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HomeMy WebLinkAbout0020 RALYN ROAD - Health 20 Ralyn.Road Cotuit A= �� -® --- — - ---- --- -- r� I� TOWN OF B STABLE IAW'I.ON _® ea / of � ' tE SEWAGE # VILLAGE �B �a � �a ASSESSOR'S MAP& LOT-- .. t . INSTAI.PWS NAME&PHONE NO. SEPTIC TANK CAPACM. LEACITNG FACILITY' (type) 1'"�� (size) 014 �f N0,OF'BEDROOMS 3 j BUILDER OR OWNER PER.MIT DA7 E:---,, M # UANC E 1DATE. Separation Distar►ce Eetws60 the; Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility hcet Private Water Supply Well and Leaching facility�(If any wells exist Ott site or dvltwn 200 feet of leaching faciUty)' Edge of Wetland and lLeaclting Facility(If any wetlands exist within 300 foot leap ia Iariliry 7'�2� �h�it✓h /•j e sec Fur►a shed by e 9tcL K TOWN F BARNSTABLE 1� .,/) I LOCATION �n IC G [ y✓I � SEWAGE # viLLAGE L 6_61 61+ ASSESSOR'S MAP&LOT Wa"O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY `06 C, - LEACHING FACILITY: (type) Lec r4 (size) �dDU 6c, �. . t NO.OF BEDROOMS 3 BUILDER OR OWNER L G t,r% P G C(CA L o. �C pERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of 1 aching facility) J Feet Furnished by J� r�li✓� /�1 ��� 5!V Ti Z ► �j, Deck ,� 9 /�-e- �o� _ ►�^�_ 1�' �+ . r 31 ' -F- 43' TO OFBARNS5ABLE _- LOCATIVN SEWAGE# VILLAGE /l!/]' � �1 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. eo SEPTIC TANK CAPACITY 'e-o$"� 7e; 4X LEACHING FACILITY: (type) l 1 � (size) f' NO.-OF BEDROOMS {' { BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ,k on site or within 200 feet of leaching facility) Feet Edge of Wetland and eac ng Facility If an ` etl s exist „ within 300 f t le c�n i;hty) - - Feet Furnished by/ ' RAU 6+ i \�Lli5", , 1. 'TOWN OF BARNSTABLE _ 9 . IrCK:AT'.rJN SEWAGE# VILLAGE ®� ��� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. r SEPTIC TANK CAPACITY LEACHING FACILTI'Y: (type) a .136,, (size) NO.OF BEDROOMS BUILDER OR OWNER 25-1�/ l�el PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fee f 1 achi facility) Feet Furnished by ' / b/ E 0 Cik T ION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME 6 ADDRESS 0 UILDE R OR OWNER TdAW Ill show , DATE PERMIT ISSUED -o��� 3 . DAT E COMPLIANCE ISSUED 43 Aw 9 f `1 I f 0 Noi3.�33 FRs.......1................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -----------------OF.......................................................................................... Applira#ion for Ui-qpn,oal Workii Tumarurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal em Sys at: _...... .... i.f 1- �� -... .... ... ------------.... ...... ................................ Location-.... res dd or Lot.No. - S'.►�.. 0 -- - .............................................. W ................ �.:...... .OSµ ......... Address......... ............... a Installer Address d Type of uilding p Size Lo . re VDwelling—No. of Bedrooms----* .....Expansion Attic ( ) GarbaGri er� '4 Other—Type of Building No. of persons............................ Showers Cafe ria 04 Other fixtures ................................. W Design Flow.........:3 ..62.........:............gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid'capacity,f0'0'Qgallons Length................ Width................ Diameter...----......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►-' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...--..--............... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....-----.............. P4 ---•---- ----.... •--------------------- --.----------------------------- ..--- ------------------------ •....... ---------- •---------... Descriptionof Soil -----------------------•-----------•---•--•--••----•------------------•-------•------------------------------•---•-----•-•--•--•---•--- x W -----••------•------------------•-•-...----•----------•••---------------------------•---••--•-•-------•-•-------•---------------------------•-------•---••••--•----••-----------•-------•-•--------..... UNature of Repairs or Alterations—Answer when applicable............................................................................................... •------------------------------------------•-------------------------------------------•--..........-------------------------------------------------------------•---------------------••-------•--..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of A. L y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the bo�d o ealth. r GG Sig --- • ••... .............. t_ a_.... A lication Approved B ...d o PP PP By..... --•- Date Application Disapprove or a following reasons-------------------------------••------------------------------------------........--•-•----•-•-•..._........._.. .........-•-••-----••--...-••---...•--••--•......................•-•-•---•-•---•-•----•-•---------••--------••••----•-•-•••------•----•-•-••-----••-----•--••--------•.......----... ---••••------- Date PermitNo......................................................... Issued-....................................................... Date � � ' ` V. . ` ' FRm--2........__--. THE oo�momvvsx�r* F � o� m��s��uuss��s ' `������ ���� ���� HEALTH -- -- ' '' '-- -- ` ' '__' `-- ' - ' ................... ....................OF................................................................A ��� �«�� �~�� _ 4���o4���� Disposal Works TouWstrurtion rumit . . ' Application is hereby made for uPermit to Construct ( \ or Repair ( \ an Individual Sewage Disposal System at: � � Lncatin '�o�mu or Lot ' Owner Installer ' Address Type of Dwelling--No of Bedrooms Attic ( ) Garbage Grieer Otb&--Ivoe of Building -----------.--' No c6 persons.......:.................... Sbwrara ( ) - r: Cafe ria - 04 Other bztocoa .------__----'--__----_-_--'-..._--'-_--''--_-____---_-_______. ' D�x6�o ��n�' day. Total 6�6, 8o�. Design ----_..--------'-'--'_�u/ooap«cyecxoo ��z '. ou ���, -'.-----------_------.gallons. Septic Tank--Liquid capacity............gallons Length.......... ..... Width................ Diameter.-.._--- Depth............... ' Disposal Trench--IVo. ---------- Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No...------- Diaoeter.----.--' Depth below inlcL---------- Iota leaching area_...............sq. f t. Z Other Distribution box ( ) Dosing tank ( ) ^� Percolation Test Ileonita I,edorozcd hy---._'--.-_---_----------'--..--_ I)�e----.-------------- 7�ut Pit No. ].---.--nnioutcay�c�oc� Depth of Test ��--'------ Depth to ground water......................... ~~ Test Pit No. 2.................minutes per inch Depth of Test Pit--.------' Deptbtogroundwater---------. ,~ -.-_-------------.---------------------'---_---'_'---'-'----------'---.__--'-- 0 Description c6 Soil.............'......................................................................................................................................................... ------------------------ _ ------,----.--__'----'--_-_-----___----_-.-_--_.--'-_-._--..-_'----_'---____-_ U Nature of Repairs or Alterations--Answer when -._._-'_.-'_-------.---_.---_.-_-_-_- ____________ Agreement: The undersigned agrees to install the mforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIEE 5 of the State Sanitary [ode— The undersigned further agrees not to place the system in oD«ruroo until a Certificate of Compliance has been issued by the board of health. --------- ---Application --- - - Approved _'-' -_-----__-______-----__-----'- --- -_--_..----- ' um" Application Disapprove o, x following reasons:................................................................................................................ , -----`-------------------''---------------`---------------------------`------- Date Peru Date THE comwomvvEALrH OF mAssACHussrrs BOARD OF HEALTH ������������......OF......................................................................... .....Tutifiratr of Tompliattrr CERJAFY, That the Individual Sewage Disposal System constructed (414 Repaired HIS IS J as been installed in accordance w h t-ie provisions of application for D�pvuu rvm^^ �vmtucumncoumt Nu���..4.---__-�..~e-.�-'- uu�u .^ .................... THE �SU�� OF THIS �U���� S�� NOT � C��� A� UARANTEE THAT THE SYSTEM WILYFJMCTION SATISFACTORY. or ' THE COMMONWEALTH or mussAo*ussrrs BOARD OF HEALTH ..................... ..................OF..................................................................................... - ^ EE to �o or an I al Sewage Disposal System C o Zns at as shown on the app fo is osal Torks Construction Permit No........ ... .... Dated.............. ZBoard of Health FORM H BBS & WARREN. INC.. PUBLISHERS i 5iw6Lr FAMILY( - 5 BEDROOM \ 2 uo GAi;,BAGE 6Q'wDE2 n, �-� ��� I4 8 25�39 SEPTIC, TPJK = 330x1500/• = A95b.Po u5E- 1000 0%,5P05AL PIT u6E 1000 5►DGWALL ARGa - I>0 5,F Ica?R20P' 150 1' 50TTO' M AREA= o S,F. Id Ip 78 tt'S6 F x I• o � • 50 6.po' /V/ IL ^foTAl-. DESIGN �25 G.PD• I n 1> 'TOTAL DA►1-Y Fti-DW - 330 G.Po, 1� 7120P TALI PER.00t-AT�oN RATEr I'�IN 2M►N o�LE55' "--'-" • -.—•^�--., 'i•. I! FtfCHAfiD 'S+ 02 ALAN Cylp A. J SAXTE.R �• o' NES U No.2.1048 No. 25 4 Q�ST hp SUR�i' / AL • O�ZJ �ST�. �� � • ' ; TE`�T 19 F&'loo TOP FWD=tdl• d �y^y LOG loov lN�• AL, SIJ13S01(.• BuX INS 59PT�G lOoo INS/ � G TANK �• ' 2 LEAGl1 PIT INV. INV. w1 ru 99.Z. Irl WASNGD K ; 6TvN6 ,I CERTIFIGP PLOT PL.AP.i';' PRUFILG hoG4-tIo1�I Coro 17 No SGAL.E 5c-ALE ILL �C7.. SATE Gj*I(-g� �n UJA I P�.A N RE P 6 2EN GE- CERTIFY THAT THE I�Sg SNc)ww NE•21 o t� GoMPi-�{5 1r�1 ITN-T NE S I pELI IJ'� � 4, A 1�1 D 5 6T 6i0.G K R. R�►R.E M E rl'T> o f 'T N E- -TowN of "BkaN/-7rA4U;ANv 22Q LOGp.TE D W ITNI IJ T '6 G a1D PL 11,1 ► L• 1 I DA'r1✓ S�I�- BAxTEQ•e WYE INC• � � ! 'T1115 Pl-D.N 15 NET gnSFo ob AN "o6TC-9-VILLE MA55• _UtAeWT Su2V><y - oFF5ET5 Suoul. NOT DE 'VSEOTO DETE.RI�I►at✓ Lo"r ►►INE APPLIC P%W r . .MMcgM� (E 1-11Vy f l U f"l ti- Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , M 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector } Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-9-09 0 Inspector's gnature Date The system.inspector shall submit a copy of this inspection report to the Approv g Authar (Bd of Health or DEP)within 30 days of completing this inspection. If the system is a shared system has a design flow of 10,000 gpd or greater,the inspector and the system owner hall submit theses report to the appropriate regional office of the DEP. The original should be sent. the sys R oar 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. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 t i Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 20 Ralyn.Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any_of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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): Y ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 �9-8-09 every page. City/Town 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 t ❑ 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: El.. '-The system has a septic tank and soil absorption,syste`m (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. t5insp official document-03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 every page. City/Town 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 ❑ ® 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 '/z day flow E ® 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. t5insp official document-03/08 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 ,, 20 Ralyn Rd a Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 , every page. City/Town 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. f 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 ❑ a ❑ 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 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection El 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 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? I ® ❑ 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)] 7 t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments M 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a.separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 6-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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/use: Date - Other(describe): t5insp,official document•03/08 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 M 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information 4 Pumping Records: ' Source of information: Owner-pumped 2005 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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) El Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments M 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit - MA 02635 9-8-09 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence.of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age:g '. � years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26 Scum,thickness 0 Distance from top,pf scum to.top of outlet tee or baffle 16" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank is in good condition with baffles installed and no sign of leakage. 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.): 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): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 . every page. CitylTown 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 worldng 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on siteplan): ' Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 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: 1-1000gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑Y 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.): Leach pit in good working order with no sign of failure and stain line at 12" below inlet invert. t5lnsp official document•03/08 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 rl Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Ralyn Rd , Property Address Laurie Waclawik 7 . Owner Owner's Name +. information is required for Cotuit MA 02635 9-8-09 every page. City/Town 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 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.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 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. OeCk t I � p� A-F- 3(' A-F- - 5-93 UO t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments . G M 20 Ralyn Rd - _ - Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 9-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope , ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans owrecord 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: Original design plans show no groundwater at 12'. { V t t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 n Commonwealth of Massachusetts '. `title 5 O clal-lns ectlon for Subsurface Sewage'Disposal System Form-Not for Voluntary Assessments ' 20 Ralyn Rd Property Address Laurie Waclawik t Owner Owner's Name information ir Cotuit - . . . .<< MA 02635 5-10-07 every page. City/Town State Zip Code Date of Inspection „- r Inspection results must be submitted on this form.Inspection forms may not be altered in any way. .. • �4/�..7 7 A. General information 1. Inspector Shawn Mcelroy.. Name of Inspector Shawn Mcelroy Enterprises • ` Company Name 29 Atwater Dr. Company Address E. Falmouth .'MA.. 02536 Cityfrown State Zip Code 1-508-495-0905 Telephone Number License Number B. Certification 4 r tf , 1 certify that I have personally inspected the sewage disposal system at this address and''tt the' information reported below is true,accurate and complete as of the time of the insl i ction.Ae inspection was performed based on my training and experience in the proper function and maintenanc of 6A'site y sewage disposal systems. I am a DEP approved system inspector pursuant by4ection45.34Ekof Title 5(310 CMR 15.000).The,system:, ® Passes. >>�s ❑ Conditionally.Passes t, '` ❑ Fa , ❑ Needs Further Evaluation b the Local Approving 1 „Authority J f M y pprovi Authori . A CD rm ,.. WN � - 5-12-07 Inspector's Signature Date k The system inspector shalt 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,©00 gpd or greater,the inspector and the system owner shall submit the a report to the appropriate regional office of the DEP.The original should be sent to the system owner a. c », , and copies sent to the buyer,if applicable, and the approving authority. , ****This report only describes conditions at the time bf inspection and under the conditions of use at that time.This inspection sloes not address hove the system gill perform in the future under the same or different conditions of use. t5ir sp•0&06 ' Tclie-5O ictal Ir spedw Fome Subsurface Sewage D'aposal Systern•Page 1 of 15' Commonwealth of Massachusetts e r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 5-10-07 every page. Cityfrown state Zip Code Date of Inspection B. Certification (cost_) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order. 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 t5insp-08/06 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection 1=ort.. Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd ++•, , Property Address Laurie Waclawik *,, + } Owner Owner's Name information is Cotuit .+, : MA 02635 5-10-07 " required for. •_ `•` every page. r Cityfrown, ' . # ` :- State Zip Code Date of Inspection - , j B. Certification (cost.) B) System Conditionally.Passes (cunt.): EY distribution boz is"leveled or replaced ". .a it', ND Explain: a in V ti ❑ 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 orthe'environment.F 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'suiface water } .❑ 'Cesspool-or"privy is within 50 feet of a bordering vegetated wefland or a salt marsh 2. System will fail unless the Board of Health(andPublic Water Supplier, if any) determines that the system is functioning'in a manner that protects the public health, -' safety and environment: . ., , t 1t "► ❑ -The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 fee_t 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. t5insp•08M' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection .dorm . , Subsurface.Sewage Disposal System Form•-'Not for Voluntary Assessments ...£: 20 Ralyn Rd Property Address Laurie Waclawik r Owner Owner's Name information is required for Cotuit MA 02635 5-10-07 ' every page. Cityfrown state Zip Code Date of Inspection B. Certification (cont.) r. • i C) Further Evaluation is Required by the Board of.Heafth (cunt.): to . ❑ 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 ❑ ® 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 y' ❑ ®` or.clogged SAS or cesspool ® Liquid depth in cesspool is less than,,6'below'irivert oravailable volume is less than '/z day flow of .l Required pumping more.than 4 times in the last year NOT due to clogged or Elr ® obstructed pipe(s).. Number of times pumped: t El ® -Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•=06 Trtfe 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 y 20 Ralyn Rd ` Property Address Laurie Waclawik Owner Owner's Name information is Cotuit a MA 02635 5-10-07 required for - every page. City/Town - State Zip Code Date of Inspection B. Certification (cunt.) t 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 conform 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 j`- ❑ LEI V 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"non,to each of the following, in addition to the questions in Section D. Yes `No _ t. ';, + ^• ❑, . ❑ -' the system is within 400 feet of a surface drinking water supply ❑`;,,i the'-system is within 200 feet of a tributary to a surface drinking water supply ❑ El 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 1f 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. t5insp•,08= Title 5 Official lnspechon Form:Subsurface Sewage Disposal System•Page 5 of 15 I ^ Commonwealth of Massachusetts Title 5 Official .lnspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit " MA 02635 5-10-07 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 4 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,exdudino 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: .® 0 ' r 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•08/06 Title 5 Official Insped ion Forth:Subsurface Sewage Disposal System•Page 6 of 15, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface-Sewage Disposal System.Form:-Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit r MA 02635 5-10-07 every page. City(rown State Zip Code Date of Inspection - D. System Information L •' . . 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 Number of current residents: 3 Does residence have a garbage grinder's 'r + , ❑ Yes ® No Is laundry on a separate sewage system?[rf yes separate inspection required] ❑ Yes ® No Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available past 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 5-10'07- � •n° - � • Date Commercial/Industrial Flow Conditions: Type of Establishment: a- - Design flow(based on 310 CMR 15:203): - j ,„' 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/use: a • Date Other(describe): t5insp•08/O6 _x Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 15 Commonwealth of Massachusetts 4 d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Ralyn Rd Property Address 1 Laurie Waclawik ' Owner Owner's Name information is required for Cotuit MA 02635 5-10-07 every page. CitylTown ' State Zip Code Date of Inspection D. System Information (cunt.) r , : General Information Pumping Records: ...: , Source of information: Owner—pumped 2005 Was system pumped as part of the inspection? ❑ Yes ❑ No If yes,volume pumped: ' gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank,distribution box, soil absorption system ; ❑ Single cesspool ❑ Overflow cesspool r ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ElInnovative/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,(d known)and source of information: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08106 . Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts f Title 5 Of'icialInspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik r Owner Owner's Name information is required for Cotuit : ' MA 02635 5-10-07 - , every page. Cityrrown ;+ State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): 18" Depth below grade: 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.): f Septic Tank(locate on site plan):, Depth below grade: 12" feet Material of construction: ® concrete_, ❑ metal- ❑fiberglass ❑ polyethylene-- r ❑ other(explain) If tank is metal, list age`. ° a t Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)_ '❑ Yes ❑ No ---------- ---------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal 4" Sludge depth: Distance from top'of sludge to bottom of outlet tee or baffle Scum thickness t) Distance from top of scum to top of outlet tee or baffle :6" i Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp-08/06 r Title 5 Official Inspection Forth'.Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Offic'ial:lnspection For - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address ' Laurie Waclawik Owner Owner's Name information is required for Cotuit MA 02635 5-10-07 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee.or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 44A '.�•i- It trr .� Grease Trap (locate on site plan): :r Depth below grade:.,„ • :, ac feet' ` Material of construction: ❑ concrete ❑ metal ❑fiberglass . r• ❑'polyethylene ❑ other(explain): Dimensions: I - 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 0 fiberglass ❑polyethylene,,e.. ❑ other(explain): 1 t- t5insp•08108 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 , 20 Ralyn Rd Property Address +' Laurie Waclawik ; Owner Owner's Name information is required for Cotuit MA 02635 5-10-07 r every page. City/Town u '; State Zip Code Date of Inspection D. System Information (cunt.) . Tight or,Holding Tank(cont.) Dimensions: Capacity: gallons Design.Flow: gallons per day Alarm present: - •t+'❑ 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 . Comments(note if box is level and distribution to outletswequal,.any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ' J, Good condition. Pump Chamber{locate on site plan): r i' • • , <;d t_y ,r.+ Pumps in working order: • _ ❑' Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp-08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts , : - = Title 5 Official.1 n'spection form , a Subsurface.Sewage Disposal System Form -Not for.Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information isrequ Cotuit MA 02635 5-10-07 everyPa f9e. City/Town 1 State Zip Code Date of Inspection y D. System Information (cunt.) F 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: 7r ® leaching pits number: 6'x6' ❑ leaching chambers number: ❑ leaching galleries-. , number: ❑ leaching trenches . _ number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool' number:, ' ❑ innovative/aftemative system Type/name of technology. Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach pit in good working order with water level at 16"below inlet inve4. t5insp•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 Forme-Not-for Voluntary Assessments 20 Ralyn Rd ` Property Address Laurie Waclawik Owner Owner's Name " required is Cotuit MA 02635 5-10-07 required for ' every page. Cityrrown 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 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.): Privylocate on siteplan): ( , Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): tSinsPr ; Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official lnspectioWfor ' . . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` w 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is-equired for Cotuit MA 02635 5-10-07 ' every page. City(rown State Zip Code Date of Inspection D. System Information (coot.) f , 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. K >r A ' . 0,�6' lJ r t5insp•08M Fife 5 Qfrtcial InspecBon Fume-Subsurface.Sewage Deposal System-Page 14 of 15 Commonwealth of Massachusetts Tittle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Ralyn Rd Property Address Laurie Waclawik Owner Owner's Name information is required for Cotuit MA , 02635 5-10-07 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope , Surface water ❑ Check cellar ❑ Shallow wells 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: Original design plans show groundwater at greater than 12'. t5insp-08M Ti@e 5 OFfidaf Inspection Form:Subsurface Sewage D4mf System-Page 15 of 15 ' COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTAR SUBSURFACE SEWAGE DISPOSAL SYSTE Y1 F61.9EIVED PART A CERTIFICATION AUG 8 2002 Property Address: 20 Ralyn Road TOWN OFBARNSTABLE C o t u i t .Mass . HEALTH DEPT. Owner's Name:Robert Sprague Owner's Address: Same Date bf Inspection:8 S 02 Name of Inspector: (please print) Joseph P. Macomber Jr. CompanyName: jog, P. Ma QMbar & Son, Inc. ®22 Mailing Address: _gnx tih MAP rant-'rvi 1 1 ay M 02632-0066 Telephone Number508-775-3 8 PARCEL. L� CERTIFICATION STATEMENT LOT 1 certify that 1 have personalty inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP Approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ,Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: / Date: da►�-dam The system inspectors 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. Notes and Comments ****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 I i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: 20 Ralyn Road Cotuit .Mass . Owner: Robert Sprague Date of Inspection: 8/5/0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D . A. y� stem Pas— s—e /J�. n ~_ ,�jGave _ot found an yin indicates that any of the failure criteria described in 310 CMR 15.303 or ui f0 CMR I 304 eki`st.- Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the Present time . 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. j(_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 ND explain: ✓JG� 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: Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem Address:20 Ralyn Road Cotuit , Mass . Owoer:Robert Surague Date of Inspection: , 8/5/02 C. Furiher Evaluation is Required by the Board of Health: AL Conditions exist which require further evaluation by th'e Board of Health in order to determine if the system is fading to protect public health, safety or the environment. I. SNstem 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 wbich will protect public bealtb, safety and the environment: ,4L0 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 S'Nstem 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,witMn 100 feet of a surface water supply or rributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple 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 feet or more from a private \+ater supply -ell" 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 faciliry and the presence of ammonia nirrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are Riggered. A copy of the analysis must be anached to this form. 3. Other: 3 L I Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Ralyn Road Cotuit ,Mass . Owner: Robert Sprague Date of Inspection: 8 5/02 D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no" to each of the following for all inspections: Yes No/ _ �/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged'SAS or _ 42cesspool , 1-4,AKx lelXJd' ,Liquid depth in ccsspoeI is less than 6"below invert or available volume is less than ''/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0 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 I of a public well. _ v 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 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 forma ,U (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 3.10 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 ��he system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Lnterim Wellhead Protection Area- IWPA)or a mapped Zone 11 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. 4 r Page 5 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Ralyn Road Cotuit ,Mass . Owner: Robert Sprague Date of Inspection: 8/5/02 Check if the following have been clone-You must indicate "yes"or"no" as to each of the following: Yes iv'o/ �/ 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 ? 9 4/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 ? 16 _ Were all system components, uding 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 conso-uction, dimensions, depth of liquid, depth of sludge and depth of scum ? Was the facility owner and occupants if different from owner)( pprovided 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 kExisting 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(3)(b)) h 5 Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:20 Ralyn Road otuit , ass . Owner: Robert. Sprague Date of Inspection: 8 5 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMF� 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: _�_ Does residence have a garbage grinder(yes or no): 4)0 Is laundry on a separate sewage system ( es or no):/-74P (if yes separate inspection required) Laundry system inspected ( s or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)):2000-17 , 000 gal Ions=46 . 58 GPD Sump pump(yes or no):AW4 O 2 — _ , gallons=54 . 80 GPD Last date of occupancy: . COMM E.RCLALULNDUSTRlAL Type of establishment: Design now (based on 310 CMR 15.203): gpd Basis of design now(seats/persons/sgft,etc.): Grease trap present (yes or no): A—)/? Industrial waste holding tank present (yes or no): ti� Non-sanitary waste discharged to the Title 5 system (yes or no); _ Water meter readings, if available: La5t date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of informationNone available Was system pumped as pan of the inspection (yes or no). If yes, volume pumped: Or gallons -- How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM Septic tank, distribution box, soil absorption system D Single cesspool 41 Overflow cesspool .VP Privy ,,V Shared system (yes or no)(if yes, attach previous inspection records, if any) A Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) &eTight tank .PJi4 Attach a copy of the DEP approval AD Other(describe): Approximate ao Of al compon is date installed (if known)and source of information: Were sewage odors detected when arriving at the site (yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM -. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:20 Ralyn Road otuit, ass . OwnerRobert Sprague Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction:,f&cast iron !'40 PVCAO' other(explain): ili/9 Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight . No evidence of Leakage .The system is vented through the house vents . SEPTIC TANK: Zoocate on site plan) Depth below grade: f� / Material of construction Y: concrete,e�o metal�fiberglass.0 polyethylene other(explain) A419 If tank is metal list age: AP is age confirmed by a Certificate of Compliance(yes or no)� z- (attach a copy of certificate) >� Dimensions: ���;��� /D,y�iaL chi/i7"/� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle; Scum thickness: %�Z Distance from top of scum to top of outlet tee or baffle: 1 , Distance from bottom of scum to bottom of outlet tee or baffle: a� How were dimensions determined: �Ss/f�p�,f Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the .SPntir tank every 2-3 y a Inlets.&.,outlet inverts are in place . The tank is structurall`y sound and shows . no evidence of leakage . Liquid level at the outlet invert is 5111 GREASE TRAI .(locate on site plan) Depth below grade: 2,14 Material of construction:4?concrete,�AmetaLL;jffiberglas&j.&olyethyleneA/0 other (explain): Dimensions: Scum thickness: 4 Distance from top of scum to top of outlet tee or baffle: — Distance from bottom of scum to bottom of outlet tee or baffle: r9 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.): Grease trap is not present 7 Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Ralyn Road otuit , ass . Owner: Robert Sprague Date of Inspection: 8/5/0 2 TIGHT or HOLDING TAN} (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete t& metal fiberglass >f polyethylene,40 other(explain): Dimensions: Capacity: gallons Desien Flow: X14 gallons/day Alarm present (yes or no): Alarm level: rf Alarm in working order(yes or no):, Date of last pumping: mil/ Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: �(if present must be opened)(locate on site plan) Depth of liquid level above outlet Wlb 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.): Distribution box has 1 lateral . No evidence of solids carry over .No evidence of leakage into or out of the ox PUMP CHAMBEV44l ulocate 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.): Pump chamber is not present :f 8 I Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Ralyn Road Cotuit ,Mass . Owner:Robert Sprague Date of Inspection: 8/5/0 2 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) 1-1000 gallon precast leaching pit packed in stone . ( 6 'X10 ' ) If SAS not located explain why: Located see page 10 Type ✓ leaching pits, number: PJ�X11J° A10 leaching chambers, number: Q ,g2,2 leaching galleries,number: 10 ,Jlz leaching trenches,number, length: CP Alt) leaching fields,number, dimensions: A2-overflow cesspool, number: 0 4a innovative/alternative system Type/name of technology: C'-feu Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy loam to fine sand No_ signs of hydraulic failure or Ponding . Soils are dry Vegetation is normal Wastewater is 54" below the invert pipe . CESSPOOLS' (cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: /f Depth of solids layer: Depth of scum laver: ,y 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.): Cesspools are not present PRIVY,4 (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.): Privy is not present _ 9 pagc 10 0( I I OFFICLAJ- INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continvcd) P,op(M-� A00f(3'1: 20 Ralyn Road Cotuit Mass . Oxocr. Robert prague Disc of Intpcctim H 5 02 SK.£TCH OF SEWACE DISPOSAL SYSTEM ho.ioc t tkcich o/thc t<wtp oitpotcl lyltcm including tics to it Icast two permanc'nt rcrcrcncc IdnGnukt o ocncrmvki Loccic to ..tilt .iitin 100 fc<t. Locctc what pvblic w&tcr ivpply cnttrt the bvilo*n6. p al h Road , Co 1v�f' w>4v! Q�.3r a� CtUJy,. mow% 77 to Page 1 1 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Ralyn Road Cotuit ,Mass . Owner: Robert S ra ue Date of Inspection: 8 5 02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: _ 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) S,e-s Accessed USGS database-explain: http//town . barnstable .ma . us . You must describe how you established the high ground water elevation: Used ; Gahrety & Miller Model . Ground water elevations above sea level , 12 16 94 USED ; USES ; Observation Well Data . June 1992 Used . USGS; Techniwcal bulletin 92-000-2 Pla e#2 Annuni ,-angpgnf ground i up of r un . water. elevations . Leaching f Pit -eet Groundwater: Feet Below Bottom of Pit High g Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottomr of the leaching pit and the adjusted groundwater table is feet. 11 l f rr.-rr^rt:rr-.'rr i-rr.-m-•nmm-r.. . . �'' TTT T.T'•.TTmr:1'a"t*T11•It�{Ti TTST14.T.IT.� _.TiiT-TT•• .. - k Barnstable '—'- - "- TOWN OF BOARD OF HEALTH I 0 SUBSURFACE SFWAGF DISfOSnL SYSTEM IN3I1ECTION FORM - PART D - CERTIFICATION •.•-••••T••.''.: �-.f�••�.T.T.�n'n:rfv DTP:RT'ITrTT.T'.��•.'1 '•M1tRT•"fT.'fTTPi'�TrTR1.'.ti.IiT'RR1"i'TR'M1T� tsm rt'�rrrrssv^.m�rrrtr.•.—.rrrr-•- —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 20 Ralyn Road Cotuit Mass . ASSESSORS MAP , BLOCK AND PARCEL # 022/043 OWNER' S NAME Robert Spr&gue PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr . 7 . COMPANY NAME J.P.Macomber & Son Inc70' COMPANY ADDRESS Box 66 Centerville Mass . 02632 Street Town or City Stat• ZIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Cl�hec one : System PASSED The inspection which I have conducted has not found any - information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 , 303 , Any failure criteria not evaluated are as . stated in the FAILURE CRITERIA section of this form , System FAILEll* The inspection which I have conducted has found that the system fails to Protect the 'public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , -and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , + Inspector Signature :"i� � / / =� Date ne copy of this t.ification must be provided to the OWNER, the BUYER ( Where applicable ) and the BOARD OF HEAL7'1(. * If the inspection FAILED, the owner or"operator ehall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 , 305 , partd . doc f v SVBSURfACE St%.%'AGE DISPOSAL SYSTEM INSPECTION FORM 'PART C SYSTEM INFORMATION Scontinvcd) rsopcnr Addoi((: 20 Ralyn Road Cotuft ,Mass. Owrom Eric Wittet 0411 of inspirc00ni 1 1/2 7/98 SX(ICH Of SEWAGE OISPOSAL SYSTEM: inclvdc tics to 4111111 two pc(mincnl rcfc(cncc{ I3ndmaiks of bcnchmirks loctle ill wclll within 100' (loCitc whc(c public w3lcf supply comcs Into house) ..1 '10 Vy/yiv gal G'07-v,' Ack . N3 yb� ' tr..►..i o�/11/fll r.v• i .t 10