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HomeMy WebLinkAbout0019 ROOSEVELT ROAD - Health LA0 RooseveltCotu39-141 � Iq goojtv-0-b— O�r\�oacA� C/Nur� -bD i q ooje veI- ' oae�� Gr1�hc ram" PAT NY a-- WAN Was NoV w _ All 14 0 �A� A i:� r.r t u' a TAS -A- Aj A f 00 Own!A; A 0— oil 4;A WIT low t�! 1�! y 11 NOT! As Q 170,10 1 Y t. P n b• , R x t= x y� �z r Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg 1 Owner Owner's Name information is Cotuit MA 02635 3-26-18 required for every f page. Cityrrown state Zip Code Date of Inspection 0.I 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:Whfirg out formsen A. General Information Q oinl the computer, �1 a-/ ��� �541 OF use only the tab 1. Inspector: key to move your o C5 A. JAMES u' cursor-do not James D.Sears = use the return key. Name of Inspector a Ca ewide Enterprises %�* •.r'F, °. Ir�l Company Name Z--4( 0 153 Commercial Street "'�4i�nnu uu Company Address > Mashpee MA 02649. Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-27-18 pector's signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page t of 17 �#b�d J 0l• a5ed xed dH L 6Z2 9 ME LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner Owners Name information is required for every Cotuit MA 02635 3-26-18 page. CrtyfTown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal Tank- D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiftration 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): tSinsdoc-rev.6/16 Tine 6 Offidal Inspection Form:Subsurface Sewage Disposal Syslem-Pape 2 of 17 6l a5ed xe:1 dH 8VZ2 860E LZ JeW rr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Roosevelt Road u Property Address Maria Hollenberg Owner Owners Name information is required for every Cotuit MA 02635 3-26-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired, B) System Conditionally Passes(cunt.): ❑ 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 : P ( P ) ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.dx•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Z6 a5ed xed dH 86:ZZ 860E LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4-11 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name ion Is reequiredquired for every Cotuit MA 02635 3-26-18 page. Cityrrown State Zip Code Date of Inspectlon B. Certification (cont) 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all Inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in NEWN is less than 6" below invert or available volume is less than Y2 day flow Pi7- t5ins.doc-rev.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 4 of 17 El, a5ed xed dH 61,ZZ 81.02 LZ JeW f Commonwealth of Massachusetts Title 5 Official Inspection Form ts Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 19 Roosevelt Road Property Address Maria HollenbeM Owner Owner's Name information is required for every CON it MA 02635 3-26-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cons) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumpgd: A❑ ® ny portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form,) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. L5ins.doc•rev.611e Title 5 Vidal Irmpection Form:Subsurface Sewage Disposal System•Page s of 17 b6 a5ed xed dH 66ZZ 860Z LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form '♦ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Roosevelt Road u Property Address Maria Hollenberg Owner Owners Name information is required for every Cotu it MA 02635 3-26-18 page. City/rows 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 NIA) ® ❑ 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) (31 D CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 16.203(for example: 110 gpd x#of bedrooms)' 330 15ins.doe-rev.6116 Title 5 Offidal Inspection Form:Subsurface Sewage Dispose!System•Page 6 of 17 g6 a5ed xed dH 66:ZZ 860E LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form t- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name information required for every Cotuit MA 02635 3-26-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2016-201.000Gal g ( y 9 (gp �� 2017-84,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15lns.doc-rev.&16 Title 5 Official Inspecticn Form:Subsurface Sewage Disposal System•Page 7 of 17 g t a5ed xed dH U ZZ 9 602 LZ JeW Commonwealth of Massachusetts ,,q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Roosevelt Road `-' Property Address Maria Hollenbera Owner Owner's Narne information is required for every Cotuit MA 02635 3-26-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5Ofticial Inspection Form:Subsurface Sewage Disposal System-Pape 8 of 17 L abed xed dH OZZZ 9 60Z LZ JaW I Commonwealth of Massachusetts Title Sewageace e 5Officia Inspection Form kv:w0l p System Form- Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name information Is required for every Cotuit MA 02635 3-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1990 3-2018 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 38 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40, Septic Tank(locate on site plan): Depth below grade: 28"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-16 Sludge depth: 2° t5ins.do:•rev.6116 Title 5 Official Irepeclion Form:Subsurface Sewage Disposal System•Page 9 or 17 91, a5ed xed dH OZZ 860Z LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vim~ 19 Roosevelt Road Property Address Maria Hollenbe Owner Owners Name information is required for every Cotuit MA 02635 3-26-18 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 28" below grade wlinlet cover at 18". Inlet Tee,outlet baffle. No sign of leakage or over loading Note: Maint pump after inspection Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain).- Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Gabe t5lns.doc-rev.6116 Title 5 Official Inspection Forn:Subsurface Sewage Disposal System•Page 10 of 17 66 a5ed xeJ dH OZZ 860E LZ JeW -7 Commonwealth of Massachusetts Title 5 Official Inspection Form ivIc-1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name information is required for every Cotuit MA 02635 3-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15lns.doc-rev.E/16 Titla 5 Official Inspection Forth:Subswfece Sewage Disposal System-Page 11 of 17 OZ abed xed dH OZZ 81.10E LZ JEW C Commonwealth of Massachusetts Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name — information is required for every Cotuit MA 02635 3-26-18 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-35" below grade w/one line out Box is new 3-2018 w/cover at 6" 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. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Tite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 6Z a6ed xeJ dH 6ZZZ 860E LZ JeW c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 19 Roosevelt Road Property Address Maria Hollenberg Owner owner's Name information is required for every Cotuit MA 02635 3-26-18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number,, ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit w/2'stone. Pit at 2' below grade. V water in pit, w/stain line at around 3', 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 E 15ins.aoc•rev.6116 Title 5 Dlr6el Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ZZ a5ed xe� dH ZZZZ 8 V LZ JeW Commonwealth of Massachusetts Title 5 official Inspection Form I' Ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name information is required for every Cotuit MA 02635 3-26-18 Page. Cityrrown State tip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6I1S Title 5 Official Inspection Form:Subsurfeoe Sewage Disposal System•Page 14 of 17 62 a5ed xeJ dH ZZZZ 8 602 LZ JeW I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F 19 Roosevelt Road LTV Property Address Maria Hollenberg Owner Owner's Name information is required for every Cotuit MA 02635 3-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R tAf p i r , _g 39- IV 0 3 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subawrface Sewage Disposal System-Page 15 of 17 tZ a5ed xe:1 dH ZZ:ZZ 9 L02 LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner owner's Name information is required for every Cotuit MA 02635 3-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 0 N 13' Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4-2-87 Date ❑ Observed site (abutting prop"/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 4-2-87- 13' no G.W., Bottom of pit at 8' below grade. Bottom of pit at 5' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.oil Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 5Z a5ed xeJ dH ZZZZ 8 1,0E LZ JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Roosevelt Road Property Address Maria Hollenberg Owner Owner's Name information is Cotuit MA 02635 3-26-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-ray.6116 Title 5 Wool Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 gZ a5ed xed dH ZZ ZZ 91,2 LZ JeW No.. Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippfication for Misposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. I q ROODV€L'7•R D_ Owner's Name,Addres ,and Tel No Assessor's Map/Parcel Q m t 9 R &-U( RD do-7;oi-r Installer's Name,Address,and Tel.'No. :5 09-4 77—$1Z 7 7 Designer's Name,Address,and Tel.No. ��// �JIA Type of Building: g Dwelling No.of Bedrooms �/ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building g No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ' gpd Design flow provided /Ir gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) / 4JO P,6<4�, Date.last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f He Sig,icd, y Date '� —�(� Application Approved by Date Z 3 Z2► - Application Disapproved by Date for the following reasons Permit No.�i�i f; '� Date Issued ,717;3_jam ? Ni. t'.t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE, MASSACHUSETTS . Yes application for Misposal 6pstent Construction 3permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 4 q RO OSC EL—r RD Owner's Name,Addres ,and Tel.No CAZwIT MAXI H©c. .cx1 . Assessor's Map/Parcel 039 1141 19 R p0$E'V&;L?` .P D �-rot-r Installer's Name,Address,and Tel.No. S O$'477-C Q7-1 Designer's Name,Address,and Tel.No. G4p��ncc E�XT�t1'R:s Type of Building: Dwelling No.of Bedrooms N P( Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A6 gpd Design flow provided AM gpd Plan Date Number of sheets Revision Date E Title Size of Septic Tank- Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -_2 AJS`Ti4t� NEl.e tf' -A c! n —!3a!C A"b P,6Q?, t Date last inspected: Agreement:. a 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.. Signe Date Application Approved by Date ° �1 7V 1 g Application Disapproved by Date for the following reasons Permit No. Date Issued -51,,•3/2 01 - e THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded Abandoned( )by � AE at _ -d Y with the rovisions of Title 5 and the for Dis osal System Construction Permit No. 01 dated 7.3 7ra I21JO S `U ?" - CC `u t €""--. has been constructed in accordance P P Y �C �i •T �! � !� Installer C.McwmG Ejt7rW4jsxE5 Designer NIA #bedrooms Approved design flow gpd The issuance of this permit shall note be gonstrued as a guarantee that the system will�tio s designe Date / (/� ,� Inspector --- ------------------- ---- - - - -------------------- --------------------------------------------- Q------------ ----- NO. 0 Feet THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair(k) Upgrade( ) Abandon( ) System located at 11 R D d S z;m_?"' Pw&b Co Li[-i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co struct)ion must be completed within three years of the date of this permit. Date' a23 J al S Approved by `i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments / 19 Roosevelt Road Property Address Jeffery Ballou Trust ' Owner Owner's Name k' r information is ff , required for every Cotuit f MA 02635, 1/5/15 page. City/Town 1 State Zip Code Date of Inspection tau F S 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. General Information filling out forms � ' on the computer, � use only the tab 1. Inspector: vy� key to move your cursor-do not use the return James Ford key. Name of Inspector tab Company Name P.O. Box 49 E :: Company Address ietom Osterville MA 02655 City/Town State lY Zip Code 508-862-9400 i, S12482 Telephone Number License Number I, B. Certification10 4. 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 E al ation by the Local Approving Authority 1/15/15 Inspect r ignature. Date The s to inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heal r DEP)within 30;:'ays of completing this inspection. If the system is a shared system or has a design flow of 10,000 ypd or greater, the inspector and the system owner shall submit the report to the appropriate re',gional 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. i' ****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 cord'itions of use. f 1� t5ins-3/13 Title 5 Official In a on Form:Subsurface Sewage Disposal System•?age 1 of 17 I� Commonwealth of Massachusetts Title 5 Official: inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments w e 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owner's Name information is required for every Cotuit MA 02635 1/5/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont') Inspection Summary: Cherck. A,B,C,D or E/always complete all of Section D A) System Passes: ;I i ® I have not found any infgrmation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3.10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. r > Comments: { t. P i. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. Thb 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. k' ❑ Y ❑ N I'; ❑ ND (Explain below): I! r ii , f l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 { II i Commonwealth of Massa:phusetts Title 5 Official.: Inspection Form Subsurface Sewage Disposa['System Form Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owners Name information is required for every Cotuit t• MA 02635 1/5/15 page. CitylFown State Zip Code Date of Inspection B. Certification (cont.. "i � f ElPump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally passes (cont.): f +. ❑ Observation of sewage'backup or break out or high static water level in the distribution box due to broken or obstructed ipipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): fl ❑ broken pipe(si)are replaced ❑ Y ❑ N ❑ ND (Explain below): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): P ❑ The system required purnping 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): I, , ❑ broken pipe(s)jte replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction isl!removed ❑ Y ❑ N ❑ ND (Explain below): i; f C) Further Evaluation is Required by the Board of Health: 1. t; ❑ 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: ii ElCesspool or privy is within 50 feet of a surface water b F ❑ Cesspool or priviy is within 50 feet of a bordering vegetated wetland or a salt marsh t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 .t ; t Commonwealth of Massachusetts Title 5 Officio Inspection Form Subsurface Sewage Dispos;al'System.Form - Not for Voluntary Assessments j, A . 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owners Name information is required for every Cotuit MA 02635 1/5/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont,) 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 aseptic 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`IsPptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a`isaptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: it { D) System Failure Criteria Applicable 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 ❑ ® Discliarge 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 '/2'day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 t t V Commonwealth of Massachusetts W Title 5 Officil'' Inspection Form Subsurface Sewage Disposial System Form - Not for Voluntary Assessments 19 Roosevelt Road ii Property Address Jeffery Ballou Trust a; Owner Owners Name i information is required for every Cotuit I MA 02635 1/5/15 page. City/Town ;i State Zip Code Date of Inspection B. Certification (cont ) Yes No .: f I ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Anypd rtion of the SAS, cesspool or privy is below high ground water elevation. ❑. ® Anyrportion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t ❑ ® AnyPortion 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. r` ❑ Z Any pdjtion of a cesspool or privy is less than 100 feet but greater than 50 feet from:a;:pnvate 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 critena,,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 c9risidered a large system the system must serve a facility with a design flow of 10,000 gpy to 15,000 gpd. ii For large systems,you must'indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the systtem 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 0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area,71lWPA)or a mapped Zone II of a public water supply well If you have answered "yes1jdl any question in Section E the system is considered a significant threat, or answered "yes" in Sectio'n,,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 with310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. j , t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 {i . .'t it `1t I i Commonwealth of Ma"achusetts W Title 5 Official: inspection Form Subsurface Sewage Dispos'al.'System Form - Not for Voluntary Assessments a 19 Roosevelt Road ; Property Address ++ Jeffery Ballou Trust Owner Owners Name informationt is q , required for every Cotuit page. CitylTown MA 02635 1/5/15 a• C. Checklist State Zip Code Date of Inspection � °` . 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 ❑ ® Wereffariy of the'system components pumped out in the previous two weeks? ❑ ® Has thel<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 asbuilt plans of the system obtained and examined? (If they were not available note as N/A) l ® ❑ Was the'facility or dwelling inspected for signs of sewage back up? 4� ® ❑ Was t4,site inspected for signs of break out? ® ❑ Were $ system components, excluding the SAS, located on site? I! . ® ❑ 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, dimension's, 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 site!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. ® ❑ Deter&hi,ed 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)] f{ t D. System Informatiol�i' t �; ,l Residential Flow Conditiorl'¢s: Number of bedrooms desi n 3 3 ( 9 ) Number of bedrooms (actual): DESIGN flow based on 31 0 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 l5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 fl + Commonwealth of Massachusetts - W Title 5 ' ' . _ Official; Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust f Owner Owners Name information is required for every Cotuit MA' 02635 1/5/15 page. CitylTown ' State Zip Code Date of Inspection D. System Informatibn ' Description: ti k I Number of current residents,, j 0 Does residence have a gak'rjbag'e grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonal use? j . ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? n ❑ Yes ® No Last date of occupancy: ; unknown Date Commercial/Industrial Flow Conditions: 5. . Type of Establishment: 41 Design flow(based on 3104CMR 15.203): . Gallons per day(gpd) Basis of design flow(seats/'Orsons/sq.ft., etc.): Grease trap present? { ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No s � Water meter readings, if available: t5ins-31 3 t,:: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i; i .9 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments 19 Roosevelt Road , A l� Property Address t ! . Jeffery Ballou Trust ' Owner it 1 Owners Name E information is required for every Cotuit MA 02635 1/5/15 page. City/Town State Zip Code Date of Inspection D. System Informati`oln (cont.) Last date of occupancy/us.e:. Other(describe below): f! j I { General Information Pumping Records: Source of information: Unknown r. : Was system pumped as part,of the inspection? El 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) and a copy of latest inspection aF the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(desciibe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official., inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owner's Name information is required for every . Cotuit MA 02635 1/5/15 page. City/Town :' .}' State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: installed in 1991 - per owner, . Were sewage odors detedfeb when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 Pvt ❑ other(explain): Distance from private water supply well or suction line: feet ;j Comments (on condition of joints, venting, evidence of leakage, etc.): fi i{ Septic Tank (locate on site plan): i Depth below grade: �i '� ' 36" I' �' ` feet ' r• i Material of construction: ® concrete ❑ motol ❑ fiberglass ❑ polyethylene i ❑ other(explain) lr f' If tank is metal, list age: i f years lt Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: °`: ; 1000 gal. y;. Sludge depth: i,. 2 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i.! :1 t ; Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Dispos'al,System Form - Not for Vol untary As o . y sessments 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owner's Name information is required for every Cotuit ' MA 02635 1/5/15 page. City/Town 1.' State ZipCode Date of Inspection D. System Information (cont.) x, Septic Tank (cont.) r . Distance from top of sludge to.bottom of outlet tee or baffle 27 Scum thickness 4 t Distance from top of scumt6 top of outlet tee or baffle 6 Distance from bottom of scum .to bottom of outlet tee or baffle 15 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. There was no sign of leakage. The inlet cover was 15" below grade. i !I . Grease Trap (locate on site flan): it Depth below grade: n/a 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: a li Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t ' Commonwealth of Masisachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposalystem Form - Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owner's Name information is required for every Cotuit MA 02635 1/5/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t. Y. i Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: i• Material of construction.- El concrete ❑ rretel. ❑fiberglass ❑ polyethylene t y ❑ other(explain): N/a s; Dimensions: Capacity: gallons Design Flow: gallons per day •, r Alarm present: ❑ Yes ❑ No N Alarm level: Alarm in working order: ElYes ❑ No Date of last pumping: Date r Comments (condition of alarm and float switches, etc.): r !, pq *Attach copy of current pub ping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 t t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 , Commonwealth of Masssachusetts Title 5 Official Inspection Form Subsurface Sewage Dispos`al.System Form - Not for Voluntary Assessments a 19 Roosevelt Road Property Address Jeffery Ballou Trust ' Owner Owner's Name information is required for every Cotuit MA 02635 City/Town/T 1/5/15 page. y own State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present:must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is Level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or qut of box, etc.): The D-box was normal G. '' L; t• a cE : i ,t M. 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.): N/a !' , * If pumps or alarms are notin working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 1 15ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 a Commonwealth of Massachusetts Title 5 Offici4l inspection Form Subsurfa ce Sewage Disposal System Form Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust r, F Owner Owner's Name I, information is required for every Cotuit MA 02635 1/5/15 page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Type: ® leaching piis number: 1-1000 gal. with 2' stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: F 7 ❑ innovative/alternative system Type/name of,ftechnology: Comments (note condition pf soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 6" of water on the bottom. The scum line was appoximately 3' up from the bottom. The bottom to Grade was 9'. The,cover was 30" below. There was no si gnoffailure. Cesspools (cesspool must:be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inletii'nvert Depth of solids.layer - Depth of scum layer Dimensions of cesspool i Materials of construction Indication of groundwater inflow El Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i 4i i; Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owners Name information is required for every Cotuit MA 02635 1/5/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition,of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan)::. Materials of construction: Dimensions °. Depth of solids Comments (note condition•.of•sail, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): l N/a f l' 1 d ; i Y t t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 19 Roosevelt Road Property Address l; Jeffery Ballou Trust i Owner Owner's Name information is required for every Cotuit MA 02635 1/5/15 page. City/Town (' State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal.System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply,e6ters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i, i tr r. t! A � Q �6 3 ale 3°I ' Q 3 l t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 li 4 i Commonwealth of Massachusetts W Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Roosevelt Road Property Address Jeffery Ballou Trust Owner Owner's Name information is i. required for every Cotuit MA 635 02 . page. City/Town 1/5/15State ZipCode Date of Inspection D. System Information (cont.) Site Exam: (l , ❑ Check Slope ® Surface water i , ❑ Check cellar i ❑ Shallow wells Estimated depth to high ground water: 22' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained fromsystem design plans on record If checked, dale of design plan reviewed: pate ® Observed site l(abutting property/observation hole within 150 feet of SAS) 1, ® Checked with local Board of Health - explain: Topo and water,,contours map ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS.,database -explain: P . You must describe how you established the high ground water elevation: l; see above L; t t 4 Before filing this Inspection,Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r: ; j. • Commonwealth of MassAchusetts Title 5 Official' Insp ection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 19 Roosevelt Road Property Address Jeffery Ballou Trust t Owner Owners Name information is required for every Cotuit MA 02635 1/5/15 page. City/Town ,, State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:;A, B, C, D, or E checked i ® Inspection Summary p (System Failure Criteria Applicable to All Systems) completed ® System Information—`Estimated depth to high groundwater I ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ii F' j' G ,r i k t' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE 1( LOCATION �f� �� k�,r .';c..t.,� , 1�,_J SEWAGE # r� VILLAGE , : ¢ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.J,� A . A. 2 1=0 i SEPTIC TANK CAPACITY tOCY LEACHING FACILITY:(type) r0) (size) NO. OF BEDROOMS PRIVATE WELL OR(P:B:L>IATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: efl � ^� VARIANCE GRANTED: Yes No �! � r >� F { o r i TOWN OF BARNSTABLE LOCATION 4 ¢ 3� e�,��.�,�,/1' /P� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 03q-8!2 INSTALLER'S.NAME & PHONE NO.\)AgA SEPTIC TANK CAPACITY loon LEACHING FACILITYAtype) P t'_ (size) 4'i-,!!� z-,AZfS NO. OF BEDROOMS PRIVATE WELL O UB/LI ATER BUILDER OR OWNER DATE PERMIT ISSUED: - -I-qt� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �y� t;'®a ,_ � Q� ,, i ��.��\ � ' `/ / � � � �� t \ � / / � i -C. `►'g, �, ,� i 4' � ® q �~ � i3 � � � �� \ � � � � 1 +, ti 1-76-43 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH '.......OF..... 1 ........... .. .. .................................. Applira tun for Uhipati al 10orkp Tuntratrttun 1hrmit Application is hereby made for a Permit to Construct (,/) or Repair ( ) an Individual Sewage Disposal S stem at .. - ............................ r ---------- al `1�... •------•-•................... r. Lo 'on -Address or Lot No. &�...... ------ --- ----- -.--- -.-.--•-••---•--.............................. 1 " Owner . j Ad .ess -------------------------- Installer Address _ t U Type of Building Z Size Lot.d......... . .............Sq-feet a, Dwelling.—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL4Other—T e of Building No. of persons......._ ................... Showers — Cafeteria Other fixt ..................... s per person per day. Total daily flow..__....•-•---•_----....._ .._.......�lons. WSeptic Tank—Liquid capacity.kE©gallons Length __ _____ Width4-.�O."' Diameter---------------- Depth.'.-_) .. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------k------------ Diameter.h`_®k._..._. Depth below inlet__��. 2--______ Total leaching area. .1....sq. ft. Z Other Distribution box (✓) Dos ng tank ) `�-1o3Z (11 Percolation Test Results Performed b _�P - DaA.=Z—g -------------------• Test Pit No. l...... _.___minutes per inch Depth of Test Pit_ . . D pth to ground water.-................. (z, Test Pit No. 2._..._�-....minutes per inch Depth of Test ..... Depth to ground water___.............. O Description of v e. -- -------------------------------- U ............................ '- - a._.__._Nle� _.t_SG o� ------------------------------- --------- 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 iITi ], 5 of the State Sanitary Code— The undersigned further agrees not to place the system in' operation until a Certificate of Compliance has be issued by thyJ,,ard1 of th., Gv y ;7 Signed =••••--•--••--•--•...---•• ---•... ........................... -•-- •._., 1.� jl} + Date Application Approved By------------- ^�!- "" .........j'..rA._6.._..-?-a.. Date Application Disapproved for the following reasons__________________________________________________________________________________.............................. Date PermitNo............. / y�...................... Issued...........................................Dat........ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ln)L.........OF.... ?-_V 0 ................................. Appliration for 11ispagal Works Tonitrnrtion Vantit Application is hereby made for a Permit to Construct (J ) or Repair ( ) an Individual Sewage Disposal System at: - ............................................................. •................................................................................................. `��Loeation-Address or Lot No. {......................... ..........i ............................................. .........._-...................................................................................... Owner Address W Installer Address d Type of Building Size Lot_d:......................St;-fest U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fix ttu-rzs ---------•--•--.-•-------------- Design Flow.............. '.='......................gallons per person per day. Total daily flow---- Z�U- gal- -- W Septic Tank—Liquid*capacity.,:..._,----•gallons Length............. Width-1_A.(7__._ Diameter---------------- Depth.......... x Disposal Trench—No. .................... Width ............ Total Length......;.................... Total leaching area....................sq. ft. Seepage Pit No.................... DiameteA�... .,....... Depth below inlet.- ...... Total leaching area ! .....sq. ft. Z Other g tank l(�r ) J_ L Pe colattion,Test Results Performed b; = ':. -1! (dLl r .c.... (,lh.v Date.:.Z_S__�...................... Test Pit No. I....G::......minutes per inch Depth of Test Pith-::�> t......... epth to ground water-_________________ GL, Test Pit No. 2._...Z_....minutes per inch Depth of Test Pit�.��......_._.. Depth to ground water...�,�--............. ..............................................................................................................•----------------------............--•-..... Description of Soil- (D 1 .�-��� � ....................................... w --------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------•••- 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 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 It cp_GIp Signed................................................. ................................ ••••--••--•-Dat.e.............. Date Application Approved By--•-•••-• ------•-• Application Disapproved for the fo owing --2ns: ......................................•...............••-__._..._--_ Date--'_•-____.... --•------•-------•---•------•...............................................................................--••--------•-----•--------------------------------------------------------------......••---- Date Permit No.......... ._. / Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ . .........OF............... .-�..., ��,OKL............................... rr#ifirau o (Iontplinnr>e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by------------------- ...........................Insta.lie _ Installer at.........../....Z 2 � • . --... .----....... ----•---• ------------------------- 1 has been instal ed in acc rdance with the provisions of TI`"Z 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------- ------- dated................................___--_-_-__-_.- THE ISSUANCE OF THIS CERTIFICATE SHAD NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEMS WILL FUNCTION SATISFACTORY. � DATE----..... `'.... �..f� ................................. Inspectgf' `_'. G ........... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'a�[......,..OF.......... -� * ' '� (! L•--•................................. No...../..1�.=./_ 1./ FEE...... .�?.f.I... '.` Disposal Vork.5 Oaono ndion rrntit Permission is hereby granted................. fir.•• ---------------------------------------•-----------------------------------......... to Construct ( or Repair ( ) an In'd1vidual Sewage Disposal System at No......... --- JP ,� -.• �f IL r�-... � . Street as shown on the application for Disposal Works Construction it No._� *: Da .......................................... - -.................... DATE. . .. 7. Board of Health ,FORM 1255 HOSES & WARREN. INC., PUBLISHERS 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS F DEPARTMENT OF ENVIRONMENTAL PROTECTION v t ae -* }t ` TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner's Name: MR. BOLME Owner's Address: 19 ROOSEVELT ROAD COTUIT, MA 02635 Date of Inspection: 8/2/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 5.08-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is, true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Pas s _ Needs Further luation by the Local Approving Authority Fails i Inspector's Signature: Date: 8/2/01 The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio . 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 tolthe buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V INSPECTION..RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. z: r. TitIF 5 IncnFrtinn Fnrm rii 5nnnn { Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k,. PART A y .. CERTIFICATION (continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which'indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement_.or repair;,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and o:v,,er 20years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is'available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system requiredpumpingmore thari�4 times a year due to broken or obstructedpipe(s). The s stem will ass Y 9 ,, Y Y p inspection if(with approval of the Board of Health): broken,.,pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR.BOLME Date of Inspection: 8/2/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner.which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50,feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in'a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and'SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used-to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicai[6 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. z 3. Other: n/a Y: t< z Page 4 of 11 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 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 %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 PUMPED 4/1101 PER CUSTOMER. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy,iswithin 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy,is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _ (Yes/No)The system.fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. y . E. Large Systems: All To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If 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. Ct Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection ? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes;uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? ' The size and location of the Soil Absorption System (SAS)on the site has been detennined based on: Yes no X Existing information. For`example;a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] F ' S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 "Number of bedrooms(actual): 3 DESIGN flow based on 310 CM.R 115.203,(for:example: 110 gpd x#of bedrooms):330 Number of current residents: 5 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes'or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO . Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 12/1/89 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: PUMPED 411101 PER�CUSTOMER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How'was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption:system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach'a copy of the current operation and maintenance contract(to be obtained from system owner) z _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components',date installed(if known)and source of information: 1991 Were sewage odors detected when arriving at the site(yes or no): NO t,: . , Page.7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR.BOLME Date of Inspection: 8/2/01 BUILDING SEWER(locate on site plan) Depth below grade: 42" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:36" Material of construction: Xconcrete_metal' fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is agetconfirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8'6" H 5''7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom bf outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations,.inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top ofo'utlet.tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, idlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc n/a 7 Pagq 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 A TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND ALSO APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER:_(locate on site plan)'* Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,; ondition of pumps and appurtenances,etc.): n/a . a Page,9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 SOIL ABSORPTION SYSTEM(SAS):- X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a Y innovative/alternative system .Type/name of technology: n/a Comments(note condition of soil,signs:of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY.PIT INSTALLED WITH TWO FEET OF STONE SURROUNDING IT. NEVER MORE THAN HALF FULL AND HAD ONE FOOT OF LIQUID AT THE TIME OF INSPECTION CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a t Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a s Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Q Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 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. . F Li gti�k g � A 0 eck f AA 1i n AC�U� PA 31 ` 'S CA CB )i cr- .q t 10 Page..I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 ROOSEVELT ROAD COTUIT,MA 02635 Owner: MR. BOLME Date of Inspection: 8/2/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS-10+FEET { S YSTES PROFILE i NOT Td SCAL E TOP FDN. FINISH GRADE FINISH GRADE OVER EL . s�•�' ;a..ee;:,. FINISH GRADE O VER FINISH GRADE, OVER SEPTIC TANK DIST. BOX LEACHING PIT _ j 12 MAX. / °o;o:o :o. ! .o •o ••a:• e: s t e:�;;.: �+:i: •:e :• 'e: r.y: ••e ;. 3" OF 1/8„ 1/2" 12" MAX d•' ..e:..:e o: a•.. ..:. t.. a e. a:� •,o PRECAST CONC. Ur :o• •�..6. •� •... R .. ASHED PEA 3TONE Q�.,�'Q.'�,°'�;� �- .. •.• °.�a .O Q BRICK G MORTAP OUTLET-PIPE LEVEL TO 12' BELOW G . DE ••::o;.•c _ e _ FOR 2 FT MIN 'Q•a.•.•' °;e°:,..®oArb:4e:� 'n.n•ra.°o.'o?•'•• :•o b i •p • O O 0• D 6 -117 O.b' XfG 7o e:.:! • %..a...: o o;b o e.p,o: .o � ;: �' �'a'p�: ° 0•. •. i:o p.: :e /fG.'cS o :'o..oro ! ;p; •a :D '� . � 1>.•�•i C. I. OR PVC TEES •riG. 3 °q:' ?q:?.' ' �.; o: esMr. FLR. GALLON DJ STRIBUTION BOX o: c INSTALL ON LEVEL BASE ' PRECAST CONCRETE 3�4 N To 1-1�2~ 40 6 ECA S T p A� WASHED I .a o. b..•.e..0; 0 .. h •; o..o.:a:.. a H- D RE.l'NFORCED s CRUSHED a �G'ONCRET : If �•p,e• .e•o-a•;o'••e:a::•oo-:0�'.p•e:0'••0' 'd 'p:'Q.•e:v.:.j•:•6 'd a o•:o: i STONE •a,' v;.p,b•.o.op:o:od•o.•oe• 'e'•�• e,b•;o.00••oa•.• :o: 'e• 'o•b:o' { 'd ' • SEPTIC TANK 0. INSTALL ON LEVEL BASE 3c.a_ ° .e•e , . n••' NO EXCA VA TE TO ELEV. DR 1 LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEATH THE L EACHING AREA 2 '-9 " 2 '-0 " REPLACE EXCA VA 7'ED MA TERIAL WI TH �, 6 '-0 " .,-- CL EAN, CL A Y FREE SAND 10 '-0 " 5 EFFECTI VE DIA E/ER /u GENERAL NOTES LEACHING PIT --L V 4e �►e ASSUMED INSTALL ON LEVEL BASE 3G " �� F 1. ALL ELEVA TIONS' SHOWN ARE BASED ON P. ALL PIPES IN THE SYSTEM MUST BE CAST IRON OR SCHEDULE 40 PVC. OSSERVA TION PIT 3.� =.THE 80O,#,�"°D 'OF �� ,OL TH .Mt]ST. BEE t.IOTI.FIE�7 TO BA CKFIL L.Z'NG" WHEN CONS TRUC r ION IS COMPLETE PRIOR � 1 . ;• ,- PERCOLATION RA TE, PRECAST CONCRETE 2 MIN./IN. o LEACHING PIT ' 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED j c WI TNESSED B Y.' BY THE BOARD G+ - HEALTH AND CAPE & ISLANDS SURVEYING CO., 2 'JC. J. Duun z ng 5. MA TERIALS AND ,1NSTALLA TION SHALL BE IN u Banns t ab 1 eBRO. OF HCA L TH I COMPL IA NCE WI TI-1 THE STA TE SA TA DESIGN DA TA 1000 GALLON �, April 2, 15'87 o t PRECAST CONCRETE CODE - TITLE V AND LOCAL APPLICABLE DA TE.' _ _ _ F SEPTIC TANK RULES AND REGU_A TIONS e 2,' �� `I , s NUMBER OF BEDROOMS 2 6. NORTH ARROW IS FROM RECORD PLANS AND o y p p GARBAGE DISPOSAL NO - srr �_ _ , IS NOT TO BErUSED FOR SOLAR PURPOSES TOPSOIL 6 v 2 zs I i 7. FL OOD HAZARD ZONE C DA IL Y FLOW GAL . 36 SEPTIC TANK PEO D. 1000 GAL . 7' p. s 4 r. ; u 6. WA TER SUPPL Y SUBSOIL SEPTIC TANK PROVIDED 1000 GAL . LEACHING REOUIRED �= ' GPD. MEDIUM _L_c• T ._3 9_ Vi l h SAND b hl SIDEI^#AL L AREA 188 S. F. . 5 6,79 F. 1 GPD 1885 F.x 2 47 1 BOTTOM AREA S.F. / LEGEND y' 79 s. F. X 1. 0�15.F. 79 GPD LEACHING PROVIDED. - P�9POSED ELEVA TION 1561 NO GROUNDWA -- -1a---EXTSTING CONTOUR SINGLE FA MIL Y RESIDENCE G OB�*ERVA TION PIT ❑ DISTRIBUTION BOX �`���� �F ti PROPOSED SEWAGE DISPOSAL S YS TIE I (� L E,,CHING PIT PREPA RED FOR /, 1 ; 0 01 sE�Trc TANK ,.;� .�,�,;�,. E �3.• h/IL L IA BA IN L O T 39 ROOSE VEL T ROA D tRPI RE,1ERVE N BARNS TABL E -- CO TUI T -- MASS. / DAVID y7�u PIPE INVERT ELEVATION cHar�I_Fs , s2 085 �>i DATE., �"=6. 7', i190 al CAPE AND ISLANDS SURVEYING CO., /,VC PLOT PLAN i2 GrST W SCALE AS NOTED osa SCALE.• .1 3 0 3 o / 3 9 a u� l3/ SF' 'lNG QARS ROAD t LAW•' sG o, PLAN NO. �s o 59 C7 FAL_44OUTH., MASS. MA. e�F:.. �'E'L. L.Q T f f .. ._..,. . . .. ., ...... ,. .M„,... ... . .. .... ,q.,. ,. ,. .. ..,,,M ...,,.. ,r•. . .,Y..,• ._.,•, , -. w,....._.