The URL can be used to link to this page

Home My WebLink About0029 RIDGE TOP ROAD - Health 29 RIDGE TOP ROAD, COTUIT A= 027142.003 --- -- - - - - - - - - - 4 c Commonwealth of Massachusetts Qa — Title 5 Official Inspection Form j' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r a 29 Ridge Top rd ., Property Address Amy Menard ' Owner Owner's Nam j information is required for every Cotuit V Ma 7/21/2020 17-' .page. City/Town State Zip Code Date of Inspection ! Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. P.O.Box 151 r� Company Address Forestdale Ma 02644 City/Town State Zip Code reran 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further.Evaluation by the Local Approving Authority 4. ❑ Fails 7/21/2020 Inspector's Si ature Date The system inspector shall s mit a co fthis inspection report to the Approving Authority(Board of Health or DEP)within 30 day ompleting this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is Cotuit Ma 7/21/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components.in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i c Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd (Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is 'Cotuit Ma 7/21/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal. to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters. due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is Cotuit Ma 7/21/2020 required for every page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form lI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (P' 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is Cotuit Ma 7/21/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous.two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official -Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information required for every Cotuit Ma 7/21/2020 page: CityTTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding.tank present? ❑ Yes ❑ No. Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge To rd P Property Address Amy Menard Owner Owner's Name information is Cotuit Ma 7/21/2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: tank original Dbox and leakching 2015 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 4' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10, feet Comments (on condition of joints, venting, evidence of leakage, etc.): none t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 3'2" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H10 1000 gal with risers If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 26" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and 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.): tees in place. no visable decay tank at working level. risers on tank t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts fn Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow:. gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dbox in good condition no carry overs. At working level t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. City/Town State Zip code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 500 gal L.0 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form I e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information. (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chamber with partial riser. 1"of water across bottom. clean sidewalls 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18. 1 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System -information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 r�a-aa e.2 j$,(o / 0 0 2 C 1j C3-ens '03 3 0 t5fnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is Cotuit Ma 7/21/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 24 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) lain: Accessed USGS database-explain: p town GIS maps You must describe how you established the high ground water elevation: Lot el. in area of septic 64. low wetlands in area 40' bottom of SAS 6' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Ridge Top rd Property Address Amy Menard Owner Owner's Name information is required for every Cotuit Ma 7/21/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Now(3 Fee / ®v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLa.tion for Bisposat6pstrm Cun$truttion permit Application for a Permit to Construct RIp it Upgrade Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 9 4oOP P4 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel dQ-3 Co+uh Installer's Name,Address,and Tel No. Designer's Name,Address,and Tel.No. 434 8 qT7 0L5 3 V. )4. Associoims Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) a 30 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /000 9Qj Type of S.A.S. '=9%1 L Q 0 Z.) Description of Soil Nature of Repairs or Alterations(Answer when applicable) JVELtJ "QLy_l.i•n 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. tgn Date Application Approved by Date ct�_ . Application Disapproved by Date for the following reasons Permit No. J Date Issued p- ' No ! Fee /lJ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppliLation for ConstCULtiou'VPCUIIt Application for a Permit to Construct( Repair(/Upgrade( 2). Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z q ;'19 C_�P R Owner's Name,Address,and Tel.No. ; Assessor's Map/Parcel 00 3 Co-i��-� t Installer's Name,Address,and Telt No. Designer's Name,Address,and Tel.No. L_34.,13 CXC 03 W11 OGs s o c Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures s Design Flow(min.required) -03 3 O gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank )0,00 9a.) Type of S.A.S._ _W09Ck1 L C Z) Description of Soil Nature of Repairs or Alterations(Answer when applicable) /V E l.J Lt Cd c Z.� •n a _ .. Date last inspected: r Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ign Date 9 - 2 - 1 Application Approved by Date ' Application Disapproved by Date for the following reasons Permit No. ` J Q Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(,/I Upgraded( ) Abandoned( )by R -0 F)(Cc ycz 4l0-sj at Z9 P;d9 r- Top Rd has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Np.b/5 dated T h Installer O-y Designer �A-s s oci akA z S #bedrooms �'3 Approved design flo �J gpd The issuance of th'l pe I it shall not be construed as a guarantee that the system wil fun. o as designed. Date 011 ( � Inspector No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposat 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(L,< Upgrade( ) Abandon( ) System located at C9 9 R;C4 q c. 7TOP and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date ( � Approved by t J Town of Barnstable Regulatory Services Thomas F.Geiler,Director : ma 's - KAM Public Health Division Thomas McKean,Director 200 Main Street,-Hyannis,MA 02601, Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 1- Sewage Permit# .20 Assessor's Map\Parcel 7 f-f2-3 Designer: . Installer: Address: llwe"57 Address: On was issued a permit to install a (date) (installer) septic stem at d P Y � 9 based on a design drawn by (ad ss) dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations' Plan revision or certified as-built by designer to follow. - AWVON HOME ` r (Installer's Signature) '- si er's Si afore( '(Affix Designer's Stamp Here) :. PLEASE ' RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU ^ arF � uo `G� s �r . 5�eW1 s � t _ Q:HealttdSeptidDesigner Certification Form 3-26-04.doc �a �Jl''0 lo Town of B i instable. P# Department of Regulatory SeMces KAM • Public Heah� Division Date -� 3 200 Main Streek 4mis MA 02601 A. i-1 11 n Date Scheduled / Time Fee Pd " ,foil Suitability Assessment for Sew, • e Disposat �dperformed By. y ASS�G/ 1fS Witnessed By. � a LOCATION&6ENFItXL INFORMATION J L.ocatlon Address +oar JQ�dfe &,,./I Owner's Name -P, C� Address 0/N6�/ Amessor's Mapffl* P ��Z Engineces Nam- I/I't" S ( S NBW CONSTRUOON RBPAIR I Telephone# 7-f Land Use / slopes(96) .I U Surface Stones_J1SL_ r "^ Distances from: dpm Water Body ft Possible Wei Area "'" ft Drinking Water Well —' ft Drainage Way —ft. Property Line _1 —ft Other ft SKETCH:(street name,dimensiods of lot,exact locations of te#t holes&pert tests,locate wetlands in proxitnity to holes) I ' ,IlefG11p oe parent material(gedlogie)�-. Depth to Bedrock. Lov. / Depth to Groundwater: Standing Water in Hole:' Weeping hom Pit Pace Bstimated Seasonal t0gh Groundwater!Dt!T- ERM1VN TION FOR SEASONAL HIOII w 4 R TA"LE Method Used: 1 Depth abgerved standinglin obs.hole: n. th 1 ft Adjustment In. eP I in. f]troundwnter AdJusttnent ft• Depth tolweeping from side of obs.hole thetor_,_.,�Adj.Groundwater Level.— Index 1 index Well level .�.�. index Well#_� Reading Date: 1 PERCOLATION TEST. Date Z4441�---� Observation I Tithe at 9" �..�. Hole# . I p ' 'Igme at 6 • Depth of Pent _ . start Pm-soak nme.0 — �f End Pro-soak 9'`��// Rate MinAnch V Site Failed; Additional Testing Needed(Y/N) .. Site Suitability Asse0sment: Site Passed __ Original:public He�ith Division Observadod Hole Data To Be Completed on Back- -- ***If percola•'on test is to be conducted within 100' of wetland,.-You must Best notify the Barnstable C41¢servation Division at least one(1)we&prior to beginning- S DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ' Other. .surface(in.) (USDA) (MMIQ Mottling (Saucm%SWnes,Boulttets. gay �. IwId awl DEEP OBSERVATION HOLE LOG Hole`# Depth from Soil Horizon Soil Texture Soil Color Soil, Other Surface(in.) (USDA) (Munsell), Mottling (Structure,Stones,Boulders. Consistency. G, d _ P k DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons.*stcncL2bOFavel) DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color $00 1 Other Surface(in.) (USDA) (Munsell) __ Mottling (Structure,Stones.Boulders. .t Flood Insurance Rate Mau: -.Above 500 year"boundary No— Yes Within 500 year boundary No✓ Yes Within 100 year flood boundary No✓ Yes Death of Naturally Occurring Pervious Material Does at least four feet of Dattua[ly occurring pervious aerial exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe ous material? ^. Certification I certify that on W (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expe ' e and experience described in 310 CIVIR 15.017. Signature U� Date cI 2//S— i •. \ I COMMONWEALTH OF MASSACHUSETTS EXECUtIV'E OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL'PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 29 Ridge Ton Road I Cotuit.MA 02635 Owner' Name: Jennifer Sonabend Owner's Address: Date of Inspection: March 21. 2013c -70 D Name o,Inspector: (Please Print)Gordon:Bumnus Company Name: Gordon Bumpus Mailing Address:. P.O.Box 1104 Osterville,MA 02655- Telephone Number: (508) 776-2345 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 ''.. ^ Inspector's' Signature:` �C! Date: March 21, 2013 The system inspector sha 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.systetn'�'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 :• ,i it ****This report only describes conditions at the time of inspection and under.the conditions of use at that time. This inspection does not address howl.the system will perform in the future under,the same or different condition's of use. Title 5 Inspection Fonn' 6/15/2000 page I f r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued] Property Address: 29 Ridge Ton Road Cotuit.MA Owner: _ Jennifer Sonabend Date of Inspection: March 21, 2013 Inspection Summary: Check A,B,C,D or.E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments:. 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,NI?)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 disti-ft:tion box is leveled or replaced ND explain: i The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken'pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTIO'N'FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Ridge Top Road Cotuit,MA Owner: Jennifer SonaUnd Date of Inspection: March 21, 2013 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 tie 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 Boardof 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: t 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Ridge Ton Road Cotuit.MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013 D. System Failure Criteria applicable to all systems: You must indicate either"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%z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool"or privy is within a Zone 1 of a public 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 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 ni&.0gen 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. i E. Large System: 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 feat 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 th'e appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTI(_➢N',FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST Property Address: 29 Ridge Ton Road Cotuit,MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013 Check if the following have been done: Youmust indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information wasEprovided 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 no'nnal 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 componenls,.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(acid 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)]. 5 a : Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C „SYSTEM INFORMATION r Property Address: 29 RidQe Top Road Cotuit,MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013.. 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: 3 Does residence have a garbage grinder(yes.or no): No Is laundry on a separate sewage system(yes:or no): N/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_pumped after the inspection Was system pumped as part of the inspection(yes or no):. Yes If yes,volume pumped: gallons--Haw was quantity pumped determined? Reason for pumping: Maintenance TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool - Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) 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: Installed on 4113192-per as built card Were sewage odors detected when arriving at the site(yes or no): No +G: 6 fl' Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEd?WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Ridge Top Road Cotuit,MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron ___440 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: n locate✓ ( o site plah)', Depth below grade: 36" Material of construction: ✓ 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: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" 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: 10" How were dimensions determined: Comments(on pumping recommendations,it and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were Present. There were no signs of'leakaze. The inlet cover was 10"below. GREASE TRAP: None (locate on site 111$n) 1. Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: i 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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 RidQe Top Road Cotuit,MA Owner: Jennifer Sonabeizd Date of Inspection: March 21, 2013 TIGHT or HOLDING TANK: None (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: eallons Design Flow: eallons/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 swi*hes,etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and:distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-box was normal. PUMP CHAMBER: None (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.): q e Y.,y 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Rid-e Ton!R'6ad _ Cotuit.MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013 SOIL ABSORPTION SYSTEM(SAS): `✓ ' (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4'x6'600 gal. with 2'stone 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 liyoraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had 2.5 of water on the bottom.Bottom to Qrade was 11'. The cover was 3 5'down CESSPOOLS: None (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)a Comments (note condition of soil,signs of,hydraulic failure,level of ponding,condition of vegetation,etc.): o. PRIVY: None (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 _ t Page 10 of 11 j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Ridge Top`Road Cotuit,MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013 SKETCH OF SEWAGE.DISPOSAL SYSTEM Provide a sketch of the sewage disposal systemjncluding ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A A Q 0 ao ay I-1 3 3 aq 3s � 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: 29 Ridge Top Road Cotuit.MA Owner: Jennifer Sonabend Date of Inspection: March 21, 2013. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30' : 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:;, r You must describe how you established the;high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 30'+1-to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 912 9 DATE. / / 6 PROPERTY ADDRESS: 29 Ri-dge Top Road Cotuit,Mass . 02635 I ya.0 °3 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1=1000 gallon septic tank. 2: 11rDistribution box. 3. 1 -41x10' Precast leaching pit. Based bn my InRrwction, I certify the following condltIons: 1 . This is a title five septic sy-stem. 7S Code 2. The septic.. system is in proper working order at the present time. SIGNATURE: Name:-J. P .Macomber Jr.. i Company:_J. P_Macomber & Son-_Inc , e Address:_-B.,,_gg------A--_,__ __Cente'rville , Mass_-0.2632 Phone:--- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY IMMEEM ESE P. MACOMBER & SON, INC. Tanks-C*sspools-Ls&chf lelds . Pump#d & Installed Town Sewer Connections x 66' Centerville, MA 02632-0066 775-3338 775-6Al2 Commonwealth of Massachusetts ExecutNe Office of Environmental Affairs Department of environmental Protection Trudy Cox* 6-uotuy David B.Struhs LL Goan. Convn4abrwf * SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addresa:29 Ridge Top Road Cotuit,Mass . Address of Owner. 30 Wild Turkey Road Date of Inspection 1 2/9/96 (If different) Sedona Arizona Name of Inspector. Joseph P.Macomber Jr. 86351 C.4mfyName,coo tddtea�a� Telephone Number. .J Y Macomber at on iris. Box 66 Centerville,Mass . 02632 508-775-3338 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 inspection. The inspection was performed based on lily training and experience in the proper function and maintenance of on•sita sewage disposal systems. The system: = Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails lnspectoes Signature �� Date: l Job k� The System Inspectors submit a copy of this inspection report to the Approving Authority within thirty(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.%L.d copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B. C, or D: A) SYSTEM 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 completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instance&. If'not determined',explain why not) The septic tank is metal, craA4 structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is immin°nt. The system will pane inspection if the existing septic tank is replaced with a ponforming septic tank as approved by tL. Board of Health. (revised 11/03/95) 1 One Winter Street * Boston, Massachusetts 02108 e FAX(617) 556.1049 * Telephone (617)292.5500 v.� Printed on R"kd Pipe r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) p,op,a,ty,dd,.m 29 Ridge Top Road Cotuit,Mass . owner. Joseph St. Thomas Date of Inspeotiow 12/9/96 B)SYSTEM CONDITIONALLY PASSES(continued) AQ Sewage backup or breakout or ho static watar level observed in the distribution boa is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution boa. The system will paw inspection if(with approval of the Board of H"Ith): broken pipe(s)are replaced obstruction is removed distribution boai is levelled or replaced �[D The system required pumper 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: M 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 IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. d_)A Cesspool or privy is within 60 feet of a surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh S) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING 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 within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply wall. 410 The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water supply well,unless a well water analysis for collform bacteria and volatile organic compounds indicates that the wall is live from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. 3) OT HF4t L. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontlnued) PrepertyAddre.. 29 Ridge Top Road Cotuit,Mass . Owner. Joseph St. Thomas Data of lnspeotlon:j 2/9/9 6 Dl SYSTEM FAILS: • I have determined that the system violates one or more of the following failure criteria as donned 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 asoessary to correct the failure. &C Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool. 226 Discharge or ponding of effluent to the surface cf chs ground or surface waters due to an overloaded or clogged SAS or cesspool. 4,V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. AAW-4 AT- Liquid depth in eeaap"! is leas than 6"below invert or available volume is lass than V2 day flow. �J Required pumper more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ 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 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system served a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health Lad safety and th•environment because one or more of the following conditions exist: the system is within 00 feet of a surface drinking water supply zjj#- the system is within 200 feet of a tributary to a surface drialdng 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) Ths 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 6.00 and 6.00. Please consult the local regional office of the Department for thither information.. v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddresa 29 Ridge Top Road Cotuit,Mass . Owner. Joseph St. Thomas Date of Inspeotlon:12/9/9 6 e Check if the following have been done: Zpwnping information was requested of the owner,occupant,and Board of Health. zNons of the system components have been pumped for at least two weeks and the system has been receiving normal Bow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this uupectim built plans have been obtained and examined. Note if they are not available with N/A. ,0The facility or dwelling was inspected for signs of"wage back-up. , The system does not receive non-sanitary or industrial waste flow Ths site was inspected for signs of breakout. ut` , All system components,ancluding the Soil Absorption System, have been located on the site. „ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. YT11 size and location of the Soil Absorption System on the site has been determined based on fisting information or apprcaimated by non-intrusive methods. ,/The facility owner(and occupants, if different from owner)were provided with Information on the proper maintenance of Sub- Surface Disposal System. J (revised 11/03/95) 4 5� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Adds csa: 29 Ridge Top Road Cotuit,Mass . Owncr. Joseph St. Thomas Date or 2/9/96 FLOW CONDITIONS R ES I D ENTLAL• D--gn flow: oas �I+P- Cb+'/ Number of bedrooms: 11 Number of current rwidsou: Garbagv,gri.ader (ya or Laundry co rrected to or ao): Sensor tl use (yea or no): X-5 Waur meur readings, if available: aj - / > Last date of owupaacy:�" COMMERCIAL NDU9TRIAL- Type of eatabLuhaient: Deaiin aow:,,e��Ioas/day Grease trap prweat: (yea or no1,Q�4 Lndustrud Waste Holding Tank present: (yes or no),4)A Non-sa.aitary wssw discharged to the Title 5 vystom: tyea or no)" Water meter readiap, if available: 4 Lan date of occupancy: 0THER: (Describe) 424 Lan date of owupaacy: - GENERAL INFORMATION PUMPING��R��E�C� „„ORDS source of inf +nation: Ale/ kl System pumped as part of inspection. tyew or uo)_e-C 11 yes, volume pumped: Kallow Reason for pumping: TYPE OF YSTE.1i Septic tru.4ldirtributioo borJsoil absorption s)wtem �Q SiL;la cu", l Overflow w:sptwl Privy She.rvd ryvum (yes or no) (If as, attach rvvious ins ion records if an Y P ) P� Y Other (uplrin) 7 e ` , ROXIMATE GE of" mpone u, u u:.+ of (if ki wn) and source of information: "`/�✓ /')G, � ,dam%� /�slil �d-4;l 0� %at w 9� 9ewave odors SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 29 Ridge Top Road Cotuit,Mass . Owner: Joseph St, Thomas Date of Inspection: 12/9/96 SEPTIC TANK: 1490 �� VA.) e (locate on site plan) Depth below grade:_ � � Material of construction: 1/concrete _metal _FRP—other(explain) Dimensions: vr'7' _ Sludge depth: Distance from top ofydge to bottom of outlet tee or baffle: Scum thickness: (i Distance from top of scum to top of outlet tee or baffle: 4 _ Distance from bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or,baffle. depth of liquid level in relation to outlet invert structural ,rity, evidence of leakage, etc.) . Pump tank' .every 2-3 years;Inlet tees and outlet- tees are in j2lace ;NgQ aan�nk�gn ggg s of leak ,,.� is S14Ucturally sound. No repairs needed a present timer. - GREASE TRAP. 4AQfJC (locate on site plan) Depth below grade:;'A14 Material of constri!nioned;oncrete _metal _FRP —other(explain) Dimensions,--A Scum thickness.. Distance from top v1 scum to top of outlet tee or baffle: dl w� Distance from bottom ni !rom 1n honnm 01 O1111P1 We Or oaf11P /U4 Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)_ _Grease trap is not present. s 4' (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontloued) Property Address: 29 Ridge Top Road Cotuit,Mass . Owner. Joseph St. Thomas Date of Inspeotion: 12/9/96 TIGHT OR HOLDING TANK&.�)6 (bcat•on site plan) • Depth below grads: 1-1,4 Malarial at construction:o=ste_metal_FRP_othar(esplain) - a1 Dimensions: Capacity ns De:iin flow: oWday Alarm level: Commaats: ( '1.1gnf or'1o°�i°ngf tanVare`nod' present. DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert: Ivo Comments: (note it level and tiou is equal,evidenos of solids carryover,evidance of's into or out of bout,etc.) D.Box leve ;No evidence of solids carry over•No evidencg' or leaRage in or out of the distribution box.No repairs needed at the present time, PUMP CHAM9ER.Axtle— (locate on sits plan) Pumps in working order.(yes or no), Comments: (nou condition of pump chamber, condition of pumps and appurtenances,etc.) Pump chamber is not present. (revised 11/03/95) 7 . _ U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add. 29 Ridge Top Road Cotuit,Mass . owner, Joseph St. Thomas Date of Inspection:12/9/9 6 SOIL ABSORPTION SYSTEM (finer.L I Ito ' 'Cj- pocate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain e Type: Lachin pits,number._ leaching chambers,number: leaching galleries,number:.= leaching trenches,number,length: leaching fields,number,dime as: overflow cesspool,number:„ Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) an ; o sign ve e a ion is normai. No repairs needed at Vie present ttms. CESSPOOLS: (locate on site plan) Number and configuration: 1410 Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool AW Matarials of construction: Indication of groundwater. _ 4111 inflow(ampool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) No cesspools present. PRIVY: (locate on site plan) Material of oonstr ction. 41 Dimensions Depth of solids:_&,� Comments:(note condition of sail,signs of bydraulic failure,level of ponding,condition of vegetation,etc.) Privy is not present. (revised 11/03/95), g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION •FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmar3 locate all wells within 100 ' 1 Cotuit Water Company 428-2687 t mole DEPTH TO GROUNDWATER � 10a depth to groundwater r+pthod of determinesion or approximation: No w t'ere - piintered- at _y ^, :ixherr: stem was- installed in April of -.1992. See. .as built,.."-P an• as i .a a erns ale board Uf'Teat - I >t 'DEC-0-196 16:49 FROM:COTTON R.E. COTUIT 1*50.9*428*6758►' T7:5087901578 . ,. ,. TOWN,,,OF BARNSTAI3LE LOCATION got 3 Re:'fn Rdf sWAcrr -,---- ' VILLAGE /trj , �¢n_`.s ;11g: gSSESbR'S MIAP & LOT I 4 ff INSTALLER'S °KAJ1E & PHONE NO, ''. �. �f I ° SEPTIC TANK CAPACITY I d Qd x G r �� LEACfUNC FACILITY:(type) P. t" (se7e) X 1 i7 NO. OP BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERJl r- I DATE PERMIT ISSUED-.- DATE COMPLIANCE ISSUED: � VARIANCE GRANTED: Yes r • w is. c D , �� 4••-•. �,,. r s k Win. n �� . ..•t�ti.. SIC f W Y ti S`S,byY �71,1 THE COMMONWEALTH OF MASSACIIiIJSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control `l•rrn r+ n.Tt*•-Tr'Srnr mr•nsenTTrtrentsT.R:•.l1•rtr7rrlT.^Rmn ne'1-1ZrT.e'trrfsl R'n �—:..�- r...` I TOWN OF Barnstable BOARD OF HEALTH Ts'r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPRCTION FORM - PART D •- CEfITJFICATION I `.� �•••rn-T••.-•. .—T.tta."r..rneTr+n•rrrrr-t1�'m7rrT.rerrt'1*•triR•�l1R�f-1'�T�A��eRA}s twn ...:rrrfr-�. .�..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 29 Ridge Top Road Cotuit,Mass . ASSESSORS MAP, BLOCK AND PARCEL i o 97- -2'9Z--00J� OWNER' s NAME Joseph St•. Thomas PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & SenK `Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Tovn or Clty State LIP COMPANY TELEPHONE ( 508 ) 775 3338 FAX (508 1 790 - 1578 CERTIFICATION STATEMENT �R I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : :XXXXXXXXXSystem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh Or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 12/12/96 One copy of this ce t.ification must be provided to the OWNER, the BUYER ( where aNplicable ) and the BOARD OF HEALTH. * If the "�'''" 'e inspection FAILED, the owner or operator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 1.5 . 305 . partd .doc ASSESSORS MAP NO: 2 2-7 It l...I: 3 PARCEL Nil: GD3 Fps THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 1 TOWN OF BARNSTABLE Appliratiun for Disposal Works Tonstrnrtiun Prrmit Applicaiion is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................ 0 "f 3 .:. - ...................._.._. + Location Ad�r ss �j or Lot No.��1� .._......../..K.-C 1 wal. ........... .�.'.........................• ...........AI_�.r...�.�lt T'S.EAI.:.._._:_...._........................... .... O n r Address w .Ta.. i----------------------------------------- ---------------------- �-!�ff�:.u......... � �s Installer ................ Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................ ,Expansion Attic ((�,b) Garbage Grinder /d '4 Other—Type e of Building ............... No. of ersons....__.__.__.....___._..._._ Showers — Cafeteria w YP g ------------- P ( ) ( ) Ga Other fixtures -----------••-------•--••------- . W Design Flow._._qS1 P................-•_gallons per person per day. Total daily flow..........,. rJ...................gallons. 1:4 Septic Disposal Trench i No .................... . ac.. -! dthns Lent Total Lengthidth................Total leaching area...-at ......sq. ft. Seepage Pit No------------- Diameter.......J4_.f..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box O Dosing tank O X_ 2 ,T X S'7 e N z x^ 3 9 Z CID Percolation Test Results Performed by.....................................................r Date----•-------•-----••---------.r....--- Test Pit No. I......... per inch Depth of Test Pit.....!-z..______.Depth to ground water....4A-__-______- Gz, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ O Description of Soil............................ -`°---•--1;�-aQ---S'B`-[.Z.....................................•---...-------•--------------•-••---..._...----•---•--•-- U ............................................................ Z-X.......-- �'� 5¢�-�........- ---— U UW -----•-•-•-•------------•----------•----•---•--------------z-'� �-`�-f........-----_A1,0__Z........�`�------------------------------------------------.....---....... 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 TITLE 5 of the. State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o ealth. C�+ / ........... --------Signed ... G / ......... Dat e q ApplicationApproved BY ---------- -------------�. �-----------------------------------------------------.......-..--- ------ Date Application Application Disapproved for the following reasons' .. .......... ................................................................................ .................................... ---------------------- ----------------------------------- ---------------------------- -...................... ---------- ------------------------------------------------------------------ ........................................ PermitNo. ..... ' 1a Y---------- ------_---- Issued ----------------------- ....................................... Date ' s f _ a �03 No f : Fps......Lad...... 1�...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j TOWN OF BARNSTABLE Appliration for Uispwial Works Tnnitrnrtiun ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........................ ...... .�..... -�............... ....... .....................__. 1 C Location-Add ess or Lot No. • ._ �.� cd d...................... 'f.....=-------------------- t .a..... ./ ...... C"c? i�.,s ............................. Owner Address a ••--•....•-•--T-1 .......... ........................................ ........................... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms........... ................. _..._Ex Expansion Attic a g— --------- p (/l�J) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures -------------------------------•----------------------••••-------•••-•-•-•---•---------------•---•----•-•---••----•---•-....-•••-••-•--•....---•-•--- W Design Flow._....... ...5.............. gallons per person per day. Total daily flow........... . .T v........._..........gallons. g g P P P Y Y WSeptic Tanker Liquid capacity__!fT?M.gallons Length................ Width................. Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-__2 oy......sq. ft. Seepage Pit No............ ....... Diameter.......-*A..f----- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing-tank ( ) X 2 ,a C S'fo N 2 x- .317 L <Z,/(Q aPercolation Test Results Performed bY.......................................................................... Date...............................j M Test Pit No. I......:?7 ...minutes per inch Depth of Test Pit-----4_.2:....._.. Depth to ground water.....�6........... 0�4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - - -- -------- ' O '. Description of Soil............................0----�`'-----..../.q. =S0 l-L V •-------- -•-------------•---•-------•---...... y�- S u •S{9 r- . ----.............�UIp --------5k?v�----------------------------------------------.............--- U 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o ealth. Signed ---------------------------- Date Application Approved By .. „�s................. (-/-- J Late Application Disapproved for the following reasons- ------------------------------------------------------------------ ----------------- - -- ----------------------- ------------ c� Date PermitNo. .- 6 b".-LI--------_------------------- Issued ........................Da------.. ------ --------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cfedifirtt#P of C omplittnre THIS IS TO CERTIFY, That the IndividualSewage Disposal System constructed ( >'r) or Repaired ( ) by-- . . -------------------z- .��'........dql e Installer at ................ i"_oT----. ......... --- ..........-......... has been installed in accordance with th provisions of TITLE 5 of The State Environmental Code.as described in the application for Disposal Works Construction Permit No. -Q --- -1---..�. _�'�' dated ---------------------- --------- - -- ---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A,GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY, r t,tf,' -- - .w DATEf - Inspector ...... .... ...................__....------........------..........---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c 3 TOWN OF BARNSTABLE No......�sat ' l ' FEE...h2n...----- Elinpnsnl lVorkii Tnnitrnr#ivit rrntit Permission is hereby granted 46 ......................................................................................... to Construct ( or Repair ( ) an Individual Sewage Disposal System y Street as shown on the application for Disposal Works Construction Permit No..��-1��! Dated,................. f a Board of Health / DATE.......k. ..... == --- ••.••••• ,' FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE %LOCATION `' g�i`crTe foe �� SEWAGE# , 2015- '-2-9 VILLAGE ASSESSOR'S MAP&PARCEL - 2- v INSTALLER'S NAME&PHONE NO. �34 9 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) / L (size) NO.OF BEDROOMS OWNER PERMIT DATE: 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 v 131=a� TOWN OF BARNSTABLE LfJCATION Lot ,dqy-r,fOV RJ1 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J 0�.� �4 /io 1 SEPTIC TANK CAPACITY 5 LEACHING FACILITYAtype) (size) 1/x 10 NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER %UtC BUILDER OR OWNER DATE PERMIT ISSUED: 9 DATE COMPLIANCE ISSUED; lq(:q7 VARIANCE GRANTED: Yes No ��I, �� _ � ' ® SAT / � c � �`� � i � � � � � sg� . ' �y/�i � may'; { Ridge T p �o ASSESSOR'S MAP: 27 a\o�15 LEGEND: PARCEL: 142-3 3 - \ �--- - —� PROPOSED CONTOUR o rit any .REFERENCE: PL. BK. 430 PG. 11 J�� o \ �� L FLOOD ZONE: X Town of Barnstable � - �� '. , .�- •.1Q � � 'a \ O[\j ss PROPOSED SPOT GRADE - 0 ve � 40 , EXISTING CONTOUR LOCUS ool� _ � � `�� #25001 C0539J (07/16/14) a �o J x 30.23 EXISTING o � 1 o 0� O/1 E G SPOT GRADE TEST PIT N av�ne EXISTING WATER SERVICE . -it 2a NOTE: Reuse Existing ��9 ��I�C�� . dap �� o o W RK Ro 1000 al Septic Tank. - v � 10 5 0 LIMIT LINE Pump and Backfill LOWS MAP N.T.S. Failed Leach Pit. �' �� •� S 00 GENERAL NOTES: �` di o 1. VERTICAL DATUM: Assumed--------- 2. MUNICIPAL WATER �S __ AVAILABLE. 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT 'i �g3 `'eoer 96 98 56 SYSTEM UNLESS OTHERWISE NOTED. `� P� g 4. ALL PRECAST UNITS TO CONFORM TO \\ N Q 5933� AASHTO: _ H=10_& 20 �� ` �2 920g �e �- Benchmark set: E 0 5• PIPE PITCH.-1%4" PER FOOT UNLESS OTHERWISE OTED. � � � -( :�' � `� Left cor. bot. brick step 6• ALL CONSTRUCTION DETAILS TO BE IN CONFO/ ANCE i � Z o / EL.= 93.54 (Assumed) WITH MA ENVIR. CODE (TITLE 5) AND LOCAL \-o REGULATIONS. �OO� 7• CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIEStX OF PRIOR TO CONSTRUCTION. o 4F g PssvCA AMY L: VON HONE U y Regrade if possible to avoid �{�5 No. io68 Vent and Depth Variance - 5' 86— — - — - s6 M 8418 ISTER� F E T 1 � 25' r IN 84 NOTE: This plan is to-be used for septic 828 system purposes only `and is not to be Vent w/ Filter—� 0- Lot 3 \ 13`'82 �: — — 82 considered a property. Line survey. x81:25 !' 13,919f S.F. \8O� Meets 0.3f Ac. 88 okoUt - =.- - - so \ / 29 RIDGE TOP ROAD Map 27 o V H -COTU:I T, M.A Parcel 142=3 73.7�. associates PREPARED Robert & L ndsa Scott N53e3 . � �9 sePnc srs1EM OE�cxas FOR: y y » 29 Ridge Top Road . W 320 Catuit Road Sandwich, MA 02563 C o t u i t, MA 02635 �1 +' w 508.833Compliance .0041 N a�.00 Title 5, S ct onbl15 405 (1)(b) 8C 1. 1 . Surveying IL B B Excavation variance, proposed 4 final cover over Terry A. warner.P.L.S. portion of Leach facility: t 22 Long Road HanWch, Mn 02M DATE REVISED SCALE SHEET NO. r (W8) 432-&V9 09/01/2015 V, 20' 1 of 2 Provide Riser over D-box NOTE: All components to be marked with NOTE: To prevent breakout, final T.O.F. (Full/Walkout) to within 6" of final grade -magnetic tape or similar prior to final cover. grade of EL. 81.0 to be carried EL. 94.73 (Cover to be watertight) out a minimum 15' beyond edge F.G. EL: 86.5-93.4f F.G. EL: 93.2 F.G. EL: 85.0 Maintain Min. 2% slope over leach facility to of leach facility. Existin revent ondin F.G. EL: 83.0-85.0 Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or in ection Port within 6" to grade outlet to within 6" of final grade Tee Geotextile Fabric ; Exist. invert L=10' (Access Covers min. 20" diam. per Code) �. •• Elev. to be 4" SCH 40 P L=130 L=10' 3/4 - 1 1/2 Double Washed Stone • 4 SCH 40 PVC ,. < Top of Peastone or Geotextile Fabric EL. 81.0 confirmed as ®S= 1%.MIN 4 SCH 40 PVC needed. 10� 14• ®5-6.1� 1% 6 CADS=57. 0.5%MIN eaBEa®® 24" Eff. Depth EL. 88.6t as®8886 Install Gas Baffle EL. 80.67 EL. 80.5 eaaaaaa 78 0 Q EL. 88.8 PROPOSED DB-3 EL. 80.0 Use 2 - 500 Galion Precast Chambers H-20 DISTRIBUTION BOX (H-20) with Double Washed Stone 4.61' (Install PVC Inlet & Outlet Tees) Watertest for levelness 4' Ends, 4' Sides EXISTING 1000 GALLON if more than one SEPTIC SYSTEM PROFILE (25 x 12.83 x 2 ) H-10 SEPTIC TANK outlet EL. TH N.T.S. Bottom of TH-2 ADDITIONAL NOTES DESIGN CRITERIA SOIL LOG 1. Contractor to confirm soil suitability prior to installation. Contact BOH Number of Bedrooms: 3 Bedrooms SOIL EVALUATOR: AMY VON HONE, R.S. S.E. #2517 and Design Sanitarian in the event of varying soils from original soil INSPECTOR: DAVID STANTON, R.S., BOH test. Design Sanitarian to certify soils at time of installation. Soil Type: Cl (Cl Horizon) DATE: SEPTEMBER 1, 2015 11:00 AM- ass I ( zon) Percolation Rate: Inch PERCOLATION RATE <2 MIN/INCH IN C1 2. Pump and backfill Failed Leach Pit. , Any contaminated materials within <2 min/ PERMIT #: 14798 5' of proposed Leach Facility to be,removed including unsuitable soils Daily Flow: below Leach Facility. Replace with clean fill per Title 5 specifications. Design Flow: 110 G.P.D./Bedrm x 3 =330 G.P.D. TH - 1 TH - 2 330 G.P.D. (Min. Required) EL. 83.67 EL. 84.39 3. Sewer line to be sleeved at any waterline crossings, as needed, per Garbage Grinder: Not Allowed Water Department requirements. Contractor to verify location of water Fill/A Fill/A line prior to construction. Leaching Area Sandy Loam Sandy Loam „ Required: (330)/0.74 = 445.94 S.F. 10YR4/2 10YR4/2 4. Distribution Box to be placed on 6 crushed stone or compacted, level - 18" 82.17 181, 82 Sg base. Septic Tank Required: 330 G.P.D. x 200% = 660 G.P.D Minimum 1000 Gallon (Existing) m y Sand Loam y y Sand Bath Use 2 - 500 Gallon Precast Chambers with Double 30" 10YR6/8 81.17 30" 10YR6/8 81.89 \,`Gr Washed Stone: 25' x 12.83' x 2' C1 C1 dry Coarse Sand Coarse Sand FLOOR PLAN ' Sidewall Area: 2(25' + 12.83')2= 151.32 S.F. 2.5Y5/6 2.5Y5/6 Living 9 � _ Bottom Area: 25' x 12.83'= 320.75 S.F. Per N.T.S. Total Area: 472.07 S.F. ® Room Bed 1 - 48" B ttom Desi n Flow Provided: 0.74 472.07 .F. _ 349.33 G.P.D. 1st Floor 29 RIDGE TOP ROAD V H COTUIT, MA associates PREPARED Robert & Lyndsay Scott 120" 173.67 132" 173.39 Bath siPnc SYSTEM DESIGNS 29 Ridge Top Road No Groundwater Observed No Groundwater Observed Bed 3 ' 320 cotuit Road Cotuit, MA 02635 Sandwich, MA 02563 PERC RATE: <2 MIN/IN. ( C1 Horizon) <5" ® 9:46 minutes 508.833.0041 I, Amy L. von Hone, R.S., hereby certify that I am currently approved by Bed 2 surveying by: B & B Excavation the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and Terry A. Warner.P.L.S. that the above analysis has been performed by me consistent with the 22 Long Road requirements of 310 CMR 15.017. 1 further certify that I have Harwich, MA 02645 DATE REVISED SCALE SHEET NO. 2 n d FI o o r (5W) 4W-8W9 successfully passed the Soil Evaluator's Exam on November, 1994. r 09/01/2015 1 =. 20, 2 of 2 i i EL.= 80.0 20' MIN. TOP OF FDUNDATlON CONCRETE' COVERS " 2 LAYER OF GEN�RAL NOTES , 1/8= CONCRETE COVERS WAS STONE] EL 79 1. THIS PLAN IS FOR INSTALLATION OF NEW SEPTIC . . , , / � � � � � i �T / / , , , � �� EL = 78. FINAL GRAD 12"MAXI / / / / 2. PLAN REFERENCE BOOK 430 PAGE 11 cbi=e / • • • / / / , • / / / , x--- EL=73f EL = 78 ORIGINAL & PITCH 1/4" PER-FT FINAL GRADES 3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM ,.:.: 4 SCHEDULE 40 P.V.C.DIST. PIPE — MIN AND NOT TO BE USED FOR SURVEYING OR ZONNING PURPOSES. FLOW , PITCH I/4" PER ITBox 4' CAST IRON 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO REP. oR sc�vLE 4o i 19' g. �$ ooPLERACIwTG Hz 0 LOADING TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS — 71 5 P.V.C PIPE oo a . ti IT OR ' . EL.—_• — INVERT cRvs�n ,o yY/7 OF COVER FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 11vvERT 4 L.L EL•—_ 71 sTo voos000ses'��vERT 4 ;:Jo E4vrvALENT 5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN EL•= 71.25 EL.= 70_8 0 o 12" OF FINISHED GRADE. - LvvLR 4 °c / 3 4 TO 1-1//2 8. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE ° o_ AA;=T" STONE" sEPTIc TANK EL.=_zL� EL.. 70.3 o w c SAME, UNLESS NOTED BY FINAL CONTOURS. 10' �1000�_GALLONS ° ,b 7. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE H2 0 WITH 6' S' �" 13' o EL = 66.3' OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OF COVER 6 DIAM. --) OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING LEACH'PIT 1, SHALL BE USED UNDER OR WITHIN 10' OF DRIVES'OR PARKING. 10' UNLESS NOTED. 8. ANY MASONRY UNITS USED rO BRING COVERS TO GRADE SHALL SOIL LOG BOTTOM OF BE MORTARED W PLACE. WITNESSED BY: TEST HOLE EL---60.2 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DATE 3�3�92 ' TEST, HOLE 1 DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO TOWN OF BARNSTABLE LEACHING SYSTEM WITHIN 250' OF OBTAIN SUCH DETERMINATION FROM APPROPRIATE A UIHORITY. EL= 70.2 PRO FILE O F PROTECTED WETLANDS-AT APPROX Jr LLEBERMAN 185' BUT BOTTOM OF SYSTEM IS . P7852 - SEWAGE DISPOSAL SYSTEM APPRox 21.3' ABOVE ESTIMATED PERCOLATION RATE _ 2 _ MIN./ INCH MAI9MUN WATER TABLE D. M10RAN01 NOT TO SCALE O 9 HEAL TH OFFICER D ALL ELEVATIONS ASSUMED DESIGN DA TA.' 00 MAX WATER ELEVATION Op�sAL� pR YI NUMBER OF BEDROOMS 3 o� ESTIMATED AT EL = 45' As ti 3 ABOVE BOG WATEr :LEIEL DR GARBAGE DISPOSAL NONE 00 CIO EL = 58.2 2' 2' oo �` `�� ,� TOTAL ESTIMATED FLOW 330 GPD NO WATER cs o �Q.l� ( 110 GAL/BR./DAY x _3 BR.) ENCO UNTERED 7 / o0o D SEPTIC TANK CAPACITY 1000 GAL O 8 cb \/ \ rye\ JNL LEACHING AREA REQUIREMENTS LOT ,2 2,�0. 7� T�� SIDEWALL AREA 2.5 GAL/S F. . _.,,�T.�Y_ BOTTOM AREA _L 0 GAL/,IF 1 LEACHING CAPACITY. (BOTTOM & SIDEWALL) 39Z _ GAL%DAY. �, d J BOTTOM 17X102:4X1=78 E 8 °se w� _ \ SIDE ILX10X4X0 5=314 6' RESERVE LEACHING CAPACITY 392-330 62 GAL./DA Y 64 \\ LOT 3 BREAK OUT POINT REQUIRED DISTANCE IS 72 — 68X 150 = 25' RE UIRED o� �` 6, nl� ,24 30' PR VIDED ( ORIGINAL & FINAL 4 2� LOT 4 GRADE ) Xx�� o APPRO VED BOARD OF HEALTH OD Q0 \ 6 0 - PROPOSED CONTOURS �,loo, ER� ,, DATE AGENT 1ti3711 zoN � 5' PROJECT LOCATION- LOT 3 RIDGE TOP ROAD BARNSTABLE .. o B ti APPLICANT MCSHANE ASSOCIATES A. OPEN / C�'SPA ,�FcISTI YANKEE SURVEY CONSULTANTS \ S \ P. O. BOX 265, 143 ROUTE 149 LOCUS 0 MARSTONS MILLS, MA. 02648 H. 508 428-0055 — FAX (508) 420-5553 �C1 \ tag c=v n SCA IDATE. \ `$ LO YELLS' 3/3/92 , V1 - BOG POND ® 1� REV. 1 mv: z» Pvc PIPE 'zj LOCATION MAP JOB NO. 50115 [SHEET 1 OF 1 �G� I� BOG 3��L OF BOG L _ 4136 gZ