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Home My WebLink About0090 RALYN ROAD - Health 90 Ralyn Toad �Cotuit P A = 022 047 t t 04 2015 22:16 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts 7 . Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road rat Property Address Jan Scullin Uy.t Owner Owner's Name information is saa, required for every Cotuit MA 02635 10-1-15 page. CitylTown State Zip Code Date of Inspection ,�Yt Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out farms A. General Information �``p�uatOF t� on the computer, H�`� •Asp%,� use only the tab 1. Inspector: :°s�= key to move your u' cursor-do not DAMES James D. Sears = c e the return Name of Inspector # ;{i key. Ca ewide Enter rises,LLC �'•.o o, Company Name ! •• 153 Commercial Street y'�ustiuwsw `��\� Company Address Mashpee Ma 02649 CitylTown State Zip Code 508-477-8877 S1623 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 16,000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-2-15 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:SubeLr(ace Sewage Die�Owvs •Page 1 of 17 Oct 04 2015 22:16 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official. Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owners Name Information is required for every Cotuit MA 02635 10-1-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) I Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: I ® 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 and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-31 3 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17 I Oct 04 2015 22:16 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owners Name information is Cotuit MA 02635 10-1-15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Oct 04 2015 22:16 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is required for every Cotuit MA 02635 10-1-15 page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) 2. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 Al J� ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in asiviiiiW is less than 6" below invert or available volume is less than '/ day flow F�l' 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Oct 04 2015 22:16 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owners Name information is Cotuit MA 02635 10-1-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the. questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Oct 04 2015 22:16 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name inforrnationis COtUIt MA 02635 10-1-'i5 i required for every i p9 wa e. Cityrron State Zip Code Date of Inspedion C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal Flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection. ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage'back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): 330 15ins•3113 Title 5 Offidal inspection Form:Subsurface Sewage Disposal System•Page 6 o117 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is Cotuit MA 02635 10-1-15 required for every page. CityfTown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Tank and Pit. I f 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes 0 No Water meter readings, if available last 2 ears usage d 2013-22,000Gals g ( y g (gP ))' 2014-19,000Gal's Detail: Sump pump? ❑ Yes ® NO NA Last date of occupancy: Date Commercialfindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurfaces Sewage Disposal System-Pape 7 of 17 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is Cotuit MA 02635 10-1-15 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: 07/11 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ InnovativelAlternative 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): loins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 90 Ral n Road Property Address Jan Scullin Owner Owner's Name information Is Cotuit MA 02635 10-1-16 ` required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 31" 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.): Pipeing is 4" PVC SCH 40& SCH 20 Septic Tank(locate on site plan): 21" 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 1000 Gal. Precast. H-10 , Dimensions: 3" Sludge depth: l5ins•3113 Title 5 Official Inspection Form:Subsurfeoe'Sewage Disposal System•Page 9 of 17 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is Cotuit MA 02635 10-9-15 required for every page City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? As -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 outlet cover at 21" below grade. Inlet and center cover at 4". In and outlet baffles. No sign of leakage or over loading. Note: Center cover and sprinkler line over inlet cover, Maint pump after inspection 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 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owners Name information is Cotuit MA 02635 10-1-15 required For 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-113 Title 5 Dfliclal Inspection Form:Subsvfece Sewage Disposal System Page 11 of V Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 12 SN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is Cotult MA 02635 10-1-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Box Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Noy' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc_): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is COtult MA 02635 10-1-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 1 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit at 22" below grade w/30"water. Stain line at 6" above water line No sign of over loading or solid carry over. 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 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Oct 04 2015 22:17 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments 90 Ral n Road Property Address Jan Scullin Owner Owner's Name information is required for every Cotuit MA 02635 10-1-15 page, CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•3A3 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 a- Oct 04 2015 22:18 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts x . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Ral n Road Property Address Jan Scullin Owner Owner's Name information is Cotult MA 02635 10-1-15 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately `3 i 0 3 R tsins•313 - Title 5 Official Inspection Form:subsurface sewage Disposal system•Pege 16 of 17 Oct 04 2015 22:18 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is required for every Cotuit MA 02635 10-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ivv 12' Estimated depth to high 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: Auger T H 12' no G W Bottom of pit at 8' below grade. Bottom of pit at 4' above T.H.- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•303 Title 5 Official Inspection Form!SubSLrfaCe Sewage Disposal Syslam•Page 16 d 17 Oct 04 2015 22:18 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 90 Ralyn Road Property Address Jan Scullin Owner Owner's Name information is COtuit MA 02635 10-1-15 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A,B, C. D, or E checked ® inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins-3113 Title 5 Oflicial Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 AAA 1 t 12/ 4 Me Y � 9 1,9g co U�ll BORTOLOTTI CONSTRUCTION,d UCTION INC. do 765 WAKEBY ROAD,MARSTUNS MILLS,MA 02 48 �. 508-771-9399 . 508-428-8926 FAX: 508428-9399 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `� f PART A CERTIFICATION w Property Address:"�__)13 Date of Inspectioni Inspector's Name: 7; r ' Qwner's Name and Address: t'o12 <_ i CERTIFICATION STAT . F.NT• I certify that I have personally inspected the sewage disposal system at this address'and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal ems. The System: Passes Conditionally Passes Needs Further Ev uation By the cal Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 - gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTIO/N rMMARv• A)SYS'r PASSES: ✓✓✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM.CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system;upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - 1 1 i J� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4. PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed 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 the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 19 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. h Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- 1 k ! _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance.with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: P— Pumping information was requested of the owner,occupant,slid Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. fAs-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 4The system does not receive non-sanitary or industrial waste flow. ✓`The site was inspected for signs of breakout. _ ---All system components,excluding the Soil Absorption System,have been located on site. P The septic tank manholes were uncovered,opened,and the interior of the septic tank.was m- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, ,,,,-depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ✓The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTLA,L: Design Flow: V;'0 allons Number of Bedrooms: Number of Current e t Residents: Garbage Grinder: A16 Laundry Connected To System: Yes Seasonal Use: Water Meter Readings,if av ilable: Last Date of Occupancy: 6a/►/'Cep CO M R Ai/IND 1 T Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informati �/ �GWrl�s7 System Pumped as part of inspection: If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If y attach previous inspection rec r�dss, if any) _O �ther(explain): � q4` AP OXIMATE AGE of all component ,date installed(if known)and source of information: cu-Qr-�z �kxt�01� Sewage odors detected when arriving at the site: A -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: ✓ . Depth below grade: Material of Construction: concrete metal FRP_Other (explain) Dimisions: .��xCo'X S Sludge Depth: S" Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 30 " Distance from bottom of scum to bottom of outlet tee or bafn6: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation t utlet invert, structural integrity,evidence of leakage,(Ptc.) _ •S w (:+?� A, &'E&qWC�E =�V' GREASE TRAP: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum'Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:, Depth Below Grade: Material of Construction:—concrete—metal FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallonstday Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: - Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: - Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) _ -5 v3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, sjgn5 of hydraulic failure level of pond' ,condition of vegetation, =61 �- « 4� �i CESSPOOLS:_ r d configuration: Depth-top of liquid to inlet invert: Number an gttra p P Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. z DEPTH TO GROUNDWATER: Depth to groundwater:_- 7 Feet ��++ Method of Dete nation or Approximation: o �kj�^�l- Ica -7- I 4 ( (� 1' TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date S Time: In Out Owner Tenant ® c Address C� 6 C��`" Address I Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities Val h Ir"Ofts. awl:.... 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal o� 16. Sewage Disposal 17. Temporary Housing - 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 7ro,z DEPARTMENT OF ENVIRONMENTAL PROTECTMN W RECEIVED � � d p a� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM Z PART A CERTIFICATION Property Address: 90 RALYN RD COTUIT 02635 Owner's Name: JAN SCULLIN Owner's Address: 160 COMMONWEALTH AV. 405 BOSTON MA. 02116 Date of Inspection: 12/9/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS�IL—1 Mailing Add ress: P.O. BOX 2119 TEATICKET, MA. 0-1536 'telephone Number: 508-564-6813 FAX 508-564-7270 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 P sses _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: ` Date: 12/9/02 The system inspector shall submit 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 . SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO PEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. This report only describes conditions at the time of inspection and under the conditions of use at that time. ]'his inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 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: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 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 n/a "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: n/a I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 ''/Z 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 OCTOBER BY MACOMBER INFO FROM OWNER. 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.] (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 X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X 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. a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 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)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 FLOW CONDITIONS RESIDENTIAL 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: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):12 0 ��U Sump pump(yes or no): NO Last date of occupancy: n/a 0 �j3! (;(;0 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: OCTOBER BY MACOMBER INFO FROM OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a 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): n/a Approximate age of all components,date installed(if known)and source of information: 1970'S BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a Page8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD T OF WATER IN IT AT THE TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN Y OF LIQUID IN IT. BOTTOM IS AT 81. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a 4 ` Page 10 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 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. B� Sce.een OA D�cG \r a 31 in Page I I of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 RALYN RD COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. II ` TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date '(l (0 Time: In Out Owner c Tenant �� I Address 6 6 mow"` / Address Complia a Remarks or Regulation# Yes VNO Recommendations 1.2. Kitchen Facilities p�pmVed� � r rR a�► -' IM 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8.Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary HousingP7V 18. Driveway Width 19. Number of Tenants Observed f ( .61 f r PART II l 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition 2 Number of Bedrooms J Number of Vehicles Allowed (max) L Number of Persons Allowed (max) Persons Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here ,_ lM No....2„L 1--:•.. Fu$............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH 1. -OF'........ ..... . .. .. .... .. Ap.V iration for Bifyosal Morkii Tomitrur#ion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at AC10 .......... .......�-.....---.- A LAN �.�..........� ..t.� ►.... .............:..�.. ...........--.------------..............-.. ..L ation.Address or Lo No. ..................... . � . ,� ....km .�.......N,V,4.��%......... . n Address Z?! ...............................................-•-.................... 0.1 M •� Installer Address UType of Buildinj Size Lot............................Sq. feet U Dwelling Y No. of Bedrooms......... ..............................Expansion Attic ( ) Garbage Grinder ( ) �`4 Other—Type e of Building No. of persons............................ Showers yP g ---------------------------- .---.P ( ) .— Cafeteria ( ) dOther fixtures ------------------------------------------• ----------------------------------------- WDesign Flow.................... ./)...............gallons per person per day. Total daily flow-___-__...... ...._....._._.....__gallons. WSeptic Tank—Liquid capacity O.- gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. �----------- Diameter • - - 4Q------s ft. Seepage Pit No._.._.__ �x� S?Depth below inlet.._.�11............. Total leaching area.._..3. q. Z Other Distribution box ( . ) Dosing tank ( ) aPercolation Test Results Pet-formed by.......................................................................... Date: Test Pit No. L.A..........minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ P4 --••----•--•---•----•-•-•.._....•..................••--•--.......:.........-••--••-•-----•---------.......................................................... O Description of Soil....................�_ .V 1? � . .. ----------------- •------------------------------------------------------------------------------------------------------------ V ...................................................-----••---••-••-----••-•-•••-.....--•••-----••.......----•-•--•-•. ---•--•---•-......•----•-•---•-••---. W ------------------------------•-----......••-•----------•------------•-•---......---•----•--........--------•--•----•-------•-----••...•--•-•------•---•-•-••-••••--•-----•--•-•----•--•--.....-••...... V Nature 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 Article XI of the State Sanitary.Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of hezjth. t Sig ne ...� ... - •---.-. Application.Approved By--•-••- ............ f Z._ --- Application Disapproved for the following reasons-----------------••-•---•---- ----••............................................................................. ......-•--•-•--------•--........-•--••--•--••••---......--•---••••----- ........................................................---•-----•-----------•-••-•-----•-----•-•---•••-----•-•---•------...... Date PermitNo.y....................................................... Issued........................................................ , t, Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... S �:-... ........ OF.....Fe -. f,,� K,.' . ! ................. I iration far;.Disposal ks Toutitrnr#ion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: z _ LoEation•Address or Lot No. ......��... .'c.M.G#:..,.�1.1,.__..a.t.;.. ./. .................................. ....... .�. l- 9C f�..: ::. ....._...?�4J t?�.�' t( ?......_. Owner _ Address ��.'s.. .l�•1k....................................... .................................................. ....... .. .................................. Installer Address Q Type of Buildings Size Lot................ ..Sq. feet U Dwelling ,ir No. of Bedrooms......... ........... .. .Expansion Attic ( ) Garbage Grinder ( ) .a Other—T e of Building No. of persons............................ Showers — QI YP g -------------------•------•- P ( ) Cafeteria ( ) Q' Other fixtures.....-----••-•-- --••--......---•------••--•-•---- W Design Flow...................:.:..e................gallons per person per day. Total daily flow............ _ f....................gallons. 1:4 Septic Tank—Liquid capacity10. _gallons Length................ Width---------------- Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area------,. . sq. ft. >> Seepage Pit No..._...�S___._._..... 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•.-.-_--_-_-___-___-__-. w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -- --------------------•---------.----.----------------------------------- --------------------- x DescriP tion of Soil.............. f_.-?.1:i.-, -•........................... V .....••-•-•••----•--------•-----•---•.........................................•.....---------•------ (� VNature 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 Article X1 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 4 r ✓ .!.. t. Signefl_ r; b: _ _._...... ." -------------- Application Approved BY........................... r M Date ........................................ ----_-------•• Application Disapproved for the following reasons:............ ..................... ......................... ............................••-----•-••-----------------...-•---•----•---------..........--•--•--•-------._...-•------------------••-----...----•-••--------•-.... ..................................... Date PermitNo......................................................... Issued....................-------•........................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEALTH f�Crx�if ir�f>� laf �gnt��i�nrr�_ T ISMS TO CERTIFYI,,T, t the Indiyjdual Sewage Disposal System constructed ( ) or Repaired ( ) by.. .. f.. ��r� ',� r T•1 y�� '�.". . ' r I� W._.�v' .t..'xv..y�,•"�,.. ----- 1nst,ilici ,4 a - m,.g ------------------•-------...------•-••------------ has een installed in ac o a w t e o of tc I of lI Y tate�at itary Code as described in the application for Disposal WO�d s Construction �ermit No...._._.��7.................. dated-__-_..---_--____...._.. . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® AS A C, 1 �AT THE SYSTEM ORAL FUN TION SATISFACTORY. DATE.....7- 47. . ... ��..-----•----•----•...............•.. Inspector....... ................. ...... .. - :....... ..�• THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH .................OF t;_'_sil. ................ NU... . FEE..... .ti-- f Permission is hereby granted f./M F xr ..-- 4u. --f'.................................................................................. to Constr ct 1(/) or Repair ( ) a>ir' n ivi uai"Se ages ispo f8ystem atNo. z 1 ...................' .. .r......... ti.. ................................. ....... ..........•--•-. __... , �� ,� 3 sir - y.. as shown on.the applic4 n for Dis s l Vo(r 6fl�st,=uctioii -Permit f �. Dated -- .............. • r r, d�� ` $ aI/ }at fclltft ` �,e� 1( t/ DATE_ .�..- -- � •--•=--------------------------------- FORM 1255 HOb B.S WARREN, INC.. PUBLISHERS TO OF BARNSTABLE LOCATION b -SEWAGE # VILLAGE ASSES R'S MAP& LOT - -R 5 `�AME&PHONE NO.00,- �rkP SEPTIC TANK CAPACITY LEACHING FACILITY: (type)�r" %, (size) U 0 NO.OFBEQRO.OMS 3 BUILDER OWNER" e PERMITDATE: 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 ��/ Feet on site or within 200 feet of leaching facility)- z Edge of Wetland and Leaching Facility(If any wetlands exist +' within 3 keetof leaching facMnk ` Feet Furnished by .r Wk 0 o IiF11, `1111. z3� i l �D ' Bay NOTES: 1.)CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS B-++• +r++• +tr-z 13'-0 &DIMENSIONS IN THE FIELD 2.)CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, . DETAILS,&FINISHES IN THE FIELD WITH OWNER 3.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETTS STATE BUILDING CODE,BTH EDITION AMENDEMENT&IRC2009 4.) 110 MPH EXPOSURE B WIND ZONE 5.) ALL LVL LUMBER/BEAMS TO BE 1.9e L1360 LOAD 6.) VERIFY ALL PLUMBING&ELECTRICAL DETAILS W/OWNERS ON THE SITE DURING FRAMING CONSTRUCTION § 7.) TIMBER FRAMING TO BE FIR NO.2 GRADE 8.) ACCESS TO LOWER ATTIC ABOVE LIVING ROOMIDINING,AND KITCHEN SPACES TO BE FROM THE EXISTING GARAGE EXIST. a EXIST. PORCH DECK B IECC2012 RESIDENTIAL ENERGY EFFICIENCY DETAILS y CLIMATE ZONE 5A(USE EITHER PRESCRIPTIVE VALUES OR RESCHECK CALCULATION I § TABLE 402.1.1(MINIMUM PRESCRIPTIVE INSULATION&FENESTRATION REQUIREMENTS) FENESTRATION I SKYLIGHT CEILING WOOD FRAMED WALL FLOOR BASEMENT WALL BASEMENT SLAB CRAWL SPACE WALL UfACTOR L-FACTOR R-VALUE R-VALUE R-VALUE R-VALUE R-VALUE R-VALUE 0.32 0.60 1 49 1 20 30 '1511B 10(2 FT.DEEP) 10113 II ., NOTES: >n • sa• 1+•-+ 2aa ff. +4'a rn 1.R-VALUES ARE MINIMUMS$U-FACTORS ARE MAXIMUMS. REMOD. EXIST. 2.15119 MEANS R=15 CONTINUOUS INSULATED SHEATHING ON THE INTERIOR OR EXTERIOR I CLOS. BATH EXIST. OF THE HOME OR R=15 CAVITY INSULATION AT THE INTERIOR OF THE BASEMENT WALL ( e BEDROOM 2 � CLOS. O� 3.REFER TO IECC 2012 CHAPTER 4 FOR ALL INSULATION&ENERGY REQUIREMENTS O EXIST. I I BEDROOM 1 LIVING RM. REMOIX EXIST. BAT HALL CEIGNG JOISTS CEILING P—CLOST, �i eEM ON THIS WALL ON. BEAR DN CLOS. q § CEILWG JOISTS EXIST. BEAR DN T"Is wALL HALL O R RAN u, II EXIST. REF GE REMOD. m I I DINING RM. EXIST. H CLOS. 4•'a rar s•-z BEDROOM 3 LUX I <d sKru°Ht 1 A CLOS- EXIST. REPLACE COV'D. `d DOOOROR E PORCH REMOD. X H KITCHEN ND°" e - a 1 9 qc-,'O^Id L10Z 8 0 AUK EXISTING GARAGE o �• Its Cott- �S�l�h+� w��l THE DESIGNER SHALL BE NOTIFIED IF ANY ERROR Ea ft COTUIT BAY DESIGN, LLC THESED DRAWINGS RIORTONS START ON THESE DRAWINGS PRIOR TO FOUND OF 43 BREWSTER ROAD WLL BE RESPONSIBLE FOR STRUCT ON.THE T E�CONTENTT� MASHPEE,MA. 02649 COMIN MFENCESSE WITHOUTNOTIFYMGTHE PH.(508)274-1166 DESIGNER OF ANY ERRORS OR OMISSIONS. THESE DRAWINGS ARE SOLELY FOR THE USE FAX(508)539-9402 OF THE OWNER NOTED.ANY OTHER USE OF THESE DRAWINGS REQUIRES THE WRITTEN 4'd CONSENTOFTHEDESIGNERUNDERTHE ARCHITECTURAL COPYRIGHT PROTECRON ACT OF 100. 24'-C' REMODELING FOR. SCALE : DRAWING NO.: PARECE RESIDENCE 1/a11= 11_011 sa4r FIRST FLOOR PLAN DATE : I Al 90 RAYLYN ROAD, COTUIT, MA 08/16/2016 .f It u 5'-0" REMOD. CLOS. o � Ii L6I EXIST. II BEDROOM 1 II I I REMO[l BAT ALF ALL 4 iv N EXIST. I I CEILING JOISTS HALL BEAR ON THIS WALL — It Q O N I 3'-8" It REF RANGE u REMOD. ` " -8" '-6" It '-2CLOS. 4' 7 5 " I I r --- 1 �I U SKYLIGHt REPLACE ABOVE L__— — EXISTING n DOOR WITH IL 2'-6"X4%0� =__ EXIST. WINDOW 4'-0" COV'D. �� PORCH REMOD. KITCHEN EXISTING GARAGE t � l� FIRST FLOOR PLAN- SCALE : DRAWING NO. : /41110RENOVATIONS FOR. 1_ 11 1 _- PARECE RESIDENCE DATE : Al 90 RALYN ROAD COTUIT, MA 02635 04/21/2017