HomeMy WebLinkAbout0694 SANTUIT ROAD - Health 3 ' -Santuit Ro Ad--
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c Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _
694 Santuit Road .a.
Property Ado ress
Steve&Alicia Furrer �
Owner Owner's Name
Information is _7
required for every Cotuit MA 02635 10-22-18 0%
page. City/Town State Zip Code Date of Inspection IZA
QJ
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.
o.11uutO OF
Important out f When p �� ��� � ...........
filling out forms A. Inspector Information �� ��� �.:��,�.,
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on the computer, •JA M ES
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Company Name �, .,ff Tt IF
Commercial Street
,gyp Comom pany Address
Mashpee MA 02649
City/Tow State Zip Code
508-477-8877 S 1623
Telephone Number Ucense Number
B. Certification
I certify that: I am a DEP approved system Inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
�., 10-22-18
hr's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.712e12018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of to
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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 is a 1500 Gal.Tank D Box and three Chambers
2) 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):
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ >s
' 694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owners Name
information is required for every Cotuit MA 02635 10-22-18
page. City[Town State Zip Code Date of Inspection
C. Inspection Summary (cont)
2) System Conditionally Passes (cunt.):
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
❑ 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 ❑ NO (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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) 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.
a. 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:
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Commonwealth of Massachusetts
,�.p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
informationis
required fo for every Cotuit MA 02635 10-22-18
required
page. Cityrfown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
❑ 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
b. 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® p
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
t5insp.doc•rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
,
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® 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'/a 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
tributary to a surface water supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
® 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.
5) 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 CA,
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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes' to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were ail 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?
El ® 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.
El ® 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)]
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c \' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1500 Gal. Tank D Box and three chamber's
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2016-207,00OGal
2017-146,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
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Commonwealth of Massachusetts
Title 5 official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
per, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? [I Yes [] No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
: ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve S Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
1998 Permit # 98-786.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 20"
rest
Material of construction:
❑cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
t5insp.doc•rev.7W2018 Title 5 Ofriclal Inspection Form:Subsurface Sewage Disposal System•Page®of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owner's Name
information is COtUit
required for everyMA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade. 101,
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: 1500 Gal. Precast H-10
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 1.r
Distance from top of scum to top:of outlet tee or baffle
8°
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Plan-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level.Tank and covers at 10"below grade. In and outlet tee's, No sign of leakage
or over loading.
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I
Commonwealth of Massachusetts
kvTitle 5 Official Inspection Form
�vl I
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspectlon
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°-� 694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owners Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
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
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"xl6"-25"below grade w/three lines out. Box is clean and solid w/no sign of over
loading or solid carry over.
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Commonwealth of Massachusetts
r� Title 5 official Inspection Form
k;i i Vr' 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owners Name
Information Is
required for every Cotuit MA 02635 10-22-18
page. CItyrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ inn ovative/alternative system
Typetname of technology
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Commonwealth of Massachusetts
Title 5 official Inspection Form
r ) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
information r e Cotuit MA 02635 10-22-18
required for every
page. cityrro m State Zip Code Date of Inspection
D. System Information (cone)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation,etc.):
Leaching is three 500 Gal. dry well chambers. Chamber's are 38" below grade.6" water in
chambers wino sign of over loading or solid carry over. Clean like new wall's
12. Cesspools (cesspool must be pumped as part of Inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
P Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owner's Name
information is
squired for every CotUit MA 02635 10-22-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
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` 0 Commonwealth of Massachusetts
- i� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve&Alicia Furrer
Owner Owners Name
information is required for every COtuit MA 02635 10-22-18
page. City/Town State Zip Code Data of Inspection
D. System Information (cont.)
14. 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
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Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. CityfrDwn State Zip Code Date of Inspection
D. System Information (cont)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 10-6-98
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)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 10-6-98-12' no G.W.. Bottom of chamber's at 5'-8"below grade. Bottom of
chamber's at 6'-4"above T.H. Depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15insp.doc-rev.7126M 18 Title 5 Official Inspection
pection Form:Subsurface Sewage Disposal System•Page 17 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Steve &Alicia Furrer
Owner Owners Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached.
For 15: Explanation of estimated depth to high groundwater included
t5imp.doc-rev.712612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 18 of 18
i
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Far TOWN OF BARNSTABLE
LOCATION SEWAGE #
VII:2-1�AGE ASSESSOR'S MAP & LO C1�k�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY i O
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS BUILDER OR OWNERn` but ffi-fiIwe-LL
PERMITDATE: 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
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 J. C-�r�C l 3 I I�Z
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AO 33
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TOWN OF BARNSTABLE
(..
LOCATION ( SEWAGE #
0
VILLAGE ASSESSOR'S MAP &LOT O �O
INSTALLER'S NAME&PHONE NO. t✓
SEPTIC TANK CAPACITY
LEACHING FACMITY: ( ) A/— z
NO. OF BEDROOMS r�L'� 3A10tJ)
BUILDER OR OWNER
PERMTTDATE: QqWCOMPLIANCE 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
3
® c� �
t
Q _ �J
No. /l �� ,P Fee API
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _es
Yes
2 5� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
rtcatton for _i ozal p item ConM tion Permit
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) Complete System ElIndividual Components
Location Address or Lot No. 6 / spy y 'f_ Owner's Name,Address d Tel.-No./
Vl�peofBuilding:
Lr) .5-� G(tite1sor's Map/Parcel606 `3
ler's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
.,,
Dwelling No.of Bedrooms Lot Size S 3, %0®sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 6 gallons per day. Calculated daily flow 3 gallons.
Plan Date /2-/- 9 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil CC— 424, 7,r Z
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 pl e t system in operation until a Certifi-
cate of Compliance has been is s d by this Board alth. ,
Signed / Date �Y 9 q
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 7,F'—7,W'? Date Issued 2
CCU
No. ,: .�.: . Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
'
/
2 ��2_ Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
application for igpogal *pgtem Congtr ction Permit ;
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( �) Complete System ❑Individual Components
Location Address or Lot No. 4 r1 y Y01-„ {1/q 2 A,Celw,� Owner's Name,Address d Tel.No.
Assessor's Map/Parcel
Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No.
CY
CQV�
Type of Building:
Dwelling - No.of Bedrooms Lot Size s 3, 9o®sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria,(. )
Other Fixtures
Design Flow Y 6 gallons per day. Calculated daily flow y 3 gallons.
Plan Date 2' != Number of sheets Revision Date
Title l
E Size of Septic Tank Type of S:A.S.
Description of Soil 1—e.-l- /> 9 ZS Z
Nature of Repairs or Alterations(Answer when applicable)
Date lasNnspected:
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 plQthystem in operation until a Certifi-
cate of Compliance has bee is d by this Board alth.
Signed / Date (� L
Application Approved by Date Z �� —
\,Application Disapproved for the following reasons �
Permit No. 7JEES Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIV'
at the On-sitn
geP posal System Constructed( Repaired( )UpgradedAbandoned( by j V
at 00gy Ia%"► /71�pr has been constructed in accordan
with the provisions of Title 5 and the for Disposal System Construction Permit No. Too-- 79-6 dated
Installer I Designer
The issuance of this p shallAol))qo strued as a guarantee that the sy' em�`,
nction as desig ed.
Date >� Inspector f�. n N �
��' j
9 — — -------------------------=-= ;
No. 7 —
Fee !;��()
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Xigpogaf tem Congtruction Permit
Permission is hereby ted to onstruc �"1 K . ( ) grade( )Abandon( )
System located at �/oe ��M
and as described in the above A&&cation for Disposal System Construction Permit. The applicant recogn' es his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction mu be co p d 'thin three years of the date of ' e
Date: ✓ Approved by `�
TOWN OF BARNSTABLE
LOCATION 6'* SAeO�f 906n SEWAGE # /
VILLAGE ft) ASSESSOR'S MAP & LOT O 'D
s
INSTALLER'S NAME&PHONE N0. L
SEPTIC TANK CAPACITY D
LEACHING FACILITY: ( ) �� A z
NO. OF BEDROOMS O 1
BUILDER OR OWNER N
PERMTIDATE: COMPLIANCE DATE: T,9�-,3 q�
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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessment
694 Santuit Road _
Property Address r.
Rich Lonstein .,
Owner Owner's Nar/fie
information is COtuit yd
required for every MA 02635 10=22-18
page. City/Town State Zip Code Datd:of Inspection
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.
\\�UW tIIIurnrpri
Important:When
filling out forms A. Inspector Information 6/4j /3y31 ,,,.`���..
on the computer, per':' ti
use only the tab James D.Sears _g: JA MES m
key to move your Name of Inspector SEARS
cursor-do not Capewide Enterprises *'.
use the return -
key. Company Name
153 Commercial Street i N SFE�'���°���
VQ Wi
Company Address
Mashpee MA 02649
ICI City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true,accurate and complete as of the time of my
inspection;and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10-22-18
spectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
t5insp.doc.rev.7064018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of fe
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Commonwe
alth of Massachusetts ,
in� Title 5 Official Inspection Form
'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owners Name
information is required for every COtUIt MA 02635 10-22-18
page. CItyfTown State Zip Code Date of Insp
ection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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 is a 1500 Gal. Tank D Box and three Chambers
2) 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):
t5insp.doc•rev.7,1M018 Tile 5 Of del Inspection Form:Subsurface Sewage Disposal oysters•Page 2 of 18
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Commonwealth of Massachusetts
o} Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is required for every C01UIt MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
❑ 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 ❑ NO(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):
3) 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.
a. 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 mannerwhich will protect public health,
safety and the environment:
15nsp.doc•rev.712&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
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Commonwealth of Massachusetts
rp Title 5 Official Inspection Form
VIi�
t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MWW
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
Information is
required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
❑ 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
b. 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 Beet or
more from a private water supply well**.
Method used to determine distance:
This system passes if the well water analysis, performed at a DE 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.
c. Other:
4) 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
t5insp.0oc•rev.7125/2019 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 4 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u-
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is
required for every Cotuii MA 02635 10-22-18
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® Slatic liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in MEMOpM is less than 6" below invert or available volume is less
than Y:day flow� �dCRM;6
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system kft. 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.
5) 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 CA.
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
t6insp.doc-my.7,1282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
g a5ed xeJ dH OZ41, 8 60Z t72 ID0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
nform
requir on is Cotuit MA 02635 10-22-18
requiredd for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat,or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for aff inspections:
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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5lnsp.doc•rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Svstem•Page 8 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1500 Gal.Tank D Box and three chamber's
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 2016-207,000Gal
g ( y g (gPd))' 2017-146,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc-rev.7/2612018 Tille 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
f. Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
�w
694 Santuit Road
Property Address
Rich Lonstein
Owner Owners Name
information is required for every Cotult MA 02635 10-22-18
page. City/Torn State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5ln sq.doe•rev.712 812 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page B of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
requir reqtionuired
is Cotuit MA 02635 10-22-18
required for every
page. CRylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
z 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 IIA system by system operator under contract
❑ Tight tank.Attach a copy of the D E P approval,
❑ Other(describe):
Approximate age of all components,date installed (if known)and source of information;
1998 Permit # 98-786.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
_Pipeing is 4" PVC SCH -40.
c5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is Cotuit
required for everyMA 02635 10-22-18
page. UylTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 10"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: 1500 Gal. Precast H-10
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle 28"
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
8'r
Distance from bottom of scum to bottom of outlet tee or baffle
17°
How were dimensions determined? Asbuilt-Plan-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc,):
Tank at working level.Tank and covers at 10"below grade. In and outlet tee's. No sign of leakage
or over loading.
t5insp.doc rev.7iM2018 Title 5 official Inspeclion Form:Subsurface Sewage Disposal System•Page 10 of 18
06 abed xed dH ZZU 8602 bZ 100
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 694 Santuit Road
Properly Address
Rich Lonstein
Owner owner's Name
information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
8. 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
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form;subsurface Sewage Disposal S•7stem•Page 11 of 18
I•I• a5ed YL J dH ZZ:6 6 9 1,02 bZ 100
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
Information is required for every Cotuit MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
8. Tight or Holding Tank (cont.)
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
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-25" below grade w/three lines out. Box is clean and solid wino sign of over
loading or solid carry over.
tansp.eoc•rev.7/2e12o18 Title S Official nspeclion Form:Suosirface Sewage Disposal System-Page 12 of 18
Z I, abed xe� dH EZU 8 60Z bZ 100
Commonwealth of Massachusetts
,p Title 5 official Inspection Form
�d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is required for every COW MA 02635 10-22-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont,)
10. 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.
11. Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
I5insp.doc-rev.T2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
£I• abed RJ dH U41, ME bZ 100
Commonwealth of Massachusetts
Vr Title 5 Official Inspection Form
rI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
`JY Property Address
Rich Lonstein
Owner Owners Name
information is required for every Cotult MA 02635 10-22-18
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont,)
11. Soil Absorption System (SAS)(cont.) -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is three 500 Gal. dry well chambers.Chamber's are 38"below grade. 6"water in
chamber's wino sign of over loading or solid carry over. Clean like new wall's.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7126t2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 16
I• a5ed xed dH 6241, ME bZ 100
Commonwealth of Massachusetts
Title 5 Official Inspection Form
d Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
pie City/Town State Zip Code Date of inspection
D. System Information (cont.)
13. 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.):
I
t5lnsp.doc-rev.W26/2018 Tdle 5 Otfidel Inspec5on Form:Subsurface Sewage Disposal System•Page 15 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
.A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner owners Name
information is Cotuit MA 02635 10-22-18
required for every State Zip Code Date of Inspection
page. Cityrr wn
D. System Information (cont.)
14. 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
I5insp.doc-rev.7126l2018 Title 5 Ottldal Inspection Form:3ut3urface Sewage Disposal System-Page 16 of 18
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Ptivete Wakf S'PPIy Well end Laachieg Fatdliq (lf any walls edit
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
ilv�e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owners Name
information is required for every Cotuit MA 02635 10-22-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Na
Estimated depth to igh ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 10-6-98
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)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 10-6-98 -12' nc G.W.. Bottom of chamber's at 5'-6" below grade. Bottom of
chamber's at 64"above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5nsp.dw-rev.712 612 0 1 8 Title 5 Official nspeclicn Form!Subsurface Sewage Disposal System•Page 17 of 18
9 6 a5ed YU dH t7Z:6 6 91.0Z t7Z 130
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
694 Santuit Road
Property Address
Rich Lonstein
Owner Owner's Name
information is required for every Cotuit MA 02635 10-22-18
page City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed &Dated and 1,2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D.System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
GR,q a�
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4
tsinsp.doc•ray.71261201E Title 5 Official Inspection Form:Subsurbca sewage 0isposai system•Page 18 of 18
6 6 abed xeJ dH SZU ME bZ 100
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
F
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d ERECEIVEEDBIE
TITLE 5
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 694 SANTUIT RD COTUIT,MA 02635
Owner's Name: ROBERT BOTHWELL
Owner's Address: BELL ONE 800 FALMOUTH RD MASHPEE MA 02649
Date of inspection: 3/4/02
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT '
certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furth r valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 3/4/02
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design Flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO
PROLONG THE'SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use'it that lime.1hls
inspection does not address how the system will perform in the future under the same or different conditions of use.
P
{ Page 2 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 694 SANTUIT RD COTUIT,MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS
TO PROLONG THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
i
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if.a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced.
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system 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: n/a
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 694 SANTUIT RD COTUIT,MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
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 3:0 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 694 SANTUIT RD COTUIT,MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this forma
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large syslem 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 CM 15.304. The system owner
should contact the appropriate regional office of the Department.
a
Page 5 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 694 SANTUIT RD COTUIT, MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period ?
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is ai issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
I
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 694 SANTUIT RD COTUIT,MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 years usage(gpd)):wfa' 2-Doo ~ 1-1 S t000
Sump pump(yes or no): NO
Last date of occupancy: 2/25/02
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to.the Title 5 system (yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
2 YEARS BY ASIIUII,T.
Were sewage odors detected when arriving at the site(yes or no): NO
6
Page 7 of l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 694 SANTUIT RD COTUIT, MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 6"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L10' 6" H5' 10" W5' 8""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 4"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL
LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
r
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUr;TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 694 SANTUIT RD COTUIT,MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locaie on site plan)
Depth below grade: n/a
Material of construction:—concrete,_metaI_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R a
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 694 SANTUIT RD COTUIT, MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
500 GALLON LEACHING leaching chambers, number: 3
CHAMBERS leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
n/a Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
CHAMBERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.CHAMBERS WERE EMPTY
AT TIME OF INSPECTION. BOTTOM IS AT 5'.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Continents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of pond ing,,condition of vegetation,etc.):
n/a
Q
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 694 SANTUIT RD COTUIT, MA 02635
Owner: ROBERT BOTHWELL
Date of Inspection: 3/4/02
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.
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' ` Page II of II
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 694 SANTUIT RD COTUIT, MA 02635
Owner: ROBERT BOTHWELL
Date of inspection: 3/4/02
SITE EXAM
Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high groundwater elevation:
HAND AUGER- 10+ FT.
I
j�
B � �
-
G
S YS TEM PROFILE
T.
NOT TO c CALE
TOP FNDN. FINISH GRADE
FINISH GRADE OVER
EL ._P�.OD FINISH G19ADE 7 8 .O FINISH GRADE OVER DIST T. BOX -T G.5 OVER TRENCHES 7 5-S
.• ,
SEPTIC TANK
f'c.o�
12" MAX. �CC�Ca
:Q.o
e '4a' Pe•••�;:��: :Od'•�C•..D�'4•'::Q•vjD'O. �o.'ep:!�'4�iL•'. � -A'ti•ip.•.r .i0 -
OUTLET PIPE LEVEL TOTAL LENGTH OF TRENCH �3'- G'"
.Q rt _
4•°:�o.• �'' _ T. MIN.FOR 2 F
' :o•.�oQ .D .9 I :jjl O ® 0� ••w: ' v '.0; '•D: ,o.. 'Id• b" •o ..e q. ..17.
0°�
4� ' +L B"
�/ oo CAP END 0
C. I. OR PVC TEES 74.53 4.2Co
•
b..a. :o 4, �4'
a 150 0 GALLON D. 'TR. 'BU T.�"ON B®
BSMT FL
EL . 73.GY> :�o.o 9b INSTALL ON LEVEL BASE '1500 GALLON DRYWELLS "
PRECA S T CONCRE TE a•
�. .'.
'
�L -7 8.6'(L�u m' _D) o.
H— /0 REINFORCED
.,t•I�p:gb.d,:y4•.Op'�:+ .-a,;p:�.: p' 4�••' py .0;0• e••'o" °
: ..o•v. p.o., .p o p.s '• .0.� Pro,Op4a ,4 V -bp 0:
L O 7 5G SEPTIC TANK TRENCH SEC TION
INSTALL ON LEVEL BASE
NO Tom• EXCA VA TE TO EL EV V. N�A OR
LOWER TO REMO VE AL L IMPERVIOUS �7
��--------- HA TERIA L BENEATH THE LEACHING AREA � t 2" MIN.
F S 28' S3' 30" E' 4" DIAM.
REPLACE EXCA VA TED MA TERIAL WI TH
3" OF 1/8"-?/2"
„oa• 7,eo6.:Q•,'.v O:pC'p b'•b :O,:p�• raj g1
CLEAN, CLA Y FREE SAND 04• `d: ,:•d .:,A ,t. WASHED PEA STONE
3/4" - ?-?/2„ WASHED '
> L07 5 5 CRUSHED STONE '°$
0 Lit 5 3, �t G✓F
o � N � ��=
i W ti GENERA NOTES TRENCH WIDTH
' 1. ALL EL EVA TIONS ISHOWN ARE BASED ON ASSUMED NUMBER OF TRENCHES ?
2. ALL PIPES IN TF',= SYSTEM MUST BE CAST IRON NUMBER OF ORYWEL L S 3
b iZ I vE N OR SCHEDUL E 40
3. THE BOARD OF HL L
5"= _J a TH MU3'T BE NO v P-9252 f _
n� ` N r- M �� _ WHEN CONSTRUCT 9N IS COMPLETE PRIOR PERCOLATION RATE.
o ��
^�D -------- — - - 61
N ,�, N TO BACKFILLING,
m., ►► -,_ �'_� ----- -- <5 MIN./IN.
_ st' 4. ANY CHANGES' IN THIS PLAN MUST BE APPROVED
° ;� _.• 18 �I666 , ., "(2 WI TNESSED B Y.'.
o ,, BY THE BOA OF HEALTH AND CAPE 6 ISLANDS
- SURVEYING CO.. . �lC
. GERRY DUNNING
_ % . N 5. MATERIALS AND J'NSTALLATION SHALL BE IN
1 '- T ¢ .. N COMPLIANCE WI Tif' THE S TA TE SANITARY
BARNS TABL F8R0, OF HEALTH DESIGN DA TA
DA TE _OC T. 6_?998
= CODE - TITLE V - AND LOCAL APPLICABLE E
RULES AND REG&A TIONS
-rc-s-c prr 1 -r -C pl'7 6 NUMBER OF BEDROOMS
6. NORTH ARROW IS FROM RECORD PLANS AND o oW dw GARBAGE DISPOSAL NO
IS NOT TO BE U."ED FOR SOLAR PURPOSES L0,NN�0-M Z L0 o 440
7. .FL ODD HAZARD ZONE C (NON-HAZARD) DA IL Y FL ON
GAL .
8. WA TER SUPPL Y_' TOWN WA TER 1500 GAL .
\ � �DY LoNeY SEPTIC TANK REO D. 1500 GAL .
f
SEPTIC TANK PROVIDED 5 0 GAD.
o i is % ----- -- --- G G
L EA CHING REQUIRED
s j r-1 I uM w.
L07 58 SI�ND 'f2" SIDEWALL AREA = ?86 S. F.Go C214
- ?37 V
i - ?86S. F. X 0. 74G/S.F. - GPO.
— ---- LEGEND INE BOTTOM AREA = 44? S. F.
! �o�tD
58 4419. F. X 0. 74G/S. F. = 326 GPD
LEACHING PROVIDED = 463 GPD
PR)POSED ELEVATION 120' NO 12ouNDW&Teg I � NO �auUDw�lE-tz
� --�'O --. EXTSTIIVG CONTOUR
SINGLE FA MIL Y RESIDENCE ZC
o ®_______OBSERVA TION PIT
� � 3 0 • D13 TRIBUTION BOX PROPOSED Jt'` j'✓E A GE DISPOSA L S YS TEM
�0 PREPARED FOR
u /60 2 o� mod' o o SEPTIC TANK I .4.: : CHARLEJr' SNOj'✓ro' 30„ ' —.— 8 �✓' LOT 55 SANTUIT ROAD ti
w I i RE'SEF,rVE AREA -'ffM
Av BARNS TABLE — COTUIT - MASS.
��.
P1PE INVERT EL EVA TION
a' 'OKI _DA TE.' _ CAPE 6 ISLANDS ENGINEERING
L O-T 54 PLOT PLAN L07 57
- - Hers a R�; SCALE AS NOTED 133 FA L MOUTH ROAD — .SUI TE 2E
SCALE.• ! 30 F�'
)� 1t-3 • 5 S `�4 . t;
{ G MA SHPEE, MASS. 16 2 C'1p
<� SFr, Qr~� r OT Hq - �.�.�.�'? AN NO. 201
.a " . PLAN