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Home My WebLink About0142 RALYN ROAD - Health 'f 42 'Ral yn ®act cotuit P A = 021 068 V /' TOWN OF BARNSTABLE LOCATION �-� _ ��I��n ?CY SSE#X 1S,P VILLAGE 0,o Tui` - ASSESSOR'S MAP&PARCEL rNff R'S NAME&PHONE NO. Wrc� C.Lo'Coftmk\ LIaQ� ]-)I SEPTIC TANK CAPACITY ►000 9J LEACHING FACILITY:(type) �✓1T ' (size) &00 NO.OF BEDROOMS 3 .OWNER PERMIT DATE: ATE: .��P �u 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY��yM f r f / fry! J f fryf J f f f r J J fryi F !ryf J ryf F J f f fry J 1 J J f f f f f f f f f J J f J r l f f f r f ryf f f ! f f f F f f f J F f f f f f ry J f J J f i f J f f f r J r J f f f J f f f f f f i f J r f f / J I F F !ryf f f f f f f f f fry f f f J J J•ryf f f F J•ryJ f J f I f f ! J f J f J fryf fryJ J J J J f f J f f J 27 2 r 32 1 43 43 J n TOWN OF BARNSTABLE 't LOCAION SEWAGE # Cl VILIAGE ASSESS 'S MAP & LOT OZ-I 6 0 NAME&PHONE NO. SEPTIC TANK CAPACTTY,OCY� LEACHING FACILITY: (type) �►��,��, (size) -. NO.OF BEDROOMS BUILDER OR OWNE PERMTTDATE: 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 leaching facility) Feet Furnished by ,.. O'V a 6 � is Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments * 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When A. General Information forms filling out I forms on the - computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name � 189 Cammett Road Company Address Marstons Mills MA 02648 "^ Cityrrown State Zip Code 508-428-1779 S1 12855 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 April 1, 2009 Iri ector'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. 0948 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page�of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635_ April 1, 2009 every page. Cityrrown 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: ® n f I have not found any information which indicates that any o the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping att his time, leaching pit has 8" of effective leaching. 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 0948 Ford.doc.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 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 ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 0948 Ford.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Ralyh Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (coot:) 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow El ® 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. 0948 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 n� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments µ 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is Cotuit MA 02635 April 1, 2009 required for 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. 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 ❑T ❑ 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. 0948 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is Cotuit MA 02635 April 1, 2009 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) 09A8 Ford.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection' Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 every page. Cityrrown 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: : Unknown 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: Currently Occupied. 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) 09418 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 B . Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Ran Road Property Address Drew Ford Owner Owner's Name information is Cotuit MA 02635 April 1 2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped two years ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑. Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 0946 Ford.doc-08/06 Title 5 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 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is Cotuit MA 02635 April 1, 2009 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' i 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.): Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of compliance? (attach a copy of certificate) ❑ Yes ❑ No- -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide 1000 gal. 2„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28 2" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 09A8 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time, liquid level was found at bottom of outlet invert. Tees are intact and clear. 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): 0948 Ford.doc-08/06 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 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) r Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ .Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 0948 Ford.doc-08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 every page. Cityrrown 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: One 600 gal pit. ❑ 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.): Liquid level was found 12-14 below inlet, high stain lines indicate pit has 8"of effective leaching. 09A8 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Ri Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1, 2009 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.): 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.): 0948 Ford.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w ' 142 Ralyn Road Property Address Drew Ford Owner Owner's Name information is required for Cotuit MA 02635 April 1 2009 — 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . „ 4„",,,, NN \ . . . , . . , . . . . . . . . . •�711�4 „ NNN N,N,N N NIN, NNN \ NNN \ N 27 2 32 1 43 43 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 142 Ralyn Road Property Address ' Drew Ford Owner Owner's Name information is Cotuit MA 02635 April 1, 2009 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to round water: 30 p g 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: with local excavators installers - attach documentation ❑ Checked ( s ) ❑ Accessed USGS database- explain:, You must describe how you established the high ground water elevation: Pond at end of road is considerably lower than bottom of leaching pit. 0948 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 ll e COMMONWEALTH OF MASSACHUSETTS' EXECUTIVE OFFICE OF ENVIRONMENTA�6.f , dA%ARNNIS TABLE DEPARTMENT OF ENVIRONMENTAL PROTECTION , "11 MAR i 1 AM 11 .,AP ARCEL c_j. ,y t�1��1Si(IN TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION UProperty Address:. . Owner's Name: Owner's Address: Date of Inspection: Name of Inspec please print) 4)k Company Nam _ Mailing Address:" AtIA OQCo ye Telephone Number:,- . CERTIFICATION STATEMENT •. - I certify that I have personally inspected the sewage disposal system at this address and that the information rr.ported 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: __._IL Passes Conditionally Passes Needs.Further Evaluation by the Local Approving Authority ails Inspector's Signature: - Date: �ZS— 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 ofthe 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 I Page 2 of 11 . I. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM .PART A CERTIFICATION (continued) i Property Address-er:oQ�6� 1Z Date of Inspection: l� 01 Inspection Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. f System Passes: �i I have not found any information which indicates that any of the-failure criteria,described in 3:10 C•MR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. stem Conditionally .SPasses Y 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 ov--r 20'years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltratic'n 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 inspecti3n.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: 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: 0 1 Page 3 of 1'1 OFFICIAL INSPECTION _ECTION FORM N T- OT F OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM # PART A CERTIFICATION(coritinued) Property Address: Cam. Owne _ Date of Inspection- C. Further Evaluation is Require 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'Boai d°of Health"determines in accordanie'with 3'10 CMR 15.303(1)(b) that the system is not functioning in a mannerwhich.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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. — The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or-ss than 5 ppm,provided that no other failure criteria are triggered. A•copy of the analysis must be attached to this form. 3. Other: 3 �1 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: J / Date of Inspection' fl BOO D. System Failure Criteria applica le to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes. No/ i/ 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 _ V Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ' water supply. 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 accep_able 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 nitr5gen.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 rave determined that one or more of the above failure criteria exist as described in 310 CMR 15303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large�system.the system must serve a facility with a'design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well r , 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. ✓ y 4 Page 5 of H OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION*FORM PART B CHECKLIST Property Address:/ W"J'7t_ A _ Owner. Date of Inspection — � Check if the following have been done. You must indicate"yes"or"nd.'as to each of the following: Yes — - ' /Pumping.information.was provided by the owner, occupant,or Board of Health V Were.any of the system components pumped out in the previous wo weeks Has the system received normal flows in the previous two week period? V Have large.volunies 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,cepth,of sludge and depth of scum? Was.the facility owner(and occupants if.different from owner).p-o.vided 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: IYes no 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(3)(b)] 5 Page of l I I OFFICIAL INSPECTION-FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: CCJ� Owner. Date of.Inspection: aj F CONDITIONS RESIDENTIAL. Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN flow based on 310 CM II 1 5.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence,have a garbage grinder(yes or no): -A G Is laundry on a separate sewage system (yys or no):�&Q f if yes separate inspection required] Laundry system inspected(ye or no):�/60 Seasonal use: (yes or no):IV .. Water meter readings, if avai able(last 2 years usage(gpd)):�,yLLO MOO Sump pump(yes or no): /VU Last date of occupancy: Ae2/rt�9' COMMERCIA`UINIDUSTRIAI//Z�) Type of establishment: Design flow(based on 310 CMR.15203): gpd Basis of design.flow(seats/persons/sq t,etc.): . Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system'(yes or no):-- Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 10 Source of informaiio Was system pumped as part of le inspection.( s or n�a If yes-Volume pumped: gallorrs--How was c is ity pumped determined? ' Reason for pumping: . ✓� TYPE F SYSTEM ptic 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): Apr it a e age of all components,elate installed(if known)and source of information :7 : Weresewage odors-detected when arriving.at the site(yes or no): Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cor_tinued) Propert Address: Owne J Date of Inspection: i BUILDING SEWER(locate on site plan Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water-supply well or suction line: i F' Comments(on condition of joints, venting, evidence of leakage,etc.): ^ N° i j SEPTIC TANK. (locate on site plan) Depth below grade: - Material of construction: concretemetal_Fiberglass lass —pof eth l.ne —other(explain) , If tank is metal list age: Is age confirmed by a Certificat certificate) e of Compliance(yes or no):_(attach a.copy of Dimensions: •$ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Z 6 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: How were dimensions determined: l e�,n l40 Comments (on pumping recommendations inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evid nce of leakage etc.): f GREASE TRAv P �locate onaite plan) { Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): 7 d ` Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: zo 22C' . Owner. l ': Date of Inspection: TIGHT or HOLDING TANK• (tank must be pumped at time of inspection)(locate on site plan) f Depth below grade: '. Material of construction: concrete metal fiberglass_polyethylene, other(explain): Dimensions: . _ Capacity: gallons Design Flow: gallors/day j Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: i of alarm and-float switches etc. Comments(condition � :_ ) F j. DISTRIBUTION BOX: V if p P resent must be o ened)(locate on site plan); ( v Depth of liquid level above outlet iner P 9 � i box is level and dist-ibution to outlet'-a ual,an evidence of solids carryover,any evidence of Comments note f q X ( kale into or out of box, et � n ./ ` PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes.or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): r ti 8 = h Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. � Date of Inspection: ,7 S SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty Pe 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, :, jaw V CESSPOOL(cesspool must be pumped as part of inspect i on)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): r ., Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,retc.)1: 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection:= L` //i 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. ��--- I � P ItS4�� 3 oQ 10 Page 11 of 11 OFFICIAL- INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) .Property Address:�� 9 � Owner: Date of Inspection: 7 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water A 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) t/Accessed USGS database=explain: You must describe.how you established the high ground water elevation: 11 Permit Number: Date: Completed by: HIGH G.R;)UND-WATER LEVEL COMPUTATION Site Location: z Lot No. Owner: U 1J. /�®J" Address. Contractor: 6 A? % A M/` Address: Notes: "ell j5 STEP 1 Measure depth to water table d tonearest 1/10 . .............................................................................. .Date month./day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index we 1...................... `�°I t QJ Water-level range zone ....................................................... STEP 3 Using monthly report ot "Curre nt Water Resources Conditicns" determine current depth to t water level for index well ........................... month/year STEP 4 Using Table of Water-leve "Adjustments I i for index well (STEP 2A). current depth to water level.for index vt2ll (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment :.....:........................................................:.......................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4; from measured depth to water level at site (STEP 1) ...... ...................................................... ... ............................................. Figure 11--Reproducible compufaiiol form. 15 i I f �TI11 � COMMONWEALTH OF MASSACHUSETTS m EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECT RECEIVED a h MAR 2 5 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� Property Address: 142 Ralyn Road MAP Cotuit MA 02635 PARCEL Owner's Name: Robert Eubanks Owner's Address: same LOT Date of Inspection: March 20,2003 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails / D Inspector's Signature: �J 2aL.-L� ( J C�1 Date: 3/Z( O 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. Notes and Comments Liquid Level in pit 8" below inlet pipe. ****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 l Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D y A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.363 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstiucted 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: I Page 3 of I 1 OFFICIAL INSPECTION FORM pOSAL OT F SYSTEM INSPECTION FORM R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE PART A CERTIFICATION(continued) Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,2003 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(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TION FORM PART A CERTIFICATION(continued) Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply ` the system is within 200 feet of a tributary to a surface drinking water supply — , the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM NOFOR YSTEM INSPECTION FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL PART B CHECKLIST Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,2003 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 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 }C 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? Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the conditio—n 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: Yes no 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY CT FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN PART C SYSTEM INFORMATION Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,200 3 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:2 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):— Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)): 2002-108,000 gal.=296 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records System has had annual pumping Source of information: Homeowner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date 5/11/87 Were sewage odors detected when arriving at the site(yes or no): No 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: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection:March 20,2003 BUILDING SEWER X (locate on site plan) Depth below grade:2' Materials of construction:_cast iron _X_40 PVC_other(explain)`. Distance from private water supply well or suction line: 20' Comments(on condition ofjoints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 8' long x 5.2'wide (1000 gal.) Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): Outlet baffle and inlet tee intact and clear. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of inspection: March 20,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level 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.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,2003 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number: 16x4(600 gal. pit) 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.): Liquid level in pit 8" below inlet pipe. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding; condition of vegetation,etc:): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Ralyn Road,Cotuit Owner: Robert Eubanks Date of Inspection: March 20,2003 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. V3V7 211 �3 Z 31 tl3 wj` nn 4� Page 11 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addr+esa: 142 Ralyn Road,Cotuit Owner: Robot Eubanks Date of Ins pection:March 20,24@3 SITE EXAM Slope Slight Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-Vchecked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board ofHealth-explain; Checked with local excavators,installers-(attach documentation) _X Accessed USGS database-explain: USGS map and GIS groundwater map You must describe how you established the high ground water elevation: Checked USGS topo asap property at or above el.50.Checked town groundwater contour asap water at or below d, 1S.Bottom of leaching pit 8'below grade more than 215' separation. F '7� ors ins------ --_----- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratiun for Disposal Works Tonstrur#iun Prrmit Application is hereby made for a Permit to Construct O) or Repair ( ) an Individual Sewage Disposal Sy em at ............. -Address or o. .dam . --- z..s...... � _ .5 ------------------•------ - c�... �` r �.:-.Lt° , ,�!I ! .11 .._1!!� :_d Owner :• -:___�_ =r Address o .. j ................................................1 �...L�.QI...Io� SI ...: . ..... j ., Installer Address dType of Building Size Lot.2."t .....Sq. feet Dwelling—No. of Bedrooms.__...'3.................................Expansion Attic 40 Garbage Grinder k) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ........................._-- .............................................. W Design Flow..........�5.........................gallons per person Ver day. Total daily flow....�30.........................gallons. WSeptic Tank—Liquid capacityA gallons Length_S.-:G`�.. Width.'4'-(6'.. Diameter._-'.... Depth..-1-_&"� x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........I......... Diameter.......I'A-------- Depth below inlet..I!5._...._. Total leaching area.:,Mcb..sq. ft. Z Other Distribution box Dosing tank (qcp q '-' Percolation Test Results Performed .11�l_�,.............. Date..ffm.� ". _ .......... W Test Pit No. I.4e2.......minutes per inch Depth of Te t Pit----to.......... Depth to ground water.Nay �i.arEayp Test Pit No. 2../-2—._._minutes per inch Depth of Test Pit....10........ Depth to ground water...!U.................. ..............................................................-.....................................-•--••••-••-•-- --------... ._.._-- ---------•--"-- O Description of Soil------14-.1........ U 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 iITLU 5 of the State Sanitary Code—The undersigned furl grees not to place the system in operation until a Certificate f Compl- has been is e bo oof ealt . �,z1-%7 Signed.._:.:.. �'.-lexq--•-• :el • - - --••••••..._.. f � � Date Application Approved B ........... _ ....................•••••••-__._.._. .....3. ._t-`p-- ..7....... Date Application Disapproved for the following reasons:----•-•--------•-----...----•-••------------------------------•----•-------.....-----------------------•-••--- -------------•---•---------...---•................_-•--•-----...-••...--•••••-•----••-••-•----------•••-------------•-•--------•-••------••--•-••----------•-••---------••-----•-•-----......•-•--•-•--- Q Date Permit No....�1.._7.'1_6cl-............................ Issued....................................................... Date FEB............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..---�-c'-`�.................OF;..:...1...... ........................................... Appliratiun for Disposal Works Tonir ion anti# Application is hereby made for a Permit to Construct (Y) or Repair ( ) an Individual Sewage Disposal s at: ..................... ............. c .. ` . ..................................------. Location-Address or Lot No. .............................. -...- .--------.....----••...._................_.............. .........._-................... ......`..------------------------_.-.-----------------......---- Owner Address a ---------------------------------------------•------•••..._.....--------------•.._...._........... ..............•...---� ' �-...... ..............---......------..............................--- Installer Address d Type of Building Size, �-�:�.....S q.Lot��;:� feet U Dwelling—No. of Bedrooms.........................................Expansion Al c 1 Garbage Grinder 6(� Other—T e of Building No. of persons............'................ Showers — Cafeteria P-4 Other fixtures ............... ••••-••-••-•............-••••-•-- . -- W Design Flow........: > ..........................gallons per person per day. Total daily flow....- :3, .........................gallons. WSeptic Tank—Liquid capacity«_-�:�gallons Length.. a'.-.(.��-... Width-••:!�_... Diameter................ Depth.::?..-.�... x Disposal Trench—No..................... Width.................... Total Length..... ..._........ Total leaching area....._.__.__.......sq. ft. Seepage Pit No.......... Diameter......yA.__..... Depth below inlet..:..-` ........ Total leaching area_�?c�,°'r�._.sq. ft. z Other Distribution box cS) Dosi�tank Z - -� Percolation Test Results Performed by._ 2a :?� �°:� _._� '. _.�.��!• _______________ Date_��'_ __ �_ Test Pit No. Lminutesperinch Depth of Test Pit... ! ?_.......... Depth to ground water.r�0�__! '�!r. ��C1 (i Test Pit No. 2. -_.___._minutes per inch Depth of Test Pit.__ C:~-_.______ Depth to ground water.......................1 ------•------ 0•. Description of Soil... ' -�- .7.`.. .._t d:� - .. t'.` :.ti )- V - .._.._ - ...... ........=r-~•-•-....-..---- -----------•-----.....------------------......--------------•---------.............--------------.......------......._ 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 TITI j 5 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. Signed........................•------..........................._---------••-....._.......-• ................................ Date Application Approved By---•-•••••. ------------------------------------ .!-.'.?.-%.A.:7-...... V Date Application Disapproved for the following reasons_______________________________________________________________________________________________________________- ...........................•----•----•------------------...................................................----------..............-•----------...........---------•-------------- - ---........_.. Date Permit ---------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tomplinnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................................................................................................................................................................................................... Installer at--------------------------------------------------------------------------------------------------•-----------------------------------------•------------------------------------------------------- has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............�':=.1.1...- -2... ------•-----•------•------------- Inspector--- -----•-•----.-------..------•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :.�.��Y ...........................................OF..........................._................. FEE..2. ._= Disposal Yorks Tonir ion unfit Permission is hereby granted..--- -----C2. ................................................................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit Noff7=_1l ..• Dated...... 7..... -------•-•--------------•-•--------•---.._..... Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �� /[BV NE�VE� �ftlD£tft16� 'Sc•2 +��j�2e � - � .... 1 1-7 1--- ALL.. ! f k Ell E V � { A RzTERl SULLIVAN1; :No ?9733 Q.% ; 3s t ! , Jt Gr ! S + SE T F � �� '� ��f'-I �-�►--i� i ,-.uiV� � � 't N�! I ��c 1 NY t N� Y- u 7►1 ; Pr' �i 9g•1 TauK, g IS rt q. WILL ' ` Y��I�ii t„'It L 1 I (•,•� .^W 1 ! f-f,�1-'j ^�+1��/Ai \ 0 I V ll U ----------------- � tj 1933410. . `c7 r ' t„( - tit au , 1 ' ��-,� 3�+� -� � � ti_ .- � i. -�k►S�1�.c..11 lS ter' - r UMA-7a ram �2?ll� lI►,ISC'1�.r �-A►�l 6ttia4LU N►C,n'-o;m us TZ� e� F L:j 7H OF 7Z r,7 ! � G t(A. g D-,fox ;: q'SixJPET r\. ` �y SULLI�IA �., N -� x NO. 2 9733 l�;7 FCaISTE.R�O`t jf TOWN OF BARNSTABLE 9n `� LOCATION 41 d_ yam/ /Yc,y I.� k��.c,_Y SEWAGE # `7 7r' 146 VILLAGE ASSESSOR'S MAP & LOT -, INSTALLER'S NAME & PHONE NO. j A y2 -�S'3S SEPTIC TANK CAPACITY % LEACBMG.FACILITY:(type) 4/00 s.��S��r/ (size) �1 X Q NO. OF BEDROOMS "3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 60,f11,0y � err;t•r DATE PERMIT ISSUED: DATE .:COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ti I. . ............ < 3 j 71� I( 1 I t I ir111/.n C.l f-rp, Y I - IL ) q I. LTi I 7.4 _- �.�I II 1 ri L 1 -Iw_:'F Cron: �:.rV,�F.S 51/•o50V 42.5 Cl,r;.. K c r I I rl • �i�Nr.`�uweE 1 i 5vy-FICOo.fc M,�f'HI �. _._ Ea�;(1.j v,-:•E,.i ... _ _ _— __ ._... - R I rT — 2.10 JO I r 12 C C _ & 1 I I 1 ' I ';t_Cp`Jr; �i C'rr.v. FRnl,t ln:cf r:c'ei{ E:„1�..1 rr 11 rt E:•1r4tc4 ..I�Ic - _... P,nLL9c Ef) Ar nic!Il�afl`J_2 N CEq -C:[ �nr`.411J Ij .....—.. � n��nl•JS(C S.I V'E S'rin5�Jcv.f K IMF'^}"IsrS - �` u 1 I II - - I 1:6•1 jt � I v,.::•]n/crns:r:tE:r.C.,-,'.,tlov (o/'\� �rv�rjlOraS 4 n��f!:K�^fwIJS ♦ -mod I 1 f � I 1 , I z BATH o o 0 o KITCHEN \o/ W I I J I , I DEN FAMILY ROOM- ----------------------- ---------------------- ; 2-CAR GAF W , I o � I m � 1 t.. I a , co ------------------------------- F- � I cn o 1 , m FOYER I , . DINING ROOM I , z , FIRST FLOOR EXISTING