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Home My WebLink About0270 SANTUIT ROAD - Health 270 Santul Road Co 11 A 020 058002 i Commonwealth of Massachusettsl�ba--- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 270 Santuit Road Property Address p Stephan Sundlin Owner Owner's Narlae ' information is �/ -" Ma 02635 required for every Cotuit June 22-2018 page. City/Town State Zip Code Date of Inspection E6 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 c filling out forms Vl� 13 a1..3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company r� Company Name 374 Route 130 Company Address Sandwich Ma 02563 Cityrrown State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-22-18 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is Cotuit Ma 02635 June 22-2018 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ' ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol u ntary.Assessments 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 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 pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced. ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 page. Cityfrown 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 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 cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 270 Santuit Road Property Address Stephan Sundlin - Owner Owner's Name information is Cotuit Ma 02635 June 22-2018 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or q P P 9 Y 99 ❑ ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is,below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is Cotuit. Ma 02635 June 22-2018 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? a ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(Actual) 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440/GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 270 Santuit Road Property Address Stephan Sundlin i Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2018-80,000gallons 2017-71,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(qpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes .❑ No t , Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is Cotuit Ma 02635 J6ne22-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information + Pumping Records: i Source of information: Owner-date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons , How was quantity pumped determined? Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . 3 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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: 1500gallons Sludge depth: 4 t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System°Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 page. City/Town 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 32" 2 Scum thickness — 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 14" 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): NA . 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 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: NA 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: a Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635� June 22-2018 page. Cityrrown 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 11 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA * 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 page. Cityrrown State Zip Code .Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (4) infiltrators 2'x 12'x35' ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Infiltrators are slung with pert pipe and show no signs of past back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 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: NA Dimensions • Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 6 y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 270 Santuit Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 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 Front A B ' Al-3W A2-4T A3-35' ` A4-29' 81-14'6" 101 132-26. 63-26'6" 64-41' 12' 4 3 2 35' • t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System!Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 270 Santuit Road Property Address , Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 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 high ground water: No GW @ 126" feet Please'indicate all methods used to determine the high ground water,elevation: ® Obtained from system design plans on record If checked, date of design'plan reviewed: Date 7 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) G ❑ Accessed USGS database-explain: You must describe how,you established the high ground water elevation: Plan on file with BOH. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' M 270 Sant6it Road Property Address Stephan Sundlin Owner Owner's Name information is required for every Cotuit Ma 02635 June 22-2018 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 1 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION Property Address: 270 Santuit Road U _ Cotuit. MA 02635 Owner's Name: Michael Redstone Owner's Address: P.O. Box 896 Barnstable MA 02630 Date of Inspection: June.30, 2006 Name of Inspector: (Please Print) James M. Ford 7 Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 r-J - Telephone Number: (508) 862-9400 " F CERTIFICATION STATEMENT E - 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 tn training and experience in the proper function and maintenance of on site sewage disposal systems. Iam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N ds Further Evaluation by the Local Approving Authority F it Inspector's Signature: Date: July 6, 2006 The system inspector shallmia y 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 I0,000 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 ****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: 270 Santuit Road Cotuit, MA Owner: Michael Redstone Date of Inspection: June 30 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 270 Santuit Road Cotuit MA Owner: Michael Redstone Date of Inspection: June 30 2006 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. I. System will pass unless Board of Health determines in accordance with 310 Cte 15.303 )that system is not functioning in a manner which will protect public health,safety and the environment:the 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of anunonia 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: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 270 Santuit Road Cotuit, MA Owner: Michael Redstone Date of Inspection: June 30 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributaryto a surface .water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile or 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 CM R 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 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. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 270 Santuit Road Cotuit MA Owner: Michael Redstone Date of Inspection: June 30 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System SAS on the site .(SAS) has been determined based o n. Yes No ✓ — Existing information. For example,a plan at the Board of Health: ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation,of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 r Page 6 of 11 d OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 270 Santuit Road Cotuiti MA Owner: Michael Redstone Date of Inspection: June 30 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown 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): Pumping Records GENERAL INFORMATION . Source of information: Pumped in 2004-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool - Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 319198-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 270 Santuit Road Cotuit MA Owner: Michael Redstone Date of Inspection: June 30 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) ) Depth below grade: 18 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): certificate) (attach a copy of Dimensions: _ 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" 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: Measuring stick Continents (on pumping recoimnendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.). Tees were present.. The Quid level was even with the outlet invert. There did not a ear to be an s&7ns of leakage. GREASE TRAP: None (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 reconunendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 270 Santuit Road Cotuit MA Owner: Michael Redstone Date of Inspection: June 30 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarn in working order(yes or no): Date of last pumping: Continents(condition of alarm and float switches,etc.) t< i 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 out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber, condition of pumps and appurtenances,etc.): r 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 270 Santuit Road Cotuit MA Owner: Michael Redstone Date of Inspection: June 30 2006 SOIL ABSORPTION SYSTEM(SAS): . ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 4-Cultec 330 chambers(2'x 12'x 35) per as built card 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.): The Cultecs were dry and clean. There did not apyear to be anv si its of failure. A video camera was used for the inspection. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no)`. Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions. Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLU NTARY ASSESSMENTS SUBS URFACE CE SEWAGE DIS POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 270 Santuit Road Cotuit MA Owner: Michael Redstone Date of Inspection: June 30 2006 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. l� n rrp(T- a 3`9 �y 3 3 e13 a(o 10 I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 270 Santuit Road Cotuit, MA Owner: Michael Redstone Date of Inspection: June 30, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/_' feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:. Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: UsingBarnstable to o ra hic and water contours ma sitite.. s the maps were showing a roximatel 25'+1-to ground water at this This rep ort has been prepared only for the septic systent and components des cribed scribed Herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the systent will function properly in the future. There Have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic systent which have not been located and inspected. 11 - _ I TO OF BARNSTABLE LOCATION 12672I C SEWAGE # C%7- SYS' 1 Vt(VILLAGE CQ ASSESSOR'S MAP & LOT 10 r 2 J- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY s LEACH NG FACIL=: (type) CAL 310 (size) a�X �3�X 3 S NO.OF BEDROOMS (� BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by T�4?7b 27 r9d ' �rotAr r A a 3 3�9 lye b 3 q3 a6 TOWN-OF BARNSTABLEv 4 LOCATION 2 70 .S'�,�P� - SEWAGE # / j VILL-AGE `e�;r °' 'ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. '�.�� Gf�� t [S`�= CSo 1� �1" 7 SEPTIC TANK CAPACITY p-tc�o LEACHING FACILITY: (type)_ Q 014C_ c�....e�coS' (size) 2x !,Z)C .s NO.OF BEDROOMS " (0G;?OR OWNER.%�& 04"2t 1,612 PERMUDATE: r,6 ,. l - R`1 COMPLIANCE DATE: Separation Distance Between-the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility- 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 ey AS,LL 3 s r4 - G . �. < 3 �,� ' ` ASSESSORS MAP NO:_0 4 � No. 9 �5 -6 : PARCEL NO. �° ' = G G 2 Fee p t. THE COMMONWEALTH OF MACf105E1rT5 N0 ASSESSORS MAP NOPUBLIC HEALTH DIVISION -TOWN OF BARNMa 1 ""BSA _'"'---S PARCEL NO. on for Xh5pogal *pgtem Con6truction permit i3S Application is hereby made for a Permit to Construct( or Repair( )an On-site Sewage Disposal System at: Location Address r Lot No. Owner's Name Address n d sad Tel.No. 10_AJJ Tl-.,) L f- U,41,j VL �T- Pe�IT� Installer's Name,Address,and Tel.No. L Designer's Name,Address and Tel.No. S.Bevi iac?uo-Lotnst-tvc i a-y-i L , <lUC - p,$ox bW Vv ForPst cL t oab sas 83 8 V" Type of Building: Dwelling L-I5ro—of Bedrooms Garbage Grinder(130 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4- 4 gallons per day. Calculated daily flow E gallons. Plan Date Nunibpo of sheets Revision Date Title ' d ""IL-yt /W/* kr, Description of Soil � —3 , � ! �—� � . �� !�✓ , W v-v Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Dated �� Application Approved by Application Disapproved for the following reasons Permit No. 7--,- Date Issued .11;�f �=4`� --d.;�*'....� �v:>--' /`-�`•' ` ,r. ...A,s�. '-,,, ,- (�J+t.c t a ors -,.`. �4,-`T��, ,,,�., Fee - A Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN.OF BARNSTABLE.,MASSACHUSETTS r at on for Migpooal.*pztem c�Conmruction permit t}S� Application is hereby made for a Permit to Construct( orRepair( )an On-site Sewage Disposal System at:' Location Address •r Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �Q 1 S.Bev;laC?vo—CIO V)sfroa tio-» gprX t - �t 6��/�e , � ,c (oa8 I Forest od6 08 Type of Building: ' Dwelling L—N—o.of Bedrooms "'7 ` Garbage Grinder(130 Other Type of Building No. of Persons Showers -) Cafeteria( ) i Other Fixtures Design Flow • 4, 40 gallons per day. Calculated daily flow 44-6-3 gallons. Plan Date 91 Num , Z Re of sheets vision Date U Title « C,U(. L. 5V741 4 /Lv Description of Soil U , Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: 1�e, The undersigned agrees to ensure the construction and maintenance of the afore'described on-site sewage disposal systm in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. rr Signed �� Dated �R VW Application Approved b"y 1'� P - Application Disapproved for the following reasons tir ., - . .. Permit No. Date Issuedey THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C T that the.On-site Sewage Disposal System installed(�or repaired/replaced( )on by �,�� //� for as ha been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7- Xdated 0—'`r-' 4—L 7-:7 Use of this system is conditioned on cqppliance with the provisions set forth below: .�. •� ! ) - z No. / '� w� Fee THE COMMONWEALTH OF MASSACHUSETTS. PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi!6pogal *pgtem Cottgtruction Permit Permission ispf reby granted to `l(/ . 4e _ to construct w )repair( an On-site Sewage System located at ✓L��C and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: /�`S Approved by./�%CIc� I. ' I '51y-16-s FaMaY StacK : E: ' pL.atil. x Ito ? . lySE CuLT6G' 33Q4*Awt�3S��s � - 1 ;ZpP06AT- N' LF.AG!•� hY> —•o�..• _ IT fjjA ij PL,4N�VI�LV� t G EQS Slit=1l,IQLL? Aszt=A' ` "xzx2 $oTrotil. _-ram' 4 ... p�GoL�"ftDiJ �d'i� L'�;��E� . :. ., .?.... . . • � _ . . . 1 . ' -- . � 1� i 3�tx�.y: . { i• a to CUL7T4-1 . SU T VAN-- f J ; 330 +io 9 ,•�—wv3s bwC _. - _ EPf+€A+w_ N0 29 _' fi � _ IZ t -. ALLYN 9 wttso�+, o►s C FILM a ao'1 216 �� d' C,Z055 .SEG1't O 3 F irW 3:��, uu , Lout� •. �. . . �s bole i9t� I , 1140 YVtLiaAM - t No 19334 L`r _ 54AL� , -T g/PS1J�'f7L�.�=-AA U.: ..15I ` 1�l1T1.1iN Q � :BAD f 4N AI'= 4 FLta7D �L�Z�-U ZoN : Cip "+ass• �« se,,s oM- �vtc atr.trs s�tctixa ►ter- B5.- _APPuc4NT:"-OxL..;jI (rSe� �v l;.s'n►uusy PRcp�rrry LWOK - O CSII.UI � s f � �V y : r it , } �� - Y. . ` ' i �. L •. f • ,.. Y�s{�,�L=r•� 2�� ` �_ > � _ .y .. f...i� _ ' /...___._ � _' � !• - t T i j= + _ IOL ►CCU ,- A��-+L iv. .ate`+T i ,,,L Y , � t - 1 �� z ! -.� � •,f - .� ��u_ -- `: ter'•' ..^t t � �` _ ' ` ... � '� ` a�`� i OF 1 PETEROf 4 Of SULLIVAN ' `. ! MMMIAAA sue, CIVIL: C. N Y E u .G No. 19334' / 'R1-n T�VL w ►J . �� S M'rC� �$ @�8 .97 _ - SLI,EET psiuGi� FAMtLI s®Rc fit= PLAl..t. oN _VA44 { . � .�•s �r� ! / -- • pies- ST�K pESL1.l v,c 4 CuLTec Q �OcJtAwti�tl VST. --- '-- dT3vu c.A,-moN A r=A ZGO V. max 1 ;iPP UG.4'nON AM P1.a14 VIt=W - LKAe4lWv G�1AM8Ee5 Slte-WALL A=4,0*7SF xzfx�.� sF Zoltr u�.�: I N for O n� f i IrW6Nia, • . p SU- ^VAN N0..29EPH 733 t. WIISOPi G-now o e. 4AM Z-. �.ism g? • 3c�S cm 3 s TAW- -T.J, 'WI LIAM G C 11�1 D FAT PLAN! No. 1%3 4 o WTr7t _.. . 34 1 �.Ttoll CC�T1T l « �uuy 2 tti�� o �Y I�5 ti�Tiv �t t 19�1 StN 4} N caMt�.`1S tiJ l'iu :.: DEUNt= AJ.t� 4�t . - tL 2�pul2 Fd1'T DF- fu :.;..'1bydN OF &Af- 2:C . . Pam- $aQ1.15T1LP A7 WT LlX ►ZD WlTu IN A 5p9aAL.' FLVOP 4AZ zvN BAD Nye 11.lG '-b ' t.AEJD 4=WY474 •Wr,!6-46Wf . ' a�sers �fzoM--_Bu ic�i NlrS sr•lo��c'a ter- 8� '- � , vsta Tb "TA IFf. e �1 L.`J 1 � � 5 t t�1 � I j•1�C�, . � . v 1 , c su z 1.. 001, 4-16 c — ST A"VW ti y7 , of 9 � 1 SULLIVANUIV N .-29 V SM AA v, clEO NYE a / A Cvu`Tr>v Q S Till M ,p No. 19334 O 9r17'9.7 it S>S " TOWN OF BARNSTABLE LOCATION 7� Sri �v°`a+� SEWAGE # VILLAGE ` ASSESSOR'S MAP & LOT Id. INSTALLER'S NAME&PHONE NO. (f,?,-+� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) g yoe (size) 2 Xr 112Y -7S. NO.OF BEDROOMS c ( ZJ ,D ?OR OWNER - PERMITDATE: %s� - 1 - q COMPLIANCE DATE:. _--- Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by f Y 3� As l �z - LM �33 *6 fill u / y i tt 1 FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 �. a,Q4 C� �S Date: Ll No. bo Commonwealth of Massachusetts Massachusetts• 'li A a Dis sal it uit Date: ... /. 1... ......... 1 Performed By: ......................... ..... ..........,.... E ............ F ......................................... Witnessed By: . .. �.. ^-e.► -r't,�..... o,=•s ww. S l W R 5l L v114 T 1-3� AddMU Or Addmu.AM Lew ,nstruction Repair ❑ Office Review Published Soil Survey Available: No Yes Yeai Published ' i qq...... Publication Scale !....1s•,•QQ° Soil Map Unit �x ski .Soil Limitations P..rrP.,A..iNl Me, s,.....r-z.,..Paop... �reP..... ........r......................... N wd n� Drainage Class a` Available: No ❑ Yes Surficial Geologic Report A r 4� 0-0 i�� Publication Scale Year Published w�~ Unit)' i "" .................................................................................... Geologic Material'(Map ) ..... a�r�................:.....:........................................................... Landform .......... Flood Insurance Rate Map: 1 No ❑Yes Above 500 year flood,boundary Within 500 year flood boundary No eyes Within 100 year flood-boundary No Dyes Wetland Area: ,�; E.ma unit) ................................................................ Ma National Wetland Inventory P(map Wetlands Conservancy Program Map(map unit) _ . ` ` � ��• s lam+co• ...... ........ Current Water Resource Conditions(USGS : Month ) Range :Above Normal []"Normal ❑Below Normal ❑ Other References Reviewed: u�5 DEP APPROVED FORM•12/07/9S r w FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site R view -� Time:.. 16 Weather �c crtR T °"1 c ti Date:::.::..�.:..�... Deep Hole Number v: ' �'�J,'::, �1:..'Tyr..,:: Location(identify on site plan) 0 3 Surface Stones ��' �' ''� Land Use y T bT. caoo Slope (%) Vegetation .. T.:r� ►t�c _ - w......:.:::. .............. ..................... .... ..... . .. ...... Landform Position on landscape (sketch on the back) Distances from: feet f Open Water Body Soo feet t ; Drainage way Possible Wet Area 1 feet t Property Line .::. feet Drinking Water Well.. v.Eo: feet .. Other DEEP OBSERVATION HOLE LOG* Other Depth from ''Soil Horizon S(USDA)re Munselll) Mottling (Structure,Stones,g avleel;rs, Consistency, % Surface(Inches) - 3�_ 8�� Gehiy+E�+h�-+� �14d CaI.E G�K+�•.� i Loo9= , �S'7o G a„ 30•• M -T2t�G-prGL to/4 NbNG Sr1-I(�L6� 6aItiN , ' He wT-k.. C ►cl L ". . k �otia-Wq- Hd.aB s��..u..a✓ mP=rr��. �a� P.Orr c 51 . i DepthtoBedrO&o Parent Material(geologic) Al Weeping from Pit Face: Depth to er:Groundwa Standing Water in the Hole: r Estimated Seasonal High Ground.Water: DEP APPROVED FORM-12/07/9$ I 1 ' I t FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Lm r 1 T`-.I T ae-'" Z Determination for Seasonal High Water Table Method Used: ElDepth observed standing in observation hole inches ❑ Depth weeping from side of observation hole.................. inches ❑ Depth to'soil mottles — inches DGround water adjustment ......!:.!..... feet , Index Well Number .MAw.k�- A Reading Date ......!�N, Index well level !.3..... Adjustment factor ......!.:..t.'.. Adjusted ground water level ............$.:.4................................. Depth.of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in a areas observed throughout the area proposed for the soil absorption system? -YE s If not, what is the depth of naturally occurring pervious material? CeCtificati'on i a certify that ton (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date 1zL'� DEP APPROVED FORM 12/07/9S ' FORM 12 - PERCOLATION TEST T D � r M "LoPe-i- � - '� Location Address or Lot No. � �'�"' COMMONWEALTH OF MASSACHUSETTS 5 E , Massachusetts Percolation Test* Date: .w.v. Observation Hole # Depth of Perc Start Pre-soak i End Pre-soak 0 3$ Time at 12" I Time at 9" Time at 6" Time l9"-6"1 4s �� M 34 s Rate Min./Inch ass T"W- 4 'LM 14-4/1*4 1 ercolation test must be•performed in both the primary area AND " Mlimufin of p reserve*area. Site Passed 9 Site Failed ❑ .....................................-.-............ ...... Performed By: . ELLts g A-,L 1 rl ^-t.,-ti-I Witnessed BY: , Comments: - a j �.,PFROvsc FORM-uWHa 1 • op � AC-s : pso , Ojo �•AO - s / Vol P� ♦ �•a�A • P1,^•- / _ �•� � _ � :�� a �So Ass olIV oft Ode ,�► - / .� Moir. ,, d� ^ 136 734 - 113 _ ... - ---