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0502 PUTNAM AVENUE - Health
502 Putnam Avenue Cotuit A = 038 008 f i i ,I ,I I' , Commonwealth of Massachusetts �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 502 Putnam Ave Property Address ., Chris Lai '' Owner Owner's Nam information is required for every Cotuit MA 02635 1-13.-20 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. QP I U Important:When A. Inspector Information 514 1133a� .�1`°� ''filling out forms .. '''Sc�� on the computer, =��i JAMES yN' use only the tab James D.Sears .M. key to move your Name of Inspector =v; :- cursor-do not Robert B Our CoAric y't use the return Company Name T I F O �� key. 363 Whites Path s,F 5 iNS?"- r� Company Address South Yarmouth MA 02664 City/Town State Zip Code law 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my �( inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1-13-20 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !3 502 Putnam Ave emu, Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system is a 1000 Gal. Tank D Box and Trench. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r , Commonwealth of Massachusetts Title 5 Official Inspection Form -le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,V 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N • ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 502 Putnam Ave Property Address Chris Lai Owner Owner's Name informati for every on is required Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 99 p ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts iP Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is COtUIt required for every MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 r , Commonwealth of Massachusetts qi lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • � �y 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal. Tank D Box and Trench. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2018-36,000Gals2019-39,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 co of the current operation and 9Y PY p maintenance contract to( be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Y ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Tank NA/Leaching 2003 Permit#2003 - 164/New D Box 2019 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l% 502 Putnam Ave V Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): < 211 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 27" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" I Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover's at 2" Below grade. In and outlet tee's. No sign of leakage or overloading. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts n. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8.• Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tea Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-13" below grade w/two lines out. Box is new w/cover at 6". t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a Trench-50'x4'x2'. Ck D Box- Prob. area-camera out lines. No sign of over loading - solid carry over or holding water. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� 502 Putnam Ave "v Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f C Commonwealth of Massachusetts Title 5 Official Inspection Form F a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is Cotuit MA 02635 1-13-20 required for every � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 �RON't oP 3O 0 4, . 43 04, 4b �-3 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f r Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells jV0 Estimated depth to high ground water: 15' 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: T.H. on File 15' G.W.. Bottom of leaching at 4' below grade. Bottom of leaching at 1 V above G.W. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 F c Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,V 502 Putnam Ave Property Address Chris Lai Owner Owner's Name information is required for every Cotuit MA 02635 1-13-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Gn�J) emu. —7/%LAIC H Il Nv G we t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye RppliLation for bisposal i�pstpm Construction Permit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System *Individual Components Location Address or Lot No. �j0�, a(-Tr-Xj-+A'( A J5 Owner's Name,Address,and Tel.No. C�j'i'i>i c' teJ 14 ltC -p106- t-L-C- Assessor's Map/Parcel ®.3 Pp ?.D (�i�AJ� to Installer's Name, ddress,and Tel.No.Sog'_1,f 7-1 >pV-1-7 Designer's Name,Address,and Tel.No. rA0�tt�ft�E?i c —�p,avIA. dv . WA Type of Building: Dwelling No.of Bedrooms 1�J�� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided /� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Z'$J�'1�.4{.t__ A109W Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed_ Date 1;L--4- Application Approved by Date �Ze/I Application Disapproved by Date for the following reasons Permit No: 2, (_Gr�_q� q Date Issued T HY J 7-0[�j lI No. a f t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS . Rpplication for Disposal 6pstem Construction 3pErmit Application for a Permit to Construct( ) Repair)o Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 56;+ Par V4M A OF Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and T 1.No. Designer's Name,Address,and Tel.No. C°.B►P�w�AE!/Zc�bc�T b 5,0j ��v7.�"g8-t� Nli4 -' Type of Building: , Dwelling No.of Bedrooms /1 ) - Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 3 - Design Flow(min.required) 11.+(1}----- gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �. Nature of Repairs or Alterations(Answer when applicable) -11) 71 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date -4-P o l9 Application Approved by Date Z Application Disapproved by Date for the following reasons Permit No. Date Issued --------------------------------------------------------------------------------t-`-'----�--'--------------------- ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by d4fiao A nua (:�Az- at � �trly�4Ml -��1 i T has been constructed in�►accordance with the provisions of Title 5 and the for Disposal System Construction Permit No1=}-I-4 dated i Installer 0,Q a (b, .0 J 0 db Designer r #bedrooms >,p _ 1 Approved design flow and The issuance of this pe its iall not be construed as a guarantee that the system wi 1 func' n as designed. Date. Inspector -------------------------------------------------------- No. . �� Fee ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair( �) Upgrade( ) Abandon( ) System located at P(r"Ad ,Am()r%: <Zam 4 Vie^ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co erm nstruction must be completed within three years of the date of this pit. Date 1 / �jTr� Approved b �_ Certified mail: 7006 0810 0000 3525 2889 x Town of Barnstable Regulatory Services anxNsr MEv 1�� Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 27, 2007 Christopher Hills 502 Putnam Avenue Cotuit, MA 02635 NOTICE OF VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND TOWN OF BARNSTABLE CODE 4 353-9-DISCHARGE ONTO GROUND PROHIBITED On June 27, 2007, Health Inspector Timothy B. O'Connell investigated a complaint regarding' effluent being discharged onto ground at the property owned by you located at 502 Putnam Avenue, Cotuit. The following violations of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and the Town of Barnstable Codes were observed: 310 CMR 15.3030) (a): Disposal system for laundry is in hydraulic failure. Effluent was observed overflowing onto the ground. Q / Town of Barnstable Code 4 353-9: Discharge of effluent onto the ground. 1 (1) You are directed to keep the on-site disposal system pumped as many times as necessary to keep it from overflowing onto the ground. Every day if necessary. (2) You are ordered to disconnect clothes washer from cesspool located in back of your home and reroute plumbing into septic which was installed on April, 18 2003. You are also order to hire licensed septic installer. Who is to pull an abandonment permit at the Health Department. Once this permit has been pulled installer is to abandon this cesspool in accordance to 310.CMR 15.00 4 170-4 of the Town of Barnstable Code: Owner's Responsibility to Register Rental Unit. The unit is not currently registered with the Town of Barnstable Health Division. Q:\Order letters\Septic\502 Putnam ave.doc You are order to comply with the above orders within fourteen (14) days of receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in the issuance of a non-criminal ticket citation of $100. Each days failure to comply with an order shall constitute a separate violation. PER ORDER OF TH BOARD OF HEALTH 114� . Thomas A. McKean, CHO, RS Director of Public Health QAOrder letters\Septic\502 Putnam ave.doc NAME OF OFFS Eq (-' I S 10 TOWN uF . IL_ L -- — --- _------ ADDRESS,OF° DER L BAR 67372 BARNSTABLE CITY,ST E.21P COD a . �e� 1 �a rI i , DA MV OPERATOR LICENSE NUMBER xnxrxT�pr,�;, OFF NSE MV/MB REGISTRATION NUMBER ; w� 1u 'c- 'o 4 e r �e r 4 � ( � 0. CG v 1` y fv er CL TIME AND DATE OF VIOLA ON r F n fi _ O NOTICE OF cc � LOCATIONOFVI�AT�ON �� w (AM, / P,M,)ON—-e t > VIOLATION S10N �NFORCI gsD 20 0 u I+ z ENFORCING DEPT. LL OF TOWN BADGE NO w I HEREBY ACKNO LEDGE RECEIPT OF CITATION X to ? [� o ORDINANCE Unable to Obtain signature of offender. LU OR Date mailed THE NONCRIMINAL FINE FOR THIS OFFENSE IS Q YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2J WILL OPERATE AS A FINAL L REGULATION DISPOSITION WITH NO RESULTING CRIMINAL RECORD. �+ CL (1)You mey sled to pa the above Ilne,either by appearin in arson between 8:30 A,M,and 4:00 P.M.,Monday through Friday,le al holida s ex tad, before:The Barnstable Clerk,230 South Street,H AAgg p y Hyannis,MA 02601,WITHIN TWENTY-0NE(21)DAYSIOF HE2DATE OF THIS NOTICE, g yy pp 01,or by mailin a check,money order or postal note to Barnstable Clerk, P.O.Box 2430, Ul 1 II you desire to contest this matter in a noncriminal proceeding,yyou mayy do so by makingg written request to DISTRICT COURT DEPARTMENT F citaRNSfora h DIVISION,COURT COMPOUND, MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal He citation for a hearin , IRS7 to a you fell to pay the above offense or to request a hearing wlthln 21 days,or II you fall to appear IDr the hearing or to pea to Hastings d e cl mined at the hearing to be due crlminal com lain!ma be issued a sins! ou. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature W-7 �IU7 r Parcel Detail Pagel of 3 ap �p q Logged In As: - Parcel ®eta i' Monday, Jul Parcel Lookup Parcel Info Parcel ID 5R038-008~ Developer Lot I Location 1502 PUTNAM AVENUE Pri Frontage�100Tm Sec Sec Road� _._ -....___. Frontage Village?COTUIT Fire DistrictCOTUIT Sewer Acct' Road Index 1324 Interactive t Mapes 1 h° J } Owner Info Owner jHILLS,rnCHRISTOPHER T& .f Co-Owner HILLS, THERESA H Streetl 1502 PUTNAM AVE , Street2 City COTUIT State�MA m zip 102635 � Country aUS Land Info Acres 10.35 use jSingle Fam MDL-01 Zoning RF rvghbd +0107 Topography �Level Road .......... Utilities iPublic Water,Gas,Septic 1 Location y Construction.Info Building 1 of 1 Year t __._-_ ++ Roof --___ ._T____.________-. Ext Built1964 1 struct'Gable/Hip wall IWood Shingle Effect,---.._.- ..._.__ Roofs_. .._ _.. .,,....._. i AC Area 1424 Co00 !Asph/F GIs/Cmp i T None Type Style Ranch Int wall!Drywall Roomds=3Bedrooms Model Residential Int i Bath 1 Full + 1 H Floor 1 Rooms _.. _, - Grade _ _....._ Total ;Average Type Hot Water Rooms Rooms http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2396 6/25/2007 Parcel Detail Page 2 of 3 Found- Stories 1 Story Heat�Oi�__-.._. Found- Poured Conc. Fuel ation i - __ ._....................... -- -- -- Permit History Issue Date Purpose Permit# Amount Insp Date Comments 9/12/2001 Windows 55796 Visit History Date Who Purpose 6/20/2005 12:00:00 AM Paul Talbot Meas/Est 9/16/2002 12:00:00 AM Paul Talbot Meas/Est Sales History Line Sale Date Owner Book/Page Sale P 1 2/15/1992 HILLS, CHRISTOPHER T& 7896/004 2 11/15/1991 FED HOME LOAN MTG CORP 7775/192 3 11/15/1986 BROWN,WILLIAM C 5414/063 4 7/15/1983 WRIGHT, CHARLES M & SARAH 3789/314 5 12/15/1980 INNELLO, 1.6 SAVERY, CHARLES CONFIRM 5423/113 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2007 $129,400 $5,800 $0 $186,600 2 2006 $115,800 $5,800 $0 $149,800 3 2005 $108,500 $5,800 $0 $135,700 4 2004 $86,900 $5,800 $0 $135,700 5 2003 $78,100 $5,800 $0 $49,700 6 2002 $78,100 $5,800 $0 $49,700 7 2001 $78,100 $5,800 $0 $49,700 8 2000 $55,600 $5,100 $0 $37,300 9 1999 $55,600 $5,100 $0 $37,300 10 1998 $55,100 $5,900 $0 $37,300 11 1997 $63,500 $0 $0 $26,100 htt ://iss 12/intran t/ r p q e p opdata/ParcelDetail.aspx.ID-2396 6/25/2007 Parcel Detail Page 3 of 3 12 1996 $63,500 $0 $0 $26,100 13 1995 $63,500 $0 $0 $26,100 14 1994 $60,900 $0 $0 $33,600 15 1993 $60,900 $0 $0 $33,600 16 1992 $69,300 $0 $0 $37,300 17 1991 $75,100 $0 $0 $63,500 18 1990 $75,100 $0 $0 $63,500 ; 19 1989 $75,100 $0 $0 $63,500 20 1988 $54,100 $0 $0 $19,200 21 1987 $54,100 $0 $0 $19,200 22 1986 $54,100 $0 $0 $19,200 Photos http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2396 6/25/2007 y _ _ f � .. r", � Search for Map/Parcel 038008 Town of Barnstable r -For Parcel Number, 038008a " ; a 17entalPro e %C A r ro _p rty{ } x_j . Business Name t , ;� .Zone of Contribution(YIN) 1 `Area Number Contamnaht Ra) Phone Fael Storage Tantc Permit F _.. C Y='- D�sposa6Works"� -z� � Construction .. Perc:Test Well Permit . FlleiPermlt N0: ����� 2003164 ', Issuance Date _ �.—Completion Date,,. tv 04/22/2003i Size of Septic Type/Size.of SAS trench(55 x 2 x 4) ank.,, X1000 a, mge c , ' „`fiotY17f1entS. 3 beds. variance granted 12/09/2001 0 -01 mappar 038008 Irowner HILLS CHRISTOPHER T& Iproploc 502 PUTNAM AVENUE n ., �✓# .,,vim r�'fid ,';.`�' *4s�>t Mh„ ,,��a��;�°y � dk �Gua.4,' a,�;�:�„5s"Y.+it,�} # r „� "}hk�` h>�4'"»sr 3 lA� ��.w. tnnoiatiire/Alte►rtativeTechnalog Septic Systerr+s ` Single or :"=IIAType '� Se vice Type: Clustered:.: 44 F r�� _ ..ter.•"' _ . v r � r• ` f1 y y, r s d �. . AIMPi w n fApr 30 10 . 08: 54a John Lyons 508-778-2276 p. 1 T)cpv mcnt of Public Health -Childhood Lead Poisoning Prevention Progam Deleading Notification Please complete all sections of this form clearly.Incomplete or,illegible forms will be returned. Lead Paint lnspector Craig Arjdgrson License#R3801 Inspection Date 04/06/l0 Property Owner Shaunna Covell Property Owner's Address P.O. 13ox 704 Broo line Ma.. Zip CodetO, 1p Authorized person performing work: John P. L ens Lic#/Auth_#001912 Address of authorized person t72+I=1i• ups Crewel!=Rd.West Yarmouth Ma_Zip Code 02673 Telephone Number , 774 353-6235 - Address where the work will be done: 5502 P-utnam�:Ave..CotuL N1a=0263:5> Building Name(if any) Floor Street Address 502 Putnam Ave. _-Apt No. City Cotuit -_Ma Zip Code 02635 The property is a_multi-family x single family. DeleadinC Method(s): a Making paint intact(high risk) Making paint intact(moderate o Applying vinyl siding on exterior 3 Demolition risk) ,X Component removal (low risk J Scraping Liquid encapsulant components) 3 Component removal/replacement X Covering U Other. _ a Dipping o Capping baseboards The work will begin on Sj1//l() and will finish by ©ef�v The work be done in the x am or weekends_ In Case of Emergency Contact 3(hn P._vons Daytime Phone 774-353-6235 Evening Phone 774-353-6235 the Property Owner must complete and sign the following information: certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning 'revcntion and Control Regulations, 105 CMR 460.000,will conduct deleading work. I further certify that the authorized )erson(s)will not exceed the scope of his/her authority and will be performing only those:activities indicated above.All of the nformation contained in this document is true and ct to the best of my knowledge and belief. ..t - -� Date ��/ o�c�/�� Signed = 7 r70 0 The following people/agencies must be notified ten days before beginning work: I. Occupants of the dwelling unit F! V) 1. All other occupants of the residential premises, if any work will be done in the common areas ' 1. Childhood Lcad,Poisoning Prevention Program, DPH Fax(781)774-670t MWRHO 5 Randolph St, Donovan Building Canton, MA 02021 L. Asbestos and Lead Program, DLWD 19 Staniford Street, l" Floor, Boston, MA 02114 Fax(617)626-6965 i_ Local Board of Hcaltli/Code Enforcement Agency. . AVIt ,ZiGIQ,,L "d * .If the home is on the State Registcr of Historic Places,call the MA Historical Commission at(617)727-9470 COMMONWEALTH OF MASSACHUSETTS •'_a^\ = F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION David B.Mason,R.S,Certified Title V Inspector,508-833-2177 19 . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' N �R Q C) Property Address: 502 Putnam Ave C— .� Owner's: Christopher.Hills Owner's Address: 502 Putnam Ave,Cotuit,MA � Date of Inspection:June 16,2008 —rs X'.. Name of Inspector: (please print)David B.Masonco �? Company Name: N.A. w r - Mailing Address:4 Glacier Path r n { East Sandwich,MA 02537 Telephone Number: 508-833-2177 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur . Date: The system inspector shall submit a copy of this inspection report to the Approving A ority(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 c4- 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. Notes and Comments: System as inspected appears to have operated based on occupancy level. Increase in occupancy may cause hydraulic failure. There is an excessive amount of grease in the septic tank and distribution _ box. The presence of this grease indicates premature failure may occur if grease had entered the leaching. The system requires pumping for maintenance purposes. The information as identified represents only the condition of the system on June 16,2008 at Noon. ****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. Title 5 Inspection Form 6/15/2000 page 1 'Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 502 Putnam Ave Owner:Hills Date of Inspection:June 16,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X 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: 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 distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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: 2 I 'Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16,2008 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. 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6' diameter leach pit with stone. Permit on file with the BOH for the pre-cast leach pit. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 3 I 'Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 502 Putnam Ave Owner: Hills Date of Inspection: June 16,2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No_(Yes/No)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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. •. l .,, 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X_ _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site. _X_ _ 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? _X _ 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: Yes no X _ Existing information.For example,a plan at the Board of Health. _X_ 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(3)(b)] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 5 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16,2008 FLOW CONDITIONS . RESIDENTIAL Number of bedrooms(design): 3 (per assessors records)Number of bedrooms(actual):.3 septic design DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (330 gpd capacity) Number of current residents:_8 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no): YES Water meter readings,if available(last 2 years usage(gpd)): 2007: 173,000gal. 2006;107,000 gal. Sump pump(yes or no):No Last date of occupancy. current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Pumping conducted after inspection as a maintenance pumping. Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: Tank was pumped due to lack of pumping and as part of maintenance. Pumped after inspected.Pumping also occurred on June 11,2007 of approx. 1000 gallons. TYPE OF SYSTEM X 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: Approx.4/22/08 Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM ENTS i Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16,2008 BUILDING SEWER(locate on site plan) Depth below grade:Approximate; 24 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK:N.A.(locate on site plan) Depth below grade: 2 inches Material of construction: X_concrete_metal -fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gallon tank Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle: 20" Scum thickness: 6 inches Distance from top of scum to top of outlet tee or baffle: 2" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Inlet tee in good condition,Outlet tee in good condition, Effluent level with outlet pipe. Evidence of Heavy grease. In need of Maintenance Pumping. No evident structural issues.Recommend outlet tee filter. GREASE TRAP: N.A. Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 502 Putnam Ave Owner: Hills Date of Inspection: June 16,2008 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert:liquid level even with outlet pipe Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Indication of solids carryover,specifically grease. Effluent level with outlet pipe inverts. No indication of leakage. Grease overflow is alarming because it may have entered the leaching trench which can lead to premature failure. Distribution box is 12 inches below grade. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16, 2008 SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number _leaching chambers,number: _leaching galleries,number: _X_leaching trenches,number,length: 1 Trench;50'x4'x2'444gpd 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, etch no saturated soil,nor signs of hydraulic failure,no indication of staining,No excessive vegetation growth. There is the potential of grease overflow which can cause premature failure. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N.A._(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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r .,, 9 I Page 10 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16,2008 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. FRONT B❑ O O W E F AC 13' AD 17' AE 15' AF 15' AG 42' BC 43' BD37' BE 46' BF 60' BG 20' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR M 10 _._ r v Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 502 Putnam Ave Owner:Hills Date of Inspection: June 16,2008 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_feet Please indicate(check)all methods used to determine the high ground water elevation- _X Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation:. Engineered plan for property indicates that there is no ground water within five feet of the bottom of the system. Abutting wetland elevation indicates that water would be approx. 15 feet below grade. 11 I a� Regulatory Set-vices HAxxseAatE, : Thomas F. Geiler, Director MASS. 9`�ArFo �61 Public Health Division Thomas McKean, Director '200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit'. If you should have any.questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTICTisclaimer Private Septic[nspections.DOC No. 2,6 _.1 `, Fee i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migpogal *pgtem Congtruction permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel ,�r_ r5p- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 27-�f n p> �•a�"f .�✓'L•�.%1i,1'�s1e��i�.E=f;��k� Type of Building: E Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder( ) Other Type of Building O-e-r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Zb' We, Type of S.A.S. 3 �,.•��/ 7®3',C '�X Description of Soil Nature of Repairs or Alterations(Answer when applicable) DESIGNING ENGINLLK MUST SUPERVISE, Date last inspected: INSTALLATION AND CERTIFY IN WRITING THE SYSTEM WAS INSTALLED IN STRICT Agreement: ACCORDANCE TO PLAN. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date �� —� Application Approved by Date y"rL-Yl,? Application Disapproved for tee reasons Permit No. UO Date Issued U (9 r,4 No. o�Q,� x 4 V' `g Fee co Entered in*` � mputer:.✓ THE1,CQAMONWEALTH OF MASSACHUSETTS _ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Miz ozar ztem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �DZ /odr/riC iY1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: - Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Gt`cI: No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date/y M Title Size of Septic Tank �'3llJ'Ti /oco, b!I. —Type of S.A.S.TOt�.�.��,/ rr' X y Description.of Soil `. Z t Nature of Repairs or Alterations(Answer when applicable) s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed - Date _,°o'0.3;e Application Approved by Date Application Disapproved for the following reasons Permit No. .J U�� V Date Issued /� U THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded) Abandoned( )by(Tires l e Bloet� at I o S /"v7"/y�4 r^^ .4/_i �t' e: o rvi i has been constructed i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,�&)3- 4 V dated / Installer JT>&Z Z &4" A- Designer The issuance oft s per/nit shall not be construed as a guarantee that the syste w' f o de 'g ed. Date 41Z 7- 6 Inspector ——————————————————————————————————————— No. a dU 3 — t Fee U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopaal *p!6tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( ) System located at Y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructio��'nmust be completed within three years of the date of thisM Date:_ L I� Approved by , !Cls, t Rpr 23 03 12: 35p Charlene Antrim 5084779072 p. 1 CAPE & ISLANDS ENGINEERING SUMMERF/ELD PARK 800 FALMOUTH ROAD,SUITE 301 C MASHPEE,MA 02649 (508)477--7271 FAX(508)477--9072 April 23,2003 Mr.Tom McKean Barnstable Board of Health 200 Main Street Hyannis,MA 02601 RE: Map 038 parcel 008,House 502 Putnam Avenue,Cotuit,MA Dear Mr.McKean: This is to confirm that the septic system installation was inspected on April 22,2003'. The system has been installed in substantial compliance to the plan on file dated October 23,2001. Sincerely, David Sanicki DS/.cma TOWN OF BARNSTABLE LOCATION -p i4 UGC SEWAGE # ASSESSOR'S MAP &LOTZB� VILLAGE v INSTALLER'S NAME&PHONE NO. lT/H-i L�BaE U,�' �7s`o-JoJ SEPTIC TANK CAPACITY -etXllrZ�' (type) (size) LEACHING FACILITY: ��ir:vGjf� i NO.OF BEDROOMS J BUILDER OR OWNER rY���J'; PERMIT DATE: —0 3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tabte to the Bottom of Leaching Facilit} X Feet � Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist �6 Feet within 300 feet of leaching facility) Furnished by A D / o� A F ,;Z aC a D s, GLCd�v� Sz'"�cV TOWN OF BARNSTABLE LOCATION el-o 1Z 4�'vT�.f#1�7 .��/C SEWAGE # ?_Da3sib VILLAGE a T"�� ASSESSOR'S MAP & LOT:B� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY _,�-LEACHING FACILITY: (type) (size)' xa NO.OF BEDROOMS BUILDER OR OWNER �/«S PERMITDATE: /'g'`o3 COMPLIANCE DATE: 17 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 Feet within 300 feet of leaching facility) Furnished,by pC 0 d . ill-db-ao? LOCATI1.ON �' SEWAC,E PERMIT NO. VILLAGE A & B CESSPOOL SERVICE q`1 128 BISHOPS TERRACE, HYANNIS, MA 02601 .'BUILDER OR OWNER 47 DATE PERMIT ISSUED g-3 DATE COMPLIANCE ISSUED �� 9 l a � 1 10.00 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ......... .........Town--....--....OF.......... ......................................... Aliptiratiou for Dispas al Works Tonstrurtiou Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: S02Putnam.Avenue.,...Cotuit..�'.....0263.5............ .•--......---------...----•-•-----•--....---------....-----...--------•--•----------------........ Location-Address or Lot No. Charles Wright...................................•----------•---.._..--------.. M2-2jahalxw...(Y— ue�..�0 lai, ,. ---0 26'a5--------.--- Owner Address A .. BCesspolervice 28.B hop __ ,-- ._..02 Q1.. _ _ S ...•.......................................... _.. Installer Address Type of Building Size Lot..............:............Sq. feet U Dwelling—No. of Bedrooms................3_.........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons.............2_............ Showers — Cafeteria Q' Other fixtures d . ------------------------ -------- W Design Flow........._123. .....�-gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity..AG ?.gallons Length................ Width----......---... Diameter--.------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length................... Total leaching area....................sq. ft. Seepage Pit No..Ia--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water.....................--. (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•---- -- ------------•---....----•-••---.....---•----------------•---•....._......---........................................................ 0 Description of Soil..................rand........ x x installation of a -1,000 gal. septic tank, U Nature of Repairs or Alterations—Answer when applicable............................................................................................... andi--a---60D.--gal-._1,eae_h--Pit--(.over-f--10w)--------------------------------------------------------------------------- •----------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sani ode—The under ' ned fur grees not t p ace the system in operation until a Certificate of Compliance as b by th _ 11/10/83 Sign --------------•- ..----------------------•---- Application Approved By............... .. 11 �e 8 ��........•-••••--------------------•---.....-- -------------- •. --------•--•-•---�-- --3-------- Date Application Disapproved for the following reasons:-------•--------------------•-------•--•----------------......-------------------------------•----------... .............••-----...----------•-•------•--•----•----------•-----------.....-----------------....•.....-----•----------------•------•------------------------•---•----•-------•-•----•-------•--•-•... /613 y Date Permit No.--------83 ......................................... IssuedL...AWD/83............................... Date N.............83'-----1 3 1 Fs$... ...10.�........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .Town...---......OF..........BA stable......... Jkv liration for Disposal Works Cnon,strnrtion rumit Application-is hereby made for a Permit to Construct ( )''or Repair ( X) an-'Individual Sewage Disposal- ' System at: 502-„Putnum Avenue,...Cotuit...MA.....02635•-•-------• ----••---•---•----------•--•-•................. Location-Address or Lot No. Charles 6lriEht_.......-•---------•-•---.._..-•-•----•------•----------------•- -592-EIA11 Avenue.#... 4tUAt.#... A---02635._..-•••--. Owner Address a A & B Cesspool Service 223 Bishops__Terr....V Hyann ... . .... 2601•-•• Installer Address d Type of Building Size Lot.................... .....Sq. feet U Dwelling—No. of Bedrooms................ ..............:.......Expansion Attic ( ) Garbage Grinder ( ) `04 4 Other—T e of Building No. of.persons.............9............ Showers — Cafeteria fll Other fixtures .---------_--_-_---- ......................Q W Design Flow........... per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity._f�Uagallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._f __t(----- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ ,.� Test Pit No. 1::..............minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZq Test Pit No 2................minutes per inch, Depth of Test Pit................•_.. Depth to ground water........................ g ....... , . .._,. 0 Description of Soil....',....... V - .. --•--_--_.. _.._k....... - - - - - - - ---- •--------•- -....----•------•----------•-•---- ---- -••----• --- --------•-- - -------....------------ W x ................. ,.. .. , iii�tallatiori--o�--a:--T;006•gaY:---sep£ic••:Unk, U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Md..&-.60.0..,a1...leaah..pit--4-oyarnalu ......--•---•--------------------------------------------•--------------------------------------------------...-----. Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitorf`y Code—The undersigned fur-tl:er agrees not to/place the system in Y g- g P Y operation until a Certificate of Compliance has been✓ssued by th o�rd-of�l:fQil S>gnefl ..................................... Application Approved By.............. '.._..........._. li/�..P/f33 Application Disapproved for the following reasons--------------------------------------------------------------------------------•--------------------------_...._ .................................•--•--•-- -- -------•-••---•-•-------•------•-.......-•-•------...•- -------------------•••-----------•----•-----•------- ......_. Date Permit No.........a - - 93:7......................................... Issued.....111i0 -83---•-------•------••-••-••••--- Date THE'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e Town Barnstable ...................... ..................OF.........................................:............................. ...... r e ;wrtifiratr of Toutpli attrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X) b A & B Cesspool Services 12S Bishops Terraces Hyannis MA 02603 Y _ Installer q. at...502 Putnam Ave., Cotuit, TIA 02635 Charles ffrright ----------••-••. has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as dessrib in the application for Disposal Works Construction Permit No.....83`............................ dated----._...._..._.. 3.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,*CONSTRUED GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....11�..1 �a3...._..... Inspector--_._ ...- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable -- ...................I......................OF.................................................................................... FEE....$ 10.00 No.._ ......._� .................... Disposal Works Tnn#rnr$Uan rrmi#. Permission is hereby granted............A_.4__B CeSssUool,-Selvl_Ce--------•.................................................................. to ConstFyl �uZnUM 17 e.r, (Co`tu tin idu 126 jags C Disposal Sy Atem t �" — at No............................................................................................................................................................................. Street as shown.on the application for Disposal Works Construction Permit No.._83 ........... Dated..-1i/10/83 •. u, 11/10/83 B.aV9f Health DATE................................................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS--- FtHE Tp� Town of Barnstable • eARNSTABM Board of Health rEn �s P.O.Box 534,Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. December 9, 2001 Mr. David Sanicki Cape & Islands Engineering 800 Falmouth Road Suite 301 C Mashpee, MA 02649 RE: 502 Putnam Avenue, Cotuit A=035- 008 Dear Mr. Sanicki: You are granted variances, on behalf of your clients, Christopher and Theresea Hills, to install an onsite sewage disposal system at 502 Putnam Avenue, Cotuit, Massachusetts. The variances granted are as follows: 310 CMR 15.211: To install a soil absorption system only five (5) feet away from the street property line, in lieu of the required minimum setback of ten feet. 310 CMR 15.211: The reserve area for the soil absorption system is designed to be placed only one (1)foot away from the street property line, in lieu of the required minimum setback of ten feet. 310 CMR 15.211: To install a soil absorption system only sixteen (16) feet away from the foundation wall, in lieu of the required minimum setback of twenty feet. sanicki3 Part VIII, SECTION 1.00: To place a soil absorption system ninety-six (96) feet away from a wetland, in lieu of the required 100 feet minimum setback. The variances are granted with the following conditions: (1) No more than three (3) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The septic system shall be installed in substantial compliance with the submitted plans dated October 23, 2001, revised November 21, 2001. (3) The designing engineer shall supervise the constriction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the susyem was installed in substantial compliance with the revised plans dated November 21, 2001. This variance is granted because the proposed replacement system will meet the "maximum feasible compliance" standards contained in the State Environmental Code, Title V. Sincerely yours, LC_ u s=�Gask, R.S. Chairperson Board of Health Town of Barnstable SGR/bcs sanicki3 I I + NOV 13 2001 �Op1HE Tp v,: tiNSI ABLE DATE: H DEPT. FEE: • BARNSrABLE, 9 MAS& 059. `0� REC. BY �f0 MA'S A Town of Barnstable SCHED. DATE: Board of Health 367 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H, Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION Property Address: 502 Putnam Avenue, Cotuit, MA Assessor's Map and Parcel Number: 035 parcel 008 Size of Lot: .35 acre Wetlands Within 300 Ft. Yes X Business Name: No Subdivision Name: APPLICANT'S NAME: Christopher & Theresa Hills Phone 508-428-0727 Did the owner of the property authorize you to represent him or her? Yes X No PROPERTY OWNER'S NAME CONTACT PERSON Name: Christopher & Theresa Hills Name: David Sanicki/Cape & Islands Engineering 800 Falmouth Road, Suite 301C Address: 502 Putnam Avenue, Cotuit, MA Address: Mashpee, MA 02649 Phone: 508-428-0727 Phone: 508-477-7272 VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) 310 CMR 1 . 05 __ SAS 5 off street properiline. SAS- 6 oil cellar wall. Reserve 1 off street property line Local Board of Health Regs. SAS 96from drainage ditch NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed,Septic System CX Checklist(to be completed by office staff-person receiving variance request application) _ Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Fuur(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,NLS.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/wP/vARZREQ CAPE &'ISLANDS ENCINEERINC SUMMERFIELD PARK 800 FALMOUTH ROAD,SUITE 307 C MASHPEE,MA 02649 (508)477-7272 FAX(508)477-9072 November 1, 2001 Mr. Tom McKean Barnstable Board of Health 367 Main Street Hyannis, MA 02601 RE: Map 38 parcel 8, House 502 Putnam Avenue, Cotuit, MA Dear Mr. McKean: The existing leaching pit servicing the existing 3-bedroom house is in hydraulic failure. The proposed repair has been designed in accordance with 310 CMR 15.404 Maximum Feasible .._....... Compliance. In accordance to 310 CMR 15.405 Local Upgrade Approval, we are requesting the following variances: The soil absorption system will be 5' off the street property line. (10' required) The soil absorption system will be 16' off the cellar wall (20' required) The reserve soil absorption system will be 1' off the street property line. In addition, Local Board of Health approval is requested for: The soil absorption system 96' from the drainage ditch(100' required). The new soil absorption system will be further from the ditch than the existing leaching pit. Soil testing is scheduled for November 15, 2001,the earliest available time. We are requesting that the variances requested be scheduled for the November 20, 2001 Board of Health meeting. Soil test information will be added to the plan and provided to the Board of Health at the meeting. Thank you for your considerations. Sincerely, CL.VLLCt.L. tiUt�. David Sanicki DS/cma Enclosure a " CAPE' & ISLANDS ENGINEERING SUMMERFIELD PARK 800 FALMOUTH ROAD,SUITE 301 C' MASHPEE,MA 02649 " (508)477-7272 FAX(508)477-9072 ^ Barnstable Board of Health 367 Main Street Hyannis,MA 02601 . RE: 502 Putnam`Avenue, Cotuit, MA Dear Mr. McKean: I,'ChristopherHills, owner of the.above referenced property hereby give Cape;&Islands Engineering permission to represent me at all hearings. Chri opher Hills r SKETCH ADDENDUM rower/Client hr;atooher and Theresa Hawkins Property Address 02 PLttnam Avenue _ City ^fu t County_Ba State MA rnstable Lender — -- Zip Code I I ' II III li ! lii ' IIII ji11 -I I III I II ij IT-,f�,` r it IHi1 : i t ! I ! ! I I it I i I I III : j ( iIi IIi ( IIi I. Ilj.l 1iI F �, 1I Lj �..L. I. I. IiII ij Iilijl I � I � II II I � i II Ills II I L L .I I i I ' I � , i I � i I , I ( I � i1 ; II � I l I"11 4-'_ � ;• I ! I , I _� � II. II ; ; IIi L, LjI I I , i ! I I I I Ili I i II it 0e'cK ' Frc� I I A1 ,7 + I ' FuL ; IIi j t I j � - �---- �3• i I III IIi j I i ,.• i I li it I I ��so�_ �d _ I 1 i i A III I I ' IIII I II I III. ji i l l � � !•� i ! Tfl II ! I III I I li , I i : I I I i 4 . � I I _ � I I ! � y < y , I I I fllj Ij i III I I � 1 ' I III III � I ! jI � � otseeF�,,.�,.e....,...r�- -•--•- - Lam. ._! i _� ' ' I I ! III � , SYSTEM PROFILE NOT TO SCALE NOTE: DISTRIBUTION LINE OUTLET ORIFICES SHALL BE EVENLY SPACED ALONG TWO ROWS RUNNING THE TOP OF LENGTH OF THE LINE,ON EACH SIDE,MIDWAY BETWEEN THE INVERT AND CENTERLINE WHICH SEPARATES FOUNDATION FINISH GRADE OVER THE UPPER AND LOWER HALVES OF THE PIPE. ORIFICES SHALL BE NO SMALLER THAN 3/8 INCH AND NO FINISH GRADE FINISH GRADE OVER LARGER THAN 5/8 INCH DIAMETER. EL. 77.8 DISTRIBUTION BOX 77.0 EL. 77.5 SEPTIC TANK 77.5 FINISH GRADE RISERS TO 6" _A^ OVER TRENCHES -*,,_RISERS FINISH GRADE ���'o� '1,0 �•°i' r'��O' '�.,r� ,•^o b4„�' '� ••o, ��b r. d' f , TRENCH LENGTH = 55'-0" RISERS TO 6" b, • o, 3 MIN. OUTLET PIPE(S) LEVEL °OF FINISH GRADE ; IMIKSLOPE 1% 3 r FOR 2'( MIN.1% SLOPE 75.20 6 MIN.SLOPE 1/o ° Q BEYOND END CAP. 3" DOUBLE WASHED PEASTONE e �.. O INLET INVERT MIN. _ - c0 - o - - - - - - - - - - - �'�� ; 13"MIN: MIN. _r ^` 0.005 FT./FT — — — — — — 0.005 FT./FT. -- ® 75.94 6 SUMP 76.15 'I IL, a_ 75.57 ` :., :. 75.40 n „ 75.69 3/4 - 1-1/2 DOUBLE oC 74- = PVC OR CAST IRON TEES =e WASHED CRUSHED INSTALL . �6_ DISTRIBUTION BOX _ STONE � GAS BAFFLE MINIMUM '.INSIDE DIMENSION 12„ -'7 ' EXISTING w ���' OUTLET INVERTS 2" BELOW INLET INVERT o MINIMUM CONCRETE WALL THICKNESS 2" - 5- axxb ' ' o _- 1000 GALLON BSMT.FLR. �' � =� PRECAST CONCRETE INSTALL ON ,COMPACTED LEVEL BASE Cr ELEV. 70.6 ooJo \6- - „ R e�S► SUwR��!,�G H-10 REINFORCED ' rorQ 40'�S 'i �r 8' ��,r, 1G C�RT�FY ,SIN STRICT •°. ,. .� ', o'r , ' •„ ,, , , e � STA AS lid :, �,�0 :0°• r. Qr. � �4 ,p .P�:i r• :r �r� `.�..�"��,�,1�`��® S'�'��\.��. r ���G A isC`z0 P � SEPTIC TANK BOTTOM OF TEST PIT EL.64.9 P INSTALL ON COMPACTED LEVEL BASE TRENCH SECTION 310 CMR 15.405 LOCAL UPGRADE APPROVAL TITLE V VARIANCES SAS TO STREET LINE 5' [10' REQ'D.] NOTE: EXCAVATE TO =C= STR/�,TUM IN ORDER TO SAS TO CELLAR WALL 16' [20' REQ'D.] REMOVE ALL =A= & =B= IMPER'�/IOUs MATERIAL g" MIN. 3" OF 1/8" - 1/2" RESERVE TO STREET LINE 1' WITHIN 5' OF THE SAS. REPLACE WITH CLEAN, CLAY-FREE SAND (80") 4" DIAM. 36" MAX. DOUBLE WASHED BARNSTABLE BOARD OF HEALTH VARIANCE: PEASTONE SAS TO WETLAND 96' [100' REQ'D.] NOTE: EXCAVATE TO =C= STRATUM IN ORDER TO GENERAL TOTES: 3/4"- 1-1/2" DOUBLE REMOVE ALL =A= & =B= IMPERVIOUS MATERIAL \ 1. ELEVATIONS SHOWN ARE BASED ON ASSUMED 24" �° �> WASHED CRUSHED I 'WITHIN r �� _ c - G , rCl1 „ALL PIPES LR Th-IE SYSTE�.1 �11UST BE CAST IRON cn I OF THE-.SAS. REPLACE�I`�I,H Cl N 2. ,���__ � STONE I CLAY-FREE SAND (80")` \. OR SCHEDULE 40 PVC. ; MUST BE NOTIFIED WHEN'LANDS ENGINEERING OBSERVATION PIT \ 3. HEALTH AGENT/CAPE & IS CONSTRUCTION IS \ COMPLETE PRIOR TO BACKFILLING. P-10,100 TRENCH WIDTH 4.ANY CHANGES IN THIS PLAN MUST BE APPROVED PERCOLATION RATE: < 2 MIN./IN 4'-0" SER�)�E "T \'\;a BY CAPE & ISLANDS ENGINEERING AND THE BOARD ';NITNESSLD BY: DAVE STANTON wPcER OF HEALTH. EARNSTABLE BOARD OF HEALTH DESIGN DATA N I 5. MATERIALS AND INSTALLATION SHALL BE IN DATE: NOV.15,2001 I.—I ' \• COMPLIANCE WITH THE STATE SANITARY CODE \ [TITLE V] AND LOCAL APPLICABLE RULES AND o„ EL.76.4 =A= LOAM REGULATIONS. 10 YR 2/2 NUMBER. OF BEDROOMS 3 . � � I � •\ � C. 6. NORTH ARROW IS FROM RECORD PLANS AND IS 6° GARBAGE DISPOSAL NO G \ NOT INTENDED FOR SOLAR ENERGY PURPOSES. =B= LOAMY AND DAILY FLOW 330 GPD; Ex\s�\N o y 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. 10YR 5/4 SEPTIC TANK PROVIDED 1000 GAL. o \ \\ 1000 G-�`p,NK \ `" 8. FLOOD ZONE C [NON-HAZARD] 12 SAND FILL LEACHING REQUIRED 330 GPD. '6048" SOIL ABSORPTION SYSTEM CALCULATIONS: VE ELL�NG 8 \ =A= LOAM o\ \� N\\ \.\ 10 YR 2l2 SIDEWALL AREA = 152 SF. s2 =B= LOAMY SAND 152 SF. X .74 G/SF. = 112 GPD. 10YR 5/4 BOTTOM AREA = 329 SF. 80" 329 SF. X 0.74 G/SF. = 243 GPD. I =C= MEDIUM SAND LEACHING PROVIDED = 355 GPD. LEGEND 10YR 7/4 - '52 PROPOSED CONTOUR NO GROUNDWATER EL.64.9 138' SEPTIC SYSTEM REPAIR 16 31, A-o- ��� \NG 4-\Q �� —� -—-52-—- EXISTING CONTOUR I Z ^^4 PROPOSED SEWAGE DISPOSAL SYSTEM - -- _ \ OBSERVATION PIT �r�y ' 10 gERE- — — z ; PREPARED FOR I i A o El DISTRIBUTION BOX I r / CHRISTOPHER & THERESA HILLS I �\ z I HSE.NO. 502 PUTNA AVENUE DRAIN PIPE _ N 1 ` � .� ..� W � ; o 0 o SEPTIC COTUIT,MASS. uj SOIL ABSORPTION SYSTEM F- — vEw AY z - PLAN N0. 102301 SCALE: AS NOTED pR\ DATE: OCT.23,2001 Pp,�ED RESERVE RESERVE AREA o ��N FILE N0. 221 BA DAVI \b`°, SEPTIC FILE N0. 70 22.26 PIPE INVERT ELEVATION o CHARLE PCS FILE: PUTNAM AVE - �` o SANK, z 28035 CAPE & ISLANDS ENGINEERING fj. I 38 8 502 �_ o o p�sS 9FrstE�cO �f/A 800 FALMOUTH ROAD, SUITE 301 C w w w / q«�`� �% M SHPEE,MA 02649 (508)477-7272 PLOT PLAN MAP SEC PCL LOT HSE > W> t o SCALE: 1" = 20' - `� L