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HomeMy WebLinkAbout0097 ROOSEVELT ROAD - Health 97 Roosevelt Road Cotuit A= 039-155 rF �- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 97 Roosevelt Road 1• 0 Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 'mp°da"t When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental , Company Name IQ 43 Triangle Circle Company Address `— - yl Sandwich MA _' 02563 Cityrrown State "_ Zip codg Mr 508 364-0894 1328 Telephone Number License Number tv �. c�:3 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes_ ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority • ��n i�J June 19, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the - report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15-2973.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic,tank-as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a;Certificate of Compliance indicating that the tank is less than 20 years old is available. ) ND Explain: t o . � �u Observation of sewage backup or break out or high static water level in the distribution box due ❑ 9 P 9 to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution tiox. System will pass inspection if(with approval of Board of Health): Lin ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explairi: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 97 Roosevelt Road M Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: et e This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ' ❑ ® Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool � ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2973.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to:.=ach 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. t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Roosevelt Road 'M Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Pit also evaluated ® ❑ 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)] t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 0 Does residence have a garbage grinder? Removal of grinder is recommended ® Yes ❑ No Is laundry on,a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 286 gpd 9 ( Y 9 (gpd)) Sump pump? ❑ Yes ® No Last date of occupancy: undeterminedDate 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: Last date of occupancy/use: Date Other(describe): t5-2973.doc•08/06 Title e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M e' 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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) ElInnovative/Alternative technology. Attach,a copyof 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: Age 20+years. Certificate of Compliance issued 10114187(Board of Health permit#87-261) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 rl Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 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.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is"age c6nfirmed"6 a Certifcate of Corrpliarice? (attach`a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in trace Scum thickness_ - Distance from top of scum.to,top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts - W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. CityTrown 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.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - "` Date of last pumping. Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity:' gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet invert Comments (note if box is level'and distribution to outlets equal, any evidence of solids'barryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M z 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: R — ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the leach pit. 15-2973.doc-06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): • Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June 19, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r LOCATIONS A B 1 37 FL 14 FL 2 49 Ft- 19 ft 3 61 FL 32 FL EXISTING DWELLING # 97 A a SEPTIC Z TANK J O ❑ E7- t D O -BOX � LEACH a l PIT ROOSEVELT- ROAD NOT TO SCALE t5-2973.doc-OB/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 Roosevelt Road Property Address Michael and Nancy Burdulis Owner Owner's Name information is required for Cotuit MA 02635 June.19, 2608 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 15 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: 10/14/87 • Date El Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: Barnstable GIS You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the bottom of a witnessed test pit in which no water was encountered Town of Barnstable GIS Department records indicate that the property is 15 feet above groundwater table. t5-2973.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 r Regulatory Set-vices MtRNSTABLE, : Thomas F. Geiler, Director Arfo �a Public Health Division Thomas McKean, Director 200-Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not. automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector.who conducted the inspection. QASEPTICIDisclaimer Private Septic Inspections.DOC i COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A l� yQ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner's Name: James Martin Owner's Address: Same °A R Date of Inspection: August 11,2005 Job#05-235 '` •: -0 Name of Inspector: PATRICK M.O'CONNELL I' Company Name: SEPTIC INSPECTION SERVICES CO. 1 Mailing Address: 189 CAMMETT ROAD W MARSTONS MILLS MA 02648 "a Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am aeoilll/►ry��� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �o��gtN 'j k OF _X_ Passes PTRI G Conditionally Passes '--i Needs Further Evaluation by the Local Approving Authority M' zz Fails Inspector's Signature- 11� Date: August 11,200 ,II NSP�G�r`�� ' The system inspector shall submit a copy of this inspection report to the Approving.Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit has one foot of standing water with no stain lines above current level, tank is not in need of pumping at this time. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX 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,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or.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: T41. �nenortinn {:nrm�ii cnnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: , August 11,2005 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 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: TiNo r, Incnarrtinn Rnrm A/1 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 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 '/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a M 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. TWA C. Tncr�artin" Gnrm�n vonnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks`? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 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? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Titles F, Incn—tinn Rn—411 VIMA 5 Page 6 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no) No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—48,000 gal. 2004—90,000 gal.= 189 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Pumped four years ago. Source of information: Homeowner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool _—Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 10/14/87 Were sewage odors detected when arriving at the site(yes or no): No Titles 4/1 r'110nn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 16" Materials of construction: _cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" 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: 8.5' long x 5.2' wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 3" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear, liquid level at bottom of outlet invert. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titles G Incnprtinn Fn—Ail,;iinnn 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: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): Liquid level at bottom of single outlet pipe,no solids or high stains. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title G Incnartinn Fn—AN c11[)M 8 r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Observed one foot standing water with no high stains. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): T41a G 1—nort;— Fnrm 4/1 S/10011 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 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. Roosevelt Road Driveway 2 Water service 1 A— 1 =37' A B A-2=49' A-3 =61' Garage B— 1 = 14' B-2= 19' B-3 =32' Titles S 1ncnvrtinn Fnrm All V1001) 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: 97 Roosevelt Road Cotuit MA 02635 Owner: James Martin Date of Inspection: August 11,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: 4/27/87 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) X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Perc test performed on 4/24/87 found no water at 144".Town groundwater contour map shows water below el.25 and topo map shows property above el.40.Bottom of Leaching pit is 9' below grade leaving more than 6'separation to groundwater. Titles G Tnvn tine Rnrm tiiT�i�nnn 11 % �, V insp�C,-60,Mi TOWN OF BARNSTABLE LUCATION d 1. SEWAGE # VILLAGE CD 4 U: t U 5 ASSESSOR'S MAP & LOT &PHONE NO. P`�-/�-� ��- (_�C)one-I I . 49 6 ' l77 5 SEPTIC TANK CAPACITY o LEACHING FACILITY: (type) _(0&= 1, i 1 (size) 10 l NO.OF BEDROOMS B 'OR OWNER COMPLIANCE DATE: C I S 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 c y�j V A 6-3 = 32 a OF BARNSTABLE ` OCATION amn SEWAG # %7- © � 3' VILLAGE �� ASSESSOR'S MAP C LN STALLER'S NAME & PHONE.NO. ,�EPTIC TANK CAPACITY 1666 �/3 LEACHING FACILITYAtype) d 6 �, I (size) NO. OF BEDROOMS ' PRIVATE WELL OR PUBLIC WATER f u c— BUILDER OR OWNER DATE PERMIT ISSUED: L o r 2k DATE COMPLIANCE ISSUED: G VARIANCE GRANTED: Yes No ✓ /'�6 � � ®��� ,� �tG ~� e6" � '�`�� ��x � � �t , � , r� L _ J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � 63?-/ Appliratiun for Disposal Works Tonutrn.rtiun rumit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at: .=.... ------•...............................•-- ,kocation-Address or Lot No. Owner Address U ✓ a 4--e ......... Installer Address Type of Building Size Lot..47._5 T:: ....Sq. feet a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons..........0.............. Showers — Cafeteria p-' Other fixtures .................................. W Design Flow........`....S? ..gallons per person per day. Total daily flow____..... 3.. .....................gallons. WSeptic Tank—Liquid ca.pacityf p O o gallons Length.._-_-6_.. Width.4�_?_"Diameter................ Depth f.'.7~... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.................-.sq. ft. Seepage Pit No......../---------- Diameter._?0.`—.�!.~. Depth below inlet_.�.'-iD.N•-. Total leaching area..L Z......sq. ft. Z Other Distribution box Dosing tank ( ) '" Percolation Test Results Performed _A!c _..__ /%.-•._-__.--•--..•--•-•-_.-.--•.•-_ ... Date 0.4 Test Pit No. I.....Z.......minutes per inch Depth of Test .... Depth to ground water_. `5........ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--•......--•---•--------- --•---.... ---••---- •---- •-•--•....._.._...•-••---•------••-----•-------•-••-•-••................••---•-- O Description of Soil..........o.-X-_5(.`' ..so.� ......S�:6s ---------------------------------------------------------- U //��r q/ �Y J/J � M ........................................................ Q___..____"/'r.�.N N__"__µ"..______.-----_ ............................................. 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 TLITLE 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 pf health. Signed-•-•� . ................................. Date Application Approved By.......... ---------------------------------- �r1.-__.1..-l._... .�.. 4 Date Application Disapproved for the following reasons:---•--••------------------------•------•------•----•---•----.........----------..........--••-•-•---••----...._ ..---•--•-----•----------•--.....--•-----•.......................................•----.........----......._..................----....--•---------..................•.........---••--- ........... Date _ PermitNo------- aX---U1---------------------- Issued....................................................... No. .7_ ./....dr Fss... .... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. dr v.*.."".."""................OF............c.... . ppliration for Disposal Works Tonstrnr#iun thrmit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: OuSQvF� /f / 'L,� .. ------ ................................................ --•----------•--•---•-•-••----•----•------. -----•---•--•-----•...................•-- J location Address or Lot No. - .......... . ........ r....-•-•-•-•----..................--•---.. ----......_...----••-•-------------..........••-••-•-s ...•••---•-----.........................-- Owner Address 5' - o Installer Address d Type of Building Size Lot_____7...................Sq. feet Dwelling—No. of Bedrooms..................................._........Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria 04 Other fixtures -----------------------••-------...............-------.----•--- Design Flow.......: .......... per person per day. Total daily flow......._.:,�-____o......................gallons. W Septic Tank—Liquid capacit�r•--•-••--•••gallons Length.__.._........ Width--_ ..=:_._.._ Diameter________________ Depth--_............. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------?_........... DiameterZl?.'.`.a.._. Depth below inlet!-..=G..._..... Total leaching area.z .......sq. ft. Z Other Distribution box ( /j Dosing tank ) '"' Percolation Test Results Performed by__ w-- ------A/r 2 y Date----era - 5;-/%fr aTest Pit No. 1.._Z.........minutes per inch Depth of Test Pit.Z: `�. ..... Depth to ground water..-16"d°'e......_ " Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --••---------------------------•--••----•---------------...........-------------••-•----••-•--....••......................................................... O Description of Soil--.......5?.:Z v �' 4 s / 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 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 ofhealth. Signed..AL�a"...,,,�; . ..........•'- Date Application Approved By----- ...................................•--•••-•_.... ••----. .7... �.I1-� Date Application Disapproved f or t �e_ff_oalow_ing reasons:--•----•---------.-1---------•---------------------------•------------------------•---............----------•-•- ...................................•-•...............-••-••--•---........--•----------••--.............._••----------......--------------------------•-••-••••---••--•.......--•-------_._...•-••------- Date Permit No....`^7 d"� -•-. Issued................. Date THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH ..................O F.......J .................. ....J�........................................... i (9rdifirtt#.eV�a� orAplinurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed„ ) or Repaired ` ) by.......... .._... jr..... ............................Inst---•--------•-•-----•-----•-----•-••----•------ Installer at....... . '7' �` -•---- ••----. •-- t. 3 - --------0A- -- has been mstied in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.- .... .._-� dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .i�L.... _...............................•--•••-----..._.. Inspector. ._.... .................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.... ..............,... .. ................... Disposal Works Tnn#.rnrtinn "permit Permission is hereby granted-•-• ..........•-•................. ... ••----•-.----------------•--------------------.--.-......------ .................... to Construct (k,) or Repair ( ) an IndividuatSewage Disposal System at No.......-•- r - - - © -Z`;7 Street as shown on the application for Disposal Works Construction Permit N -- Dated.......................................... DATE......................................................................••-------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS S TES' FROF ,1-E NOT T:� SCALE TOP FDN. FINISH GRADE-4-4 80 FINISH GRADE OVER EL . 4 5.50 e: . FINISH GRADE 0VE. FINISH GRADE OVER .p'•° A. ) DIST. BOX SEPTIC TANK4a .— LEACHING PIT_4 4. 2 :e Q o: VAP,IES � ; ; 0 0:0' a :.• x N — a • :e o °•• . a 12 MAX o. :e.. .,. . e..•n a. :e:u ,• • a, • ° ,e, •:e..•.. PRECAST CONC. OR ASHED PEA STONE BRICK 6 MORTAR 3 e. ° r';.o T. OUTLET PIPE LEVEL TO 12" BELOW GRADE o FOR 2 FT. MIN. D• 4 'o:.�q::e D• __- � a ;a•..s•..o: •o: o�, •o.•;a••o••o.••'o,a.e .o.• .d. e.. .b..e. .o ,•e. .o. o I 'O e. 0 0 0' ry/�( /�/y o do 42.8Z Ar:o: �{ 2.5� e; .:�•y.,o..,: o 0;:0: '' W.e:p:v: :a e.Q eor_ �'��•6: � c. I. oR Pvc ��:p.�S �e.. 42.4� 4Z. °.o:'�:b;e:p•' � ' .•d.o D e:o: 4 s . 10 • •O •.Q oA 'o- I'.o•.0 ,e s p�•e. A d. BSMT. FLR. .: .1000 G/ _:.k�..:.ON EL . 5 e ^^ ,CIS TRIBUTION BOX% o e' ;, — a INSTALL ON LEVEL BASE S/4" TO 1-1/2" a 6 PRECA,S'T COS�,�°�RE �_ PRECA S T °'.•e.'p:•o:o. 6 WASHED 6. H— l 0 REINF 0,RCED cRusHED a CONCRETE 'i O:o .Ao-o':o:"e:b :o- o.e'.o e:o.'p.:°:`,*•'" ::•::.'a'-:�. 'o. b o.-.a. STONE , b;,o;•o. b.o.o?.o:o,'p •o:o e.,•c •o.•.o,.o •o, o:o o.• :e..o;. o b. o. (, 4 H— l 0 REINF. o Q IC �: :o••.'e.l INSTALL ON LEV_. : BASE NO TE: EXCA VA TE TO ELEV. 5-Z-It OR LOWER TO REMOVE ALL IMPERVIOUS — — —"- MA TERIAL BENEA TH THE L EA CHING AREA 2 '—0 " 2 '—0 fit REPL A CE EXCA VA TED MA TERIAL WI TH 6 *—Om CL EA At. CL A Y FREE SAND 10 '—0 " EFFECTIVE DIAMETER GENERA L NO TES LEACHING PIT • INSTALL ON LEVEL BASE 1. ALL EL EVA TION. SHOWN ARE BASED ON ASSUMED -__ ,.. ALL .PIPES._ IN SHE SYSTEM MUST BE CAST IRON VC.OR SCHE C ',S R VA± TION PIT LOT cJ Z 4.� 57. THE BOARD OF ilEAL TH MUST BE NOTIFIED LOW 6 YELLER INC. WHEN CONSTRUC j ION IS COMPLETE PRIOR TO BA CKFIL L IN;, PERCOL A TION RATE: 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED 2 MIN./IN. s U� BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WITNESSED BY. 4 O • E � �. � � SURVEYING CO., INC.hA s� 8 -s,_. 2_ _ . .5: MA TERIALS AND INSTALLA TION SHALL BE IN 4 4 COMPLIANCE WI TH THE S TA TE SA NI TAR Y _�7LL2 tit• BRO. OF HEAL TH DESIGN DA TA APR. 24_ 19B7 38 \� s. \o CODE �— TITLE V — AND LOCAL APPLICABLE DATE.• _ / g"o 2� RULES AND REGULATIONS NUMBER OF BEDROOMS 3 6. NORTH ARROW I FROM RECORD PLANS AND 0 L GARBAGE DISPOSAL NO 60 �s ys c� IS NO T TO BE L ISED FOR SOL AR PURPOSES TOPSOIL 6 �r 7. FLOOD HAZARD .70NE c SUBSOIL DAILY FLOW 330 GAL 8. WA TER SUPPL Y TOWN WA TER GAL . 24 SEPTIC TANK REO D. --��0•-3 SEPTIC TANK PROVIDED 1C:)00 GA L ._ 2 7, OCO± S � L EA CHING REGUIRED _3 30 GPD. ` tis � 1 ;� --•_...., _ e� LOT 54 MEDIUM SAND SIOEWALL AREA 188 S. F. 188S. F. X 2. 5G/S. F. = 4-7 1 GPO 4 BOTTOM AREA ='7g—S. F. o\ _ LEGEND 7 CO S.F. X 1. O G/S.F. _ 19 GPO 40 L EA CHING PRO VIDEO 5 50 GPO --- �} -38 F,r 7OPOSED EL EVA TION 144" NO GROUNDWA TER .3Z . I os.°°� — --40 —- EXISTING CONTOUR SINGLE E FAMILY RESIDENCE G OI:�SER VA TION PIT I ' __ 34' 34 r• �ZH OF ❑ G a.S TRIBUTION BOX � RICHARD fry E PROPOSED SEW GE DISPOSA L S YS TEM oo 'r a2 LAMES s o L.,'-ACHING PIT sERrRAn N No. 29891, PREPARED FOR IM o o SEPTIC TANK SIONAL E� 9 �a©.5�,lf NAMES GUILD At3AN (�OIJ �n 30 IRPI RESERVE ���'� OF. � LOT 53 ROOSEVEL T ROAD c 124 N&�- 12Y ELoc1 4 8 = DAV;D BARNS TABL E — MA SS. 41 .5O cl PIPE INVERT ELEVATION DA TE-7A_F2. 22, 1987 CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN SCALE: 1 "= 3O• LL3 5 15 5 5 3 F y� SCALE AS NOTED P. 0. BOX 334 `y PLAN /VO. '5 7 2 8�7 TEA TI CKET, MASS. 31