system components,okluding the Soil Absorption System, have been located on the site. 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. IThe 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 ov;ner land occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. Recommendations . 1 . Leaching trench must be installed off 1000 gallon tank in rear left. 2. Leaching trench must be installed off 1500 gallon tank.Rightside 3. Leaching trench must be installed on the front system. 4. Distribution box must be installed in front system. 5. System is in failure. '(revised 8/is/95) 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 96 Prudence Lane Cotuit,Mass . Owner: (Edwin ,uJ s,�Rina Jr. Date of Inspection: 1 1 /2 0/9 5 FLOW CONDITIONS RESIDENTIAL: Design flow.•bP-Q gallons perd�9Y Number of bedrooms: ✓" Number of current residents:CL Garbage grinder(yes or no):,D J Laundry connected to system (yes or no): 51 Seasonal use (yes or no):P Water meter readings, if available: Last date of occupancy:,(_ COMMERCIAUINDUSTRIAL: Type of establishment: 91� Design flow:IJA aallons/day Grease trap present: (yes or no).W Industrial Waste Holding Tank present: (yes or no)j* n-sanitary waste discharged to the Title S system: (yes or no)1� ,,,,ater meter readings, if available: Al Last date of occupancy: OTHER: (Describe) A Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)rfh� If yes, volume pumped. 0 gallons Reason for pumping: TYPE 9F SYSTEM _V_ Septic tank/riistcitluticA-taax/soil absorption system ,ft_ Single cesspool A)b_ Overflow cesspool Privy —�j Shared system (yes or no) (if yes, attach previous inspection records, if any) --IL Other(explain) 1 -1000 aallon 1-1 00 . APPROXIMATE AGE of all components, date installed (if known) and source of information: anry # 77-329 See pace 6A rage odors detected when arriving at the site: (yes or no)_ (revised 8/15/95) 5 JJ + Tr Pit- -plwo1AA1Ce �_ 7 3 ' J;G��Ir14 .4c%s a 14 I� , (7D SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 96 Prudence Lane Cotuit,Mass . Owner: Edwin (J:hrPirna Jr. Date of Inspection: 11 /20/9 5 SEPTIC TANK: ���/�� 1.15dO 10TWO (locate on site plan) `r Depth below grade: Material of construction: concrete metal FR other(explain) t oe- 2 $� „ Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle_:_0 Scum thickness: B Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relati n o tlet invert structu I integrity, evidence of leakage, etc.) um se tic tanks ever 2-3 years . �nTe`T teen on `folding tanks must be chartW. BroughtTO the let en of tanks not the mi e , Septic an s s run ura y soundo e ea a e . Hoilng tanks must have eac 1ng act i ies Insucall VIMIL11 systt',ILI also must have a ieaching facility installed. GREASE TRAP: (locate on site plan) Depth below grader Material of construction/tl�concrete _metal _FRP —other(explain) AM Dimensions: Va Scum thickness: Distance from top of scum to top of outlet tee or baffle:& Distance from bottom ni Srom t- bottom of outlet tee or baftle:Ala_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) A)OAk (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Prudence Lane Cotuit,Mass . Owner: Edw•'n, '(Pina Jr. Date of Inspection: 11 /20�9 5 _ e TIGHT OR HOLDING TANK: r (locate on site plan) Depth below grade:" Material of construction: ]-fconcrete_metal _FRP—other(explain) .. W! 1(r Dimensions: Xbo ��l tr�Na vr ��l�eCfi y��d`�l,11►C1�±, Capacity: V6D a gallons Design flow: gallons/day Alarm level: Altlye Comments: (condition of inlet tee, condit�pn of alarm and float switches, etc.) Inlet tees must %oved. Tees must come into the inlet end of the tanks not t.hP mi ddl P _ T,Pnc hi ng ili�ies must be added too both holding tanks . w No alarm or float sitc es in tanks . DISTRIBUTION BOX:d (locate on site plan) Depth of liquid level above outlet invert: AJh Comments: (note ii level and distributwi. +3 equa!, evidence of so!ids carryover, evidence of leakage into or out of box, etc.) AkAIP— PUMP CHAMBER:&& (locate on site plan) Pumps in working order:(yes or no)A Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/i5/9s) 7 i SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:96 Prudence Lane Cotuit Owner: Pjdw n J.`-'P=ina Jr. Date of Inspection: 11 /20/95 Q` SOIL ABSORPTION SYSTEM (SAS):2 ' (locate on site plan, if possible; excavation not required, but0 may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:;Q leaching galleries, number: leaching trenches, number,length:_ ______ leaching fields, number, dime sions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Sandy soils no signs of hydraulic failure r 12-ondi ng- VegPtat.; nn ; G green ana normal. CESSPOOLS: am (locate on site plan) Number and configuration: AM Depth-top of liquid to inlet invert:�;�i) Depth of solids layer: AIR Depth of-scum layer: AM Dimensions of cesspool: W Materials of construction: N 4 Indication of groundwater: I _ inflow (cesspool must be pumped as part of inspection)�/Q Comments: (note condition of soil, signs of hydraulic (ailuie,.level of ponding, condition of vegetation, etc.) /1MAle, PRIVY: (locate on site plan) Materials of construction: Dimensions: ilJ Depth of solids:, v),�_' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) AR (revised 8115195) 8 l% SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Prudence Lane Cotuit,Mass . Owner: Fdwirr-J:. rPina Jr. Date of Inspection:) 1 /2 0/9 5 SKETCH OF SEWAGE DISPOSAL SYSTEM: Y include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Town Water e r _s• ,;fit — O a 6 N �Z ,L DEPTH TO GROUNDWATER /, d G 0 Depth to groundwater:) 5± feet method of determination or approximation: See page 6A. 1'b i ter encountered when installe 77- 29 i (revised 8/15/95) 9 P t' d e n ce 14' rnnT•n.—rs rrr.rr— czr:=r.•ntr..rr..rxr...—.r.::f:r_rr:sr:-ta--sf-s*=—:rc^--._- ._. .._ ._... - _.. ._.. .—. ' I TURN OF Barnstable BOARD OF HEALTH SUI)SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION .,.� F.•••rr•:-T••.-::r--.::-•'.--nrrn•r.:rrs—:.---.—r.-rr—•.f—:.--s.---r---�-s-re.---rscrrr.—•z-rrsr�—srrnrosr..rsrxrmsmrrsrrrrcrre-nrr-r.:—rrr•r.--. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 96 Prudence Lane Cotuit,Mass . ASSESSORS MAP , BLOCK AWD PARCEL * lot 98 040-049 OWNER' s NAME Edwin Ji:j�I?� na' Jr. PART D - CE1?7'IFICATI0N r NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Pox 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 3338 FAX ( 508 790 - 1 578 . m CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj 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: 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 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. XXXXXSystem FAILED* The inspection whiclh 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 . ,r 1 Inspector Signaturexwpd XK A t Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF 11EAL1'il. * If the inspection FAILED, the owner or""operator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in ' 310 CMR 15 . 305 . w 7 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. s 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 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the -ion of Water Pollution Control © a dy9 No. \ ,y ` "4 Fee 3 0•0 0 THE COMMONWEALTH F MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pplication for �Dig;poor *p!tem Cow5truction Permit Application is hereby made for a Permit to Construct( )or Repair)(X)o an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 96 Prudence Lane Cotuit Mass . ' Pina Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. .P.Macomber Jr. Same ox 66 Centerville ,Mass . 02632 Type of Building: Dwelling X No.of Bedrooms 4 Garbage Grinder(Nq Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) 3—infiltrators added to a. 1500 gallon tank for one bedroom. 4=330 Bechar-gars for remainder of house _ Off of existing 1000 Date last inspected:gallon tank. 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 issue by this Bo d tlt. Signed : Date 1 2/1 8/9 5 ` Application Approved by pp Application Disapproved for the following reaso -/`- / f Permit No.� �/ Date Issucd ✓ 4�yrh.' � .". .,.^' +f s :." .. .+ �.sp 1F.�1LA Y..e 1^' .. 1 _�.. -t o M �y.Tj ,�- ."�i i Jam,�,{. / / Fee 30. 00 No. � [� THE COMMONWEALTH MASSACHUSETTS PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migpogal *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or RepairXXI)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 96 Prudence Lane Cotuit Mass. Pina Installer's Name,Address,and Tel.No. 5 0 8—77 5—3 3 3 8 Designer's Name,Address and Tel.No. .P.Macomber Jr. Same Pox 66 Centerville,Mass . 02632 Type of Building: Dwelling No.of Bedrooms 4 Garbage Grinder(NO) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) 3—infiltrators added to a 1500 gallon tank for one bedroom 4:=330 ,Rechargers for remainder of house Aff of existing 1000 Date last inspected gallon tank. --""Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on.-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by this Bo dWh.Signed a Date 12 18 9 5 Application Approved by Application Disapproved for the following reas Permit No. f✓ �I Z Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced.KX)on 12 18 95 by J.�Sanh P. Ma n.nmbAr jr. for Pina as has been constructed in accordance r, with the provisions of Title 5 and the for Disposal System Construction Permit No dated .� Use of this system is conditioned on compliance with the provisions set forth-B low: w. 4.1 No. r `" Fee 3 0.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS li,5pogar *pgtem Congtruction Permit Permission is hereby granted to Joseph P. Macomber Jr. to construct( )repairY(XX)an On-site Sewage System located at 96 Prudence Lane Cotuit 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. All construction must be completed within two years of the date below. Q Date: /17 Approved CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) e I, Joseph P. Macomber Jr, hereby certify that the application for disposal works construction permit signed by me dated 12/18/9 5 , concerning the property located at 96 Prudence Lane Cotuit 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 no variances requested or needed. SIGNED : DATE: 12/1 8/9 5 LICENS 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]. 1 gg 0 e 0 THE COMMONWEALTH OF MASSACHUSETTS v BOARD OF HEALTH �v 9 ...............OF...../—184..14 - Apphration -fur 4iipniitti Works Tonsfrurtinn Vrrnii Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: —� / 74 .................................... 'u/ -'-.....------------------- -------------------------------•----------..... Loc tmn-Address or Lot No. Owner dress I -taller Addres U Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........ .._ Expansion Attic ( ) Garbage Grinder W} Other—Type of Building ---&-6�:C�--___-_-_--. No. of persons............................ Showers a) — Cafeteria ( ) Otherfixtures -------------------------------------------------- ------------------------------------------------------------------------------------------------ W Design Flow..................................gallons per person per day. Total daily flow.... 5.Z..........................gallons. WSeptic Tank—Liquid capacity/046__gallons Length... -------- Width.....5....... Diameter................ Depth._S.-S....- x Disposal Trench—No- --------------------- Width-------------------- Total Length__.__ ._._...:._.. Total leaching area....................sq. ft. . Seepage Pit No.�d_�_ _______ Diameter..... ............ Depth below inlet____.___._..._...... Total leaching area..` --_---sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------_ .......... Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water___.._---_-----...___- f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.--.--___-___-____.._. P4 - - O Description of Soil___ �' !t✓C.. x V ------------•--• -- - {} W - � -17- ��------------ U Nature of Repairs or Alte ations—Answer when applicable. ZtU.... e.>e,1�/._------j______________ ------------------.---------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article aI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o ealt OF roL Sig ed = �. --------------- ................................ Application Approved By---- � !1� d _-7 �.-. ,�.�._.?. ..... Date Application Disapproved for the following reasons: ............... ............................................................................---•••--•-•- Date Permit No......................................................... Issued.----1!r 3- 7 ----------------------------- Date VA .. THE COMMONWEALTH OF M•ASSAC'HUSETTS ; �. BOARD'; `, F. I-IEALTH y +. ,1 Ap"p, iration •fear Uhipoiitt1. park# Tiatuitturtion Vanift ;Application is hereby made for a Permit to Construct (. or 'Repair ( ) ari f Individual Sewage Disposal System p a e, a /t _GA � -dress *' � tEn• f .__. ___.__.. ..�'__ .._ .... ' ....____ Owner dress r . I taller Addre ;1 atv Qc d.... Type of Building Size L t---== ----------------Sq. feet y .. U Dwelling—No.� of Bedrooms.--___ > ..Expansion tttc ( ) Garbage Grinder per, Other—Type of Building p _--___-__ Showers ( } := Cafeteria ( ) ---�sAft�..-------- No. of el ions.. .:. . _.., Other fixtures ------------------------ -- ...............R Y W Design Flow galloris per person pef -daily flr 1r� g111ons: R� Septic Tank—Liquid cap„�city/Arkk.-gallons Length _____ WQ,4tli...... Diameter...................Depth-. .J*S t Disposal Trench-No. ............ ........V��idth __ __-_: Total Length � � Total leaching area..-.._ ._____Sq. ft: Seepage Pit No. 4y4 4_..... Depth 'below inlet.__ " _, Total leaching area:- �-__..Sq. ft. ,f_____________ Diameter..: Z Other Distribution box ( ) Dosing tank b '-' Percolation Test Results Performed by.____._ ... .. .`'' •--•---_ Date....a Test Pit No. 1................minutes per:inch Depth ;of`Test,Pit ____-____-: Depth to ground water....-_ ._-_-.._..- (s Test,.Pit No. 2___-•.._________minutes per inch Depth of Test°Pit........................Depth to ground water--.-..--_-_.-----.-_---- �ry -----•-- - --------------• .............................................-••----•---___------••-•------------------------•------- ODescription of,Soil__-a d.,A._1�,C-•�_-` ......................------------------------------------------------------------------------------ -----"--------- - U4 ,' c� ' L ---•----•----•--------•-•-----••--•--•------- - ------- r U Nature of Re airs or Altel/ations—Answer when applicable..�� -/f „�.�it --------- - ....... . ...... .........------------------- Agreement: The undersigned agrees to install„,the aforedescribed Individual Sewage Disposal Syst'`m in accordance with the provisions of'Article XI of the State Sanitary Code- The undersigned further.,agrees not to place the system in a° r operation until,a-Certificate of Compliance has been issued y the board o ealt 3 Sig ed=- -' -' -� _ ate'' Application Approved BY jr« � � '� �� 7 ... 1 .. ------ 'bate Application Disapproved f or the folio w- irtg reasons--------------- --------------- ----------------•---------- Date ? Permit No. -- -- ................... Issued:. . s .. � �ma x. . a _ Date y' r THE sCOM,NIONWEALTH'OF MASSACHUSETTS f BOARD `OF H'EA'LT , }� 1. r ..........OF...... . .... �.. . . . .. .._..� . ..... 1: (9`rdif itt-6 ' 'of Tomplia8ur F. {•{THIS S' CERT T *alh Individual Sewage Disposal System constructed ( or Repaired X. 417 ---------- 4 -- nitary Code as has applic tion installed Dispo al accordance Construction Perm t No Article X of ze State Sated �1 described in the, THE :ISSUANCE OVTH'IS {CERTIFICATE'SFIALL NOT-BE CONST ED AS GUA NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY _., : . ............... . Ins e � THE COMMONWEALTH OF MASSACHUSETTS 1 1 ' BOARD OF HEALTH ...- - F r 3�- r . ... OF............. .' No----------- ----�-'---- FEE --�----- -----..., 5 CENO. tr t �1�It Vamit a �------- a Permission by g 2nted :._..-• K 4�L� ---- - -•-- ---- t ,,to Construct. e it s( ) Indi dual`Sewa e posal S tem t r gat No -*--.. ... ......................... Y �Y� a.." �� � v Street f{ - as shown o tea 1 cation for Disposal Works onstructton Perated JwA J E PP oar of Health DATE s.ar- t �• FORMI'255- HOBBS'-& WA14REltl. -I NC iPUBLISH IRS r _ IW 23 , � V-4<X Cs SOT T 89 IRS a� '38 149 - o 1 •� a a )o : C t r� I i I r i AVd ICY S 1, C414 le 5 51� 4 7�c AOV r � v TOWN OF//BARNSTAB_LE LC ATiON SEWAGE iV VILLAGE -�` -- ASSESSOR'S MAP 6i LOT INSTALLER'S DAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sLze) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: O V. � a i /, flGO 9r Ark q( Prudence- fin) GoTul+ TOWN OF PARNSTA B V L.LQCE Co��j ASSESSOR'S i di LOT._.,.. _ INST�Lj ER.'S NAME&PHONE NO._ N SEPTIC TANK CAPACITY .- ZL� 20 LEA CIl1NCi FA,CILITX: (rM / L�G•k�l�s (size) i /' t NO.0F'BSDROOMS..... A(,.12 ..�.... BUILDER OR OWNER. I PER1 IT®A TE: _.� .._. CO r UANCE DATE: Separation Distance Between the; �l Maximum Adjusted Groundwater Table to the B�:totn of Leaching Pac;ility Wei Paivate Water Supply Well and Leaching Faccilit' (If any wells exist on site or Within 200 feet of teaching Feet Edge of Wedand and Leaching Facility(if any w�etlan exist within 300 feet o�eachins jlity�j � Pee Furnished by o l Fro". OK 17 a A � - s�•• .�'E- s3 6•- 65''9" 6-/H- jq� 8-/4- 33' 36 ' 6-K-36' TOWN OF BARNSTABLE L )CATION � j Ube SEWAGE VILLAGE !2e2jtj ASSESSOR'S MAP & LOTS ,O INSTALLER'S NAME & PHONE NO.-J �C� kj p r,c; l v�C SEPTIC TANK CAPACITY LEACHING FACILITY:(type)A er 5 (sire) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER �� R nR 0FNER DATE PERMIT ISSUED: DATE COZIPLIANCE ISSUED: � � ,°� ,�� 1 � � � � Y � w,4 r ♦ :� �/ '/^/^'' \\\\\\ \� � // /�... / �j'/ � ��� ,r C, l,J- C f S t TOWN OF BARNSTABLE maw-" late 1-.00ATION / RUd:e n C. - SEWAGE# zezz "-Vl%LAGEC;r)y 4-1 ASSESSOR'S MAP&LOT04 a" E4STALLER'S NAME&PHONE NO. �I� Yn Acickyrh P_.: s0n .L� C SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 14 --ReCJ ja MQ r ,E (size) NO.OF BEDROOMS ` aLUaM OR OWNER 015�t W, " PERMrr DATE: I Z- 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility); Feet h Furnished by 1b r� I vv � b OL� f