HomeMy WebLinkAbout0021 ROUTE 130 - Health 4728 FALMOUTH ROAD, COTUIT
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Commonwealth of Massachusetts
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Executive Office of Environmental Affairs
Department of
Environmental Protecti p,pR 16
Wllllam F.Weld 100 OF BARNSTABI E xe
O oMrtwr HEALTH DEPT T
Argeo Paul Calluccl
Lt.Gammor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address..4 7 2 8 Falmouth R d. Cotuit Address of Owner: Charles Marr
Date of Inspection: (If different) 3L Screacham Way
Name of I nspector:F r e d e r i c k K i e l y Cotuit MA
Company Name,Address and Telephone Number:Environmental Reclamation Inc.
446 Waquoit Hwy. Waquoit MA 02536 ( 508) 457-5020
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
XXX Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: <. � Date:4/2/97
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, 8, C, or D:
A] SYSTEM PASSES:
XXX I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or,ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03/9a) 1
One Wlrtter Street • Boston,Massachusetts 02108 a FAX(617)556.1049 a Telephone(617)292-5=
A
Pnnled on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) /
Property Address:
Owner. 4728 Falmouth Rd. Cotuit
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
3) OTHER
(revised.11/03/95) 2
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r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Pioperty Address: 4728 Falmouth Rd. Cotuit
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
N/A I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system.is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
�. ;revised 11/03/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART B
CHECKLIST
Property Address: 4728 Falmouth Rd. Cotuit MA
Owner:
Date of.Inspection:
Check if the following have been done:
X_Pumping information was requested of the owner, occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
NIL-As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
X,All system components, excluding the Soil Absorption System, have been located on the site.
X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
evised 11 03 95 lr / / 1 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
t SYSTEM INFORMATION
Property Address: 4728 Falmouth Rd. COtuit -MA
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Qallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):_
Laundry connected to system (yes or no):_
Seasonal use(yes or no):_
Water meter readings, if available:
Last date of occupancy: current.
COMM ERCIA UI N D U STRIAL:
Type of establishment: offi�P
Design flow: aallons/day
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)—
Water meter readings, if available:
'ast date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or noWes
If yes, volume pumped: _ 90 sraalions
Reason for pumping:_ inspection
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
XXXX Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: unkr?&;pn unknown
Sewage odors detected when arriving at the site: (yes or no) NO
(revised 11/03/95) $
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4728 Falnouth Rd. Cotuit
Owner.
Date of Inspection:
SEPTIC TANK:N/A
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP_other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP: % N/A
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4728 Falmouth Rd. Cotuit
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:NSA
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
r
Capacity: gallons
Design flow: aalions/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:NSA
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/9S) 7
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4728 Fa.lMouth Rd. Cotuiir
g'^er.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation,etc.)
CESSPOOLS: 3
(locate on site plan)
Number and configuration:f 314;t- t is gray water. Pits 2 and 3 are a tank and SAS combination
Depth-top of liquid to inlet invert:_ 4 fppi-
Depth of solids layer: n/a
Depth of scum layer:
Dimensions of cesspool: FYR_
Materials of construction:
Indication of groundwater: pl was empEy.its 2 &: 3 had no inflow after pumping
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: N/A
(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.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
proms, Address: 4728 Falmouth Rd. Cotuit
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
PIT 1
OFFICE \ /
\ PIT 2
PIT 3
MASHPEE RIVER
DEPTH TO GROUNDWATER
Depth to groundwaser. 12 feet
method of determination or approximation:
elevation of the Mash-pee River 100 feet away
(revised 11/03/95) 9
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�ryEO
MAR
6 1997
BORTOLOTTI CONSTRUCTION, INC. V
765 WADE j)�Y ROAD,I6�IAItST®NS MILLS, 1►'IA 02G48 �
508-771-9399 508-428-8926 FAX: 508-428-9399 8
SU13SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIIr ICATI®N
Property Address: za---el
Date of Inspection: _ Inspector's N me:
Owners Nam and EAddre s: Z"
�I£ICATI®Pt�TATF'1!� �'r'
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
t
ion reported below is true, accurate and complete as of tile e time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on sewage
disposal stems. The System:
11 Passes
Conditionally Passes
Needs Further Eva nation By the ocal Aproving Authority
Fails
Inspector's Signature: DIate: �
Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Enviromnental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
TNSPFC'r'I®N�TI1YIlix AR w°
A)SYS4M PASSES:
`V I have not found any information which,indicates that the system violates any of the failure
criteria as defined in 310 CIVIR 15.303. Any failure criteria not evaluated are indicated
below.
R)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor, or not determined(Y,N, OR ND). Describe basis of determination in all instances. If
,not determined", explain why not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The.Board of Health):
- I -
'� 1 itaa�§yf y SUBS'!'RFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL,PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A]MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVI-gONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has aseptic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and citrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM EAIILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2
day.flow.
Required pumping more than 4 times in the last year NDI due to clogged or obstructed
pipe(s). Number of times pumped
-2 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. if the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds, ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System) and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the '
groundwater treatment program requirements of 314 C(viR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART .B
CHECKLIST
Check if the following have been done:
✓Pumping information was requested of the owner, occupant, and Board of Health.
P1one of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
✓As-built plans have been obtained and examined. Note if they are not available with N/A.
_;LThe facility or dwelling was inspected for signs of sewage back-up.
//The system does not receive non-sanitary or industrial waste flow.
✓The site was inspected for signs of breakout.
"All system components, excluding the Soil Absorption System, have been located on site.
1/The septic tank manholes were uncovered,opened, and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
of sludge,depth of scum.
he size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods. ;e
-3-
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SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants, if different from owner) were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART, C
NFO .,
SYSTEM INFORMATION
/ FLOW CONDITIONS
V
Design Flow: •� allons Number of Bedrooms: _ Number of Current Residents:
Garbage Grinder: Laundry Connected To Systern:/L)O Seasonal Use: Q
Water Meter Readings, if available:
Last Date of Occupancy:� 64,
COMMERCIAL./INDUSTRIAL:
Type of Establishment:
Design Flow: gallons/day :Grease Trap Present: (yes or no)
Industrial Waste Holding Tank.Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy: _
GENERAL I:NFO.RMIATION
PUMPING RECORDS and source_of informat'o :_
System Pumped as part of inspection: If yes,volume roped: Qgallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared.System(If yes, beach previous inspection records, if any)
Other(explain):
APPROXIMATE AGE of all components, date installed (if known)and source of information:
Sewage odors deAk w en arri ng at the site: .62
-4 -
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SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION
S ECTI®N F®RIbI
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: concrete metal FRP Other
(explain) —
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle.-
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)
GREASE TRAP:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain)
— �- — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle: s
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage. etc.)
TIGHT OR HOLDING TANK:Z-11
Depth Below Grade: Material of Construction:—concrete—metal—FRP—Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition.of.inlet'tee, condition of alarm,and float`switcl?es.
DISTRIBUTION BOX:Ak
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
or out of box, etc.)
PUMT CHAMBER:�Jd
Pump is in wonting order:
'Comments: (note condition of pump'chamber, condition of pumps and appurtenances, etc.)
-5-
`• 2 y. ./
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Irk SYSTEM INFORMATION (continued)
SOLI.ABSORPTION SYSTEM(SAS): 11�
(Locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive
methods) If not determined to be present,explain: _
Type _
Leaching pits, number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields, number, dimensions: _
Overflow cesspool, number:
Comments: (note condition of soil, signs of h draulic-ailure le el of pond in condition of vegetation,
e U
CESSPOOLS:
Number and configuration: -&'V5 Deptli-top of liquid to inlet invert:
Depth of solids layer: Depth of scum laver' Dimensions of Cesspool: ��
Materials of construction: " ,/Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, leve of pwtding, condition of vegetation,
etc..
PRIVY:-
Materials�fconstrucbon: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
-6 -
SUBSURFACE SEWAGE DISIPOSAC SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benclunarks.
Locate all wells within 100 Feet.
IDEPTH TO GROUNDWATER:
Depth to groundwater: . / Feet ` e
N1et4pd of eternunation or App oximati /� !�{�/•?71r� i �O v` ' J �� T
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Page
CERTIFICATE OF APTALYSIS
era �x Barnstable County Malth,Laboratory.
Report-Dated:. 03/13/2002i
Report Prepared Fors
Order-Number: G0213589
Richard,Barry:
4728 Falmouth Rd.
Cotuit,.NIA. 02635
Laboratory ID#: 02:13589-Ot Description: Water
Sample#: K655 657' Samplin¢Location: 4728 Falmouth Rd Cotuit-MA. Collected: 03/04/2002
Collected by: L MuMeen Received: 03/04/2002
EPA.524.2- Volatile Organics by GUMS
ITEM ' RESULT UNITS MDL MCL Method#- Tested
LAB: GUMS'
1,1,1,2-Tetrachloroethane.: BRL ug/L .0.5 EPA 524.2 03/12/2002
1,1,1-Trichloroethane BRL ug/L 0.5° 200 EPA 524:2 03/12/2002.
1,1,2,2-Tetrachloroethane'. BRL ug/L ; os '` EPA 524.2 03/12/2002.
1,1,2-Trichloroethane BRL ug/L 0.5" 5.0 EPA 524.2 03/12/2002
1;1-Dichloroethane BRL u92 os EPA s24.2 6112/2002
.0 0.5 EPA 524,2. 03T12/300'2
�1;1-Dichl'o'roethene BRL. g/1- 7:0
11=Dichloropropene BRL u o ErAs24:2. o3iizi?ooi.
12 3-Trichlorobenzene: BRL ug/L 0:5 EPA s24:i o3 iiT2oo2.
112;3=Trichloropropane BRL ugL 0.5 EPA"5242 03/12/2002
1,2,4-Trichlorobenzene BRL. ug/L 0.5 70'' EPA 524.2' 03/12/2002,
1,2,4-Trimethylbenzene BRL ugfL 0.5 EPA 524.2 03/12/2002
1,2-Dibromo-3-chloropropan BRL. ug/L o:5 EPA 524.2 03/12/2002
1,2-Dibromoethane(EDB) BRL ug/L 0.5 EPAs24.2.° 03n2/2002
1,2=Dichlorobenzene BRL ug(L 0.5 600 EPA 524.2. 03/12/2002
1,2-Dlchloroethane BRL ug/L .0.5 . 5.0 EPA.524:2_ 03/12/2002
1,2-Dichloropropane BRL ug/L 0.5 EPA52U 013/12/2002
1,3,5=Trimethy1benzene:, BRL ug/L 0.5 EPA 524.2. 03n2/2002
1,3=Dichlorobenzene BRL ug/L 0.5 EPA k4.2 03/12/2002
1,3=Dichloropr op' ane '`{` BRL ug/L os EPA 5,24: . 03/12/2002
1``' u 52. 03/17J2002.
1;4-Dichlorobenzene' BRL' g/1< Q-A 5.0 EEA24:
I 2;2=Dlchloropropane: BRL ugJL' qs_ EPA s24:% 03/f2/iWil_
i 2'=Chlo`rotoluene'' '' BRI: ug2' 0:5'_ t'S EPA 5242 037^P3/2002
4-Ch16rof61uene
s"r u 0:5: EPA 5242 03112/2002'
° BRL;:
Superior-Court:House.,PO.Box 42.7, Barnstable, MA. 02630 Ph::508-375-6605
Page: z
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Dated: 03/13/2002
Report Prepared For:
Order Number: G0213589
Richard:Barry
4728 Falmouth Rd.
Cotuit, MA 02635
Laboratory ID#: 0213589-01 Description: Water
Sample 4: K655 657 Sampling Location: 4728 Falmouth Rd Cotuit MA Collected: 03/04/2002
Collected by: L Mulkcen Received: 03/04/2002
Benzene BRL ug/L, 0.5 5.0 EPA 524.2 03/12/2002
Bromobenzene BRL ug/L 0.5 EPA 524.2 03/12/2002
Bromochloromethane BRL ugfL 0.5 EPA 524.2 03/12/2002
Bromodichloromethane BRL ugfL 0.5 EPA 524.2 03/12/2002
Bromoform BRL ugfL 0.5 EPA 524.2 03/12/2002
Bromomethane BRL ug/L 0.5 EPA 524.2 03/12/2002
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 03/12/2002
Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 03/12/2002
Chloroethane BRL ug/L 0.5 EPA 524.2 03/12/2002
Chloroform BRL ug/L 0.5 EPA 524.2 03/12/2002
Chloromethane BRL ug/L 0.5 EPA 524.2 03/12/2002
cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 03/12/2002
cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 03/12/2002
Dibromochloromethane BRL ug/L 0.5 EPA 524.2 03/12/2002
Dibromomethane BRL ug/L 0.5 EPA 524.2 03/12/2002
Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 03/12/2002
Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 03/12/2002
Hexachlorobutadiene BRL ug/L. 0.5 EPA 524.2 03/12/2002
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 03/12/2002
Methyl-tert butyl ether BRL ug/L 2.0 EPA 524.2 03/12/2002
Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 03/12/2002
n-Butylbenzene BRL ug/L 0.5 EPA 524.2 03/12/2002
n-Propylbenzene BRL ug/L 0.5 EPA 524.2 03/12/2002
Naphthalene BRL ug/L 0.5 EPA 524.2 03/12/2002
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 03/12/2002
sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 03/12/2002
Styrene BRL ug/L 0.5 100 EPA 524.2 03/12/2002
Superior Court House, PO. Boa 427, Barnstable, MA 02630 Ph:508-375-6605
I�
I
CItTIryFICATE: OF ANALYSIS Page:
Barnstable:County Realth Laboratory
Report Dated: 03113/2002:.
Reuort Prepared For:
Ordim Number:_ G0213589"
Richard Barry .
4728 Falmouth Rd
Cotuit, NIA. 02635
Laboratory ID#: 0213589-01 Description: Water
Sample#: K655 657 Samnline Location: 4728-FahnouthRd.Cotnit,MA Collected: 03/04/2002'
Collected by: L Mulkeen ' Received: 03/04/2002:
tert Butylbenzene BRL, ug/L 0.5 EPA.524:Z: 03/12/2002.
Tetraihlbroethene BRL ug(L 0.5' 5.0 EPA 524:2' 03/12/2002.
Toluene BRL ug/L 03 1000 EPA.524.2: 03/12/2002
Total.xylenes BRL. ug/L 0.5 10000 EPA-524.2' 03/12/2002
trans=1;2'=Dichloroethene BRL ug/L 0.5 100 EPA 524.2:.' 03/12/2002
trans-1;3-Dichloropropene BRL ug/L 0.5 EPA 524.2. 03/12/2002
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.Z 03/12/2002,
Triddorofluoromethane.: BRL ug/L 0.5 EPA524.1' ` 03/12/2002',
Vinyl.chloride:,` BRL: ug/L. 0.5 2.0: EPAS24.2. 03/12/2002:
Note: ' Water-sample meets the.recommended.limits for•drinking,water of-all above,tested..parameters:_
Approved By:
(Lab Director)
Superior Court'House,. M,Box 427. Barnstable,_.MA 02630 Ph:-508=3:75-6605