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Home My WebLink About0051 PUTNAM AVENUE - Health 51 Putnam Aven ��= A= 036-041-001 COW it ;ip ij III Massachusetts Department of Environmental Protection Bureau of Resource Protection ` Well Completion Reports r , Well Driller i is Please specify work performed: Address at well location: I�ti New Well Street Number: Street Name: P, �r 51 PUTNUM AVE r: Please specify well type: Building Lot#: Assessor's Map#: Irrigation 036 { Assessor's Lot#: ZIP Code: Number Of Wells: 041 001 02635 City/rown: Well Location BARNSTABLE In public right-of-way: GPS 1 (-Yes r No I North: West: 41.62255 70.43242 Subdivision/Property/Description: Mailing Address: click here if same as well location address ......................................................................................................................................................... Property Owner: Street Number: Street Name: JOE POPOLO 9002 DOUGLAS AVE City/town: State: Engineering Firm: DALLAS TEXAS ZIP Code: 75225 Board of health permit obtained: Yes r Not Required Permit Number: Date Issued: W2020 014 105108/2020 ....................................................................._............. Massachusetts Department of Environmental Protection Bureau of Resource Protection-Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger Choose Bedrock— WELL LOG OVERBURDEN LITHOLOGY From(ft) To(ft) Code Color Comment Drop in drill Extra fast or slow Loss or addition stem drill rate of fluid 0 20 Fine To Coarse S . Brown '; Fast Slow r r — �—m— YES NO 's _______ Loss Addition C, 20 30 Fine To Coarse S Brown �W- r f7 Fast t"Slow `? YES NO Loss Addition 30 40 Coarse Sand 'Brown $�Fast `Slow — III YES NO _____ loss Addition .......... 40 50 Fine To Coarse S!1. Brown Fast i Slow YES NO ��111I Loss Addition WELL LOG BEDROCK LITHOLOGY ..._...._.............._...._.,......._..............................._............._.............._.................._._.............,..........._.._....._.._.........._........_...._....._......._........_..._..........._....p....................._....................................... ..._.._.._.................._.............................I.................._............... ................................. Drop in Extra fast or Loss or Visible Rust Extra' From(ft) j To(ft) Code Comment addition of Large drill stem !slow drill rate fluid Staining Chi f Is YES NO f" (� Choose Code— riYes! Yes; Fast Slow Loss Addition = ADDITIONAL WELL INFORMATION Developed Yes#'No Disinfected Yes f No Total Well Depth 50 Depth to Bedrock: ................................ ............. Surface Seal Type None �racture Enhancement Yes No CASING Is Casing above ground? From: 1 To: 0 From To Type Thickness Diameter Driveshoe ......................................................._............_........_.......... ..._._............_........_................_._................._..........._. 42 Polyvinyl Chloride Schedule 40 � ;Yes ............ SCREEN T7.No Screen I From To Type Slot Size Diameter 42 50_ �inless Steel Well Point 0.012 4 .... .. ....... WATER43EAPJNG ZONES r DRY WELL: _ .........._._. �. .. .......... ............ From To Yield(ftpm) 30 50 12 = PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed 1� Pump Description Horsepower Submersible 1/2 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program �. Well Completion Reports(General) Pump Intake Depth(ft) 46 Nominal Pump Capacity(gpm) 12 ANNULAR SEAL/FILTER PACK ........_.._..............._.._.................................................._..__......................................................................._.................................-......................................._._......._......................................t......._............................................................ ,............................_._ ...................._...._......._......... __........_... From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement Choose Material i Choose Material —Choose One WELL TEST DATA Date Method Yield Time Pumped Pumping Level(ft Time To Recover Recovery(ft (gpm) (HH:MM) BGS) (HH:MM) BGS) 05/18/2020 Constant Rate Pump + 12 n 130 31 00:01 30 WATER LEVEL i Date Static Depth BGS(ft) j Flowing Rate(gpm) Measured 3 i 05/18/2 220 30 i i 12 i COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. DESMOND DEREK Monitoring[M] Supervising Driller Signature III DrillerGOODWIN Registration# 764 THOMAS,E DESMOND WELL Firm DRILLING INC. Rig Permit# 0089 Date Job Complete o5/28/2020 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. F,NVIROI Cr .LABORA.rORI,t,5, INC 8'Jan Sebastian Drive Vnit12 santlwirh,;1M 02563 (501f)888-6460 ,1-800-339-6460 r.4 (508)888-6446 Client Alante:- Desrnontl Well Drilling 17ctttitttt Address. PO Box 2783 51. Putnam Ave Orleans; MA Cotuit,.MA 02653 Leib Number: DW-201240 Collected By: DWo Da1e.ReceiveEl: 05118120 Santple Type Well.Vpees Irrigation 50730' tt truer artr y a YCti,le tt..... tl AtraljsLv Reriitiqted Units Recominendetl Limits Aualvs Date Atualrzwl 4na4zed BY Total Coliform CFU/100mL 0 0 8M92226 05118/2020 KF @ 17:30 _... pH pH units 6.5=8,5 5.99 SM 4500-1-1-14 05/18/2020 ILL Specific Conductances umhos/cm 500 275 EPA 120.1 05/18/2020 KF _ . ... NitriteW mg/L 1.00 <o.006 EPA 300.0 05/1.9/2020 LL Nitrate-N m9 lL 10.0 2.33 EPA 300.0 05/19/2020 ILL Sodium mg/L 20.0 35 EPA.200.7 06/20/2020 KB _._ . . ...... ..._ .. .....9 _.... _..... Total Iron m /L 0.3 0.02 EPA 200.7 05/20/2020 KB Manganese mg/L 0.05 0.034 EPA.200.7 05/20/2020 KB C't inutents•: Sodium level is not a health hazard.. Low pH indicates high corrosive characteristics. All samples were analyzed within the established guidelines of`US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge, Water meets EPA.standards and is suitable for drinking for parameters tested. i Date 5/20/2020 Roffal(I J.Sntirt Laboratory.Dirertor BRL_Relow Reportable LiniHs *See AMOW Page of 1 Certification&.not available for•this analyze for potable water saurples.. No. oe �� Fee i 4 BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou jf or Yell Cou5tructiou Permit Application is hereby made for a permit to Construct�, Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel �, Payola 51 P4nvy, Ate.-Cd OA,�10 o-z�Z5 Owner Address SyY.o-nc� Nk- N AytiA Box. Z-1s3 , OcWys Yhh O-L U Installer-Driller Address Type of Building Dwelling �C Other-Type of Building No. of Persons Type of Well "P,1 9I S(Mkib N f C Capacity i'„JC" Purpose of Well �CCi�� 14rn Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signe 5 2S7 Date Application Approved By a Dat Application Disapproved for the following reasons: Date Permit No. Issued Date ----------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed N), Altered( ), or Repaired( ) by Z)2SVY0n,'-x \40\ O ri\\1 rW 3NL Installer at 51 P v-,-v A� I j& U1 has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector a c _U N V� Fee TOWN OFARBARTNSTABLE M f 2pplication jFor Yell Construction Permit00, ' Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: 55 P'kY,aVY� AJe -i Location-Address Assessors Map and Parcel p " �ScQl. 10PU10 51 ?4nu)-„ A\1 o-i(35 Owner 1 Address S�rnon� \W\ ?-U- gwx Z7�3 , QcWv\v Yhp oz�53 Installer-Driller Address Type of Building Dwelling Y Other-Type of Building No. of Persons Type of Well S CA Capacity j Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signe j-1-J_ t' owts) /Date Application Approved By Dat Application Disapproved for the following reasons: Date Permit No. Issued Date li BOARD OF HEALTH „I TOWN OF BARNSTABLE (tertificate of (Compliance THIS IS TO CERTIFY,that the individual well Constructed(A), Altered( ), or Repaired( ) by ng, , `Y)L. i Installer at 51 p has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell (Con.5truction Permit No. 1A) Fee Permission is hereby granted to \NQ 1 h� Installer to Construct ), Alter( ), or Repair( an individual well at: No. 5 V-0 (211 C cif- Street , as shown on the application for a Well Construction Permit No. 1/U,40 - OE Dated Date rho Approved By V l • TOWN OF BARNSTABLE LOCATION V1-tnG� p�V�% SEWAGE VILLAGE v 1 v1' ESSOR'S MAP&PARCEL p, 114&T,64J.ER'S�NAME&PHONE NO. �'� � � ,u �� SEPTIC TANK CAPACITY 1560 k`( i LEACHING FACILITY:(type) 0ikc vv► (size) ,j GG J NO.OF BEDROOMS 5- OWNER_ gw ef,[ PERMIT DATE: G&1 �DATE:!ZISP /0/ /( i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet FURNISHED BYC/ f r /•/yf { f Y ! r ! f J t r F'f'!-•! f I f J / 'f f / ! f f / { f f f f f { / f�r r•}4/ f / / f f r f r / ! l r f / r f r / f } ! f / / f J ex f f r J f h ♦ h ♦ h \ 4 h h ♦ ♦ h \ \ h h h \ \ h ♦ \ \ ♦ h \ _ i h i h ♦ \ i \ \ ♦ h h h ♦ \ i \ h A 4 ♦ \ ♦ h \ h ♦ \ 4 \ h A f f f f f f ! ! { f r f r r r f r r f f f f 25 ! f r J r ! \ \ \ \ \ A • n r / r J J ! \ \ h \ h f f f f f r r f f f f f \ ♦ \ 72 43 J f ! { r J f f 7 49 . . R vp 1 � r1, ; QOO ,` Lill r -th ^ ` O 21.05 1 N"' 81 04 03 W ca , ter G� DEE vim° �.,---30•d 30.0! �► �ppR4X1 SEPTIC IW I 00 Zn USIO 34 PI 35 NN \ ww__4�tiw 30 27 —. w.--26 1__rye _*•_`_^� 1� Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. xl / / / / / / / PSI / J / / / / / \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \/\/♦/\J\/\J\/\/\ ♦ ! / r ! / / ! / / / / / J Water 25 Service \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 72 -43 7 49 • �i�iveuva�y�• , ....h If,. . . . . Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every 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. Impotent: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification 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 11 r�; c.a was performed based on my training and experience in the proper function and maintenance of on site c'' sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of 6 Title 5�(310 CMR 15.000).The system: u� W' o ®i Passes ❑ Conditionally Passes ❑ Fails t t � �, ❑�Needs Further Evaluation by the Loc pproving Authority tea � ram•. ' c October 22, 2009 In ector's Signal ure 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. lv/ 1 09-217 Emery.doc•06106 Title 5 Official Inspection Form:Subsurface Sewage Di osal ystem•Page 1 of 15 Commonwealth of Massachusetts w : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: Tank is not in need of pumping at this time, leaching chambers have no standing water or sidewall stains. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 09-217 Emery.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. 09-217 Emery.doc•011106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09-217 Emery.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a_tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes' in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09-217 Emery.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery -- Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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)] 09-217 Emery.doc 08/06 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 0 Number of current residents: 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 ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d N/A irrigation g ( Y g (gp )) system. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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: Last date of occupancy/user Date Other(describe): 09-217 Emery.doc-06/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-217 Emery.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 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.): Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6„ Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 09-217 Emery.doc-06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every 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.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. Trap locate on site plan): Grease p ( p ) Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 09-217 Emery.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-217 Emery.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: Five 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching chambers had no standing water or sidewall stains. 09-217 Emery.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 09-217 Emery.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Putnam Ave _ Property Address Donald Emery -- Owner Owner's Name information is Cotuit MA 02635 October 22, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Water 25 \ \ . \ ' ♦ \ Service /\/\J♦/ ♦J\/\/♦ \, 7 49 ,.. .•. .•. . . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Putnam Ave Property Address Donald Emery Owner Owner's Name information is required for Cotuit MA 02635 October 22, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 30 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Ocean elevation at opposite side of property is considerably lower than SAS. 09-217 Emery.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15