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Home My WebLink About0645 SANTUIT ROAD - Health 645 SANTUIT ROAD Cotuit i ,' �� +�,�� Q �� t ,� t�� I� TOWN OF BARNSTABLE 1`0CATION SEWAGE# .461 1 VILLAGE Ot t I —ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Cho N j� Apt- 1 ��C% LlKc�1 LEACHING FACILITY:(type) y i (size) NO. OF BEDROOMS OWNER o t,�3—i rOIZ- PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ya� 0 yy� ' sq LOCATION iy,y�' SEWAGE PERMIT NO• VILLAGE 6 r1elr/ INST LI�� AME i ADDRESS - 2 U I L D E R OR OWNER e ® e DATE PERMIT ISSUED f4) DATE COMPLIANCE ISSUED `l ylgo a r. Fee No. / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipphtation for Misposal *pstem ConstCurtion 3pPrmit Application for a Permit to Construct( ) Repair(),�' Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.(e q$ Owner's Name,Address,and Tel.No /_ Assessor's Map/Parcel UD610 xg � b P�"1"`� >P� 13�,�c4 f _ 3S Installer's Name,Address,and Tel.No. �g �{�Fs 8�}�CP Designer's Name,Address,and Tel.No. . �c�-o�v"� Co✓rS{-�'c��'csvt,�e �C9•�.12C pJG� �� Type of Building: Dwelling No.of Bedrooms 1V Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) AI N gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when applicable) 1 pp CP5.5 c� — 5 P ( PP ) �D(l.nd!c�Ul (� � !��(110� eiv-e>r 4' S 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 Enviro ntal Code a t ace the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Si Date Application Approved by Date / Application Disapproved by7 Date for the following reasons Permit No. Date Issued w. No. _ 1 Fee THE COMMONWEALTH"OF MASSACHUSETTS Entered in computer: PUBLIC-HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS Yes 'Application for 313ispoBar *pstpm Construction Permit Application fora Permit o'Construct( ) Repair(1 f Upgrade( ) Abandon( •) ❑Complete System A Individual Components Location Address or Lot No.(d(� � f Owner's Name,Address,and Tel.No, /- §$ -- 12199? Assessor's Map/Parcel Uc �-Y �7 �#�' RD r 9 E 0v -t-.r a 1°• ,U A Installer's Name,Address,and Tel.No. 4�k .'S q�; Designer's Name,Address,and Tel.No. ('„i�r'['Y)� d4'�r.� ilG/G.C•^f GF��.min, '00. , :"X )o V I 1/1/1d,'�, rscrt c tl� CJ Type of Building: - Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other ,. Type of Building No.of Persons Showers( ) Cafeteria( ) N Other Fixtures 1� Design Flow(min.required) I� gpd., Design flow provided�Alk gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described o site sewage disTosa system in gyp.. � . accordance with the provisions of Title 5 of the Environmsental Code and-nof to place the system in operation until a Certificate of Compliance has been issued by this Board of Health �. - Signed "' S"..�-t,_ Date.a t P IV Application Approved by .._._. Date Application Disapproved by / / _ Date44 w for the following reasons Permit No. j,Q ~-• rr Date Issued � �{ ------•--------- ---------- ---- - _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance 1. THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k) Upgraded Abandoned( )by Xsr^�r>1��. Lr_>-A!n e__.f-te re _?.re. at( q'�~ n �., ;� k-1 ' C,(,4t,;J has been constructed in accordance f with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated / Installer 1`j('AolyttA nit-r C 'ror,, __!ne_ ' Designer el- #bedrooms pal ' Approved design flow x gpd The issuance of this permit shall Aot be construed as a guarantee that the system twill fun ti`o�n� d} tse� gned. Date Inspector --------- - -'.j?- - .:-- _ _ - . _ ------------- )�----y-- -._-__ No. �U` FeeJVt/ � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction Permit Permission is hereby granted to Construct( ) Repair(A) Upgrade( ) Abandon( ) System located at /, �l ;w,`f 1.1 f.i ` ' e�c�c� (''1!>4y_L*". - ° f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his,her duty to omply with Title 5 and the following local provisions or special conditions. µ Provided:Construction must be completed within three years of the date of this permit. Date_V�1 �• / Approved by L0 CA I0 t V 1 `S ��'� � S E by � � ADE A G f ST Y AME 8 A DID DE I Aj iL S S k. 0 UI( pED i �--- on OWNER D A vT E P EA`M�'T i IS•S U E 0 o P7 DATE - :C0MPl1A H C E lSSUEDA Town of Barnstable Barnstable Regulatory Services Department BARNSTABLL • t MASS.. ,m� Public Health Division - �''°�fo �s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0558 June 6, 2018 PONTIFEX, ROBERT A TR PO BOX 91 COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 645 Santuit Road, Cotuit,MA was inspected on 05/21/2018 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The outlet tee has corroded and fallen off. The septic tank needs a new outlet tee. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OJE OARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\645 Santuit Road Cotuit.doc • Town of Barnstable i i AI ANGTIATF R 16,59.N Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA02601' Office: 508-862-4644 Richard Scab,Dirrctor FAX 508-790-6304 ,. Thomas A McKean,CEO Feb 6,2007 Rev. 5111116 DEADLINES T.0•REPAIRFAILED.S'YSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ 'An`x'marked in the❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Amy portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis.*(This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single'Cesspool 7"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) , ❑Leaching facility with standing liquid level at,or above the invert pipe (per Town Code §360-20 h) : OTHER Repair deadline: W.SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 0 06p�-ba8 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C-A M 645 Santuit Rd. Property Address l Pontifex Owner information Owner' Na UJ is required for "J� � -' every page. Cotuits ✓ MA 02635 5/21/18 b a City/Town State Zip Code Date of Inspgction r It ;X «� 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. A. General Information -/30S"Lf 1. Inspector. Frank Nunes III - Name of Inspector, saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 16.340 of Title 5(310 CMR 16.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/21/18 Inspecto i at Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: Conditional Pass. There are 2 systems at this home one of which is a single cesspool. Single cesspools are not allowed in Barnstable. It shall be abandoned and all plumbing shall be tied into the system of record per 11/14/80 compliance. This will require permitting through the BOH. Once complete the system will be considered to"Pass" 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 Citylrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) i 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 '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 City(rown 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 obstructed pipe(s). Number of times pumped: ❑ N Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ E 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 A ❑ ❑ 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.doc•rev.6/16 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 , 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/16 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? ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 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 s ' 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ❑ No Laundry system inspected?. ❑ Yes ❑ No Seasonal use? ❑ Yes,® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy:, Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203)- Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-doc-rev.6/16 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 M 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No recent pumping per 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 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 645 Santuit Rd. Property Address Pontifex Owner information Owners Name is required for every page. Cotuit MA 02635 5/21/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1980 compliance Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1211 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site,plan): 4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, outlet T has corroded and fallen off it is reccomended that it be replaced If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 4" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 Cityrrown 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 >12 Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle >2 Distance from bottom of scum to bottom of outlet tee or baffle >2„ 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.): Pumping suggested every 3 years to prolong the life of the system 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•�''p 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: . gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert 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 3' below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ -Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * • If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Bottom of leach pit is 10'6" below grade, cover raised to 6", it is damp at this time, stain line 5' below invert, sidewalls are clean above stain line, no indication of past hydraulic failure 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 t5ins.doc•rev.6116 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 •''� 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name everyage.ed r Cotuit MA 02635 5/21/18 every 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.): Soils are compact and dry Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name everyage.ed r Cotuit MA 02635 5/21/18 every page. Cityrrown 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 \�31 CC)- c�L A, ,)3 t5ins.doc•rev.6116 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 , 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name everyage.ed r Cotuit MA 02635 5/21/18 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high groundwater: >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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 1980 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping SAS is at 24'msl and nearby surface water is at 2'msl You must describe how you established the high ground water elevation: See above F Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 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 , 645 Santuit Rd. Property Address Pontifex Owner information Owner's Name is required for every page. Cotuit MA 02635 5/21/18. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.. U G a 6 r�� Fps.J........................ ,A V 0' THE COMMONWEALTH OF MASSACHUSETTS O�0 BOAR® OF HEALTH a.w_hi........... 7.3 • �� Appliration for Disposal Works Tonstrnr inn Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: •--............ ....... -6 �.....-.. - .. 1'W... . .. . . ........ .....••-••. .•-•-•-•....-•-•------•................-- �,,,,G Location-Addres or Lot No. ....-----............. .._ ......--? ............... ...........---............................. ............... ... Q O ner Address ................................ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building .............. No. of ersons................_•..._.._... Showers� yp g --------•••--- p ( ) — Cafeteria ( ) d Other fixtures -•--•------------------------------------------- .------------------------ .. W Design Flow........a..................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date...................................... 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ---•----••------------------------------------------------••-----------......-----------...-••-••---......................................................... 0 Description of Soil......................................................................................................................................................................... x W -•--------•-----------------••-----------------••---•-----•----------••--------------------------------•----•. -------- •---- ........................... 0 Nature of Repairs r Alter ns—An'swe& when applicable ! O G. e /4 . .. " Agreed Z The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by the board ofAealt 7 igned LX •------ ------- ---- l �/z z� !3 -------------------•. Date Application Approved BY , `/`'i .................... Zr/ ------ Date Application Disapproved for the following reasons:................................................................................................................. ..............•-------...--•-------------...•---•-------------•---•-------•---•=----------...------....-------------•--...-----------------------•-------------•----------------------------•----------- Date PermitNo.............................• Issued-....................................................... Date No..��,,•Gzs6- FEs .... �...........- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,....r.- .... ............OF.... Appliration for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System�t�: ........... ...:. - ...... � ---.--•---•----------•---•-•------.-.-.-...---- / �'"`•"C. or Lot No. .. .. ... ........... ............................................. ----------............................... ner Address aW °' ....... '............................. .......................................... Fa. .......................... Insta ler K dres`s' _ (� Type of Building Size Lot....:.......................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ NO."of persons_....__..................... Showers ( ) — Cafeteria ( ) a - Other fixtures .........................................................�"�..,, - -----------------------•---•-------------------._._.....------------------- W Design Flow....................:.......................gallons per person per day., Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length____._..._.___ Width................ Diameter--'---------_ Depth................ Disposal sposal Trench—No..................... Width.................... Total Length.:'._.,_.......� _ Total leaching area.................... ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet..............; .. Total leaching area..................sq. ft. z Other Distribution.box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . (s, Test Pit No.. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' ----•-•-•-------------------•---••..........•-•-••-----•------......••••--------•-------•-----.............................................................. ODescription of Soil..................................................................................................................;I...................................................... x U •••....................•--•---•-------......................_......--•.........•-•-••----------•-----•-------------•-•.......--•••--•-----------•--•-----••-•-•---------------•-._.............---•----- W --- --- ------------- U Nature o Repairs Alterat'ons—Answe 'when applicable.___._ �f r Agree'lenIt�: �� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of-Compliance has been issued by the board.of Health. Signed`'....--- -- - /aL;e-7 �!3 Application Approved By-... _....-�e�.�i�� . ................................... ............. --------- ......------ Application Disapproved for the f ollowang reasons:-------•-•--•------•••---•---•-•---------•------------•-----•-•------------- ---..-•--•-------. ...............................-................................................................................................................................................................. Date PermitNo..*....................................................... Issued....................................................... :. Date THE3COMMONWEALTH OF MASSACHUSETTS BOARD OF . HEALTH f ........ .......................:.OF.. ...... (9rr i lrtt t aurr THI',-JS 0 CE FYPat the ndividual Sewage Disposal System constructed ( ) or Repaired b � .� ... Installer has ben installed in accordance i e isI s0i7 of°`i`I= State Sanitary Code as described in the application for Disposal Works Construction Permit No................:....................... dated__.../-®_.r....A__.2 ,e_# *...... THE ISSUANCE. OF THIS CERTIFICATE SHALL NOT BE CONSTRUE®.AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................................................._.....--•-----•-.----_. Inspector.............................-..........................................�... THE.COMMONWEALTH OF MASSACHUSETTS / BOARD OF. HEALTH ..OF FEE.�y....�.61 .... Permission is hereby granted.... -- ........-• ----. .. • ---• . ........................................................................ to Construct ( ) or Repait�/ ) an Individual Sewage isposal System atNo.------. ...... .............• ------------•---.•------•-----.------•----•--•--•-•--•--•--•---•-••-•---------.-- as shown on the application for Disposal Works Construction Permit No.............. .... Dated... Q."_xz'. d..'.--- ....................................... DATE ....Jl` . ��.'.....-•--•---------------•-------........ 4 FORM 1255 HOBBS a WARREN. INC.. PU I SHERS