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HomeMy WebLinkAbout0694 SANTUIT ROAD - Health 3 ' -Santuit Ro Ad-- 'Cotuit;' �I D0to` N 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 �� ��� �.:��,�., y, on the computer, •JA M ES use only the tab James D.Sears = key to move your Name of Inspector ; —r cursor-do not Ca wide Enterprises use the return key. 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 abed Xed dH L941, g i3OZ g0 AON 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): t5insp.doc•rev.7126/2018 Title 5 Official Ins pection Form;Subsurface Sewage Disposal System•Page 2 of 18 Z a6ed xeJ dH LS:1.1, 91,0Z g0 AoN 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: t5insp.doe•tev.7I2612018 Title 5 Official Inspection form Subsvleoe Sewage Disposal System-Page 3 of 18 £ a6ed x2J dH L941. 860Z 80 AoN 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 abed xeJ dH L5 i.i, g i3OZ g0 AON 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 t5insp.doc•rev.7/26l2t]18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pepe 5 of 15 5 abed RJ dH L561, 860Z 20 AON 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)] 15insp.doc•rev.712812018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System Page 6 of 18 9 a6ed xeJ dH L9 61 ME 80 AON 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 t5insp,doc•rev.7126/2018 Tdle 5 Official Inspection Form:Subwrface Sewage Disposal System-Page 7 of 18 L abed xed dH K 66 ME SO AON 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: t5insp.doc-rev.M612018 Title 5 Official Inspection Forth:Subsurface Sewage oisposal system•Noe 8 of 18 9 a6ed xed dH 99:66 9I,0Z 80 AcN 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 6 96ed xed dH 69:6 6 9 60Z 80 ^oN 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. t,%nsp.doc•rev.7126/2016 Title 5 Official Inspaction Form:Subsurface Sewage Disposal system-Page to of 1a 06 a6ed xeJ dH 6941, 860Z 80 AON 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 t5insp.doc-rev,7128l2018 Title 5 WOW Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 6 a6ed xed dH 6566 91,OZ go ^oN 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsu-face Sewage Disposal System-Page 12 of 18 z I• a6ed xeJ dH 69:1.6 8 602 80 AoN 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 15insp.doc•rev.7128l2018 7We 5 Ofriciel Inspactlon Form:Subsurface Sewage Disposal System-Page 13 of 18 8 t abed xed dH 65 6 6 8 Xe 80 AoN 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.): t5insp.doc•rev.712812016 Title 5 Official Inspccf*n Form:Subsurface Sewage Disposal System•Pagg 14 of 10 t,l, abed xed dH 00Z I. 8l•0Z 80 AON 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.): t5lnsp.tloc-rev.726/2018 Title 5 Official Inspection Forth:Subsurface Sewage oisposal system•page 15 of 1S 5 a5ed xed dH 00 Z I. 8 60Z 80 AcN ` 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 wnsp.doc-rev.7j7612016 Title 5 Offidal Inspection Form:Subsurface Sewage❑isposal System-Page 16 of 18 96 abed xed dH WE 1 8 60Z 80 AoN (���^_ TOWN OFBARNSTABLE /OCATIONLA u Sllb l l't' j2d. SEWAGE 8 VM1AM_CQ U j ASS$SSOR'S KAP& WSTALLEWS NAME&PHONE NO. SEPTIC TANK CAPACITY� t LFACKATO FACLM:(lrael (mm1 No.OF BEDROOMS BUILDER OR OWNER PERNIITDATB: Ct7�i lANCg DAM Sagndota Dswa Betwan ON: Maximum Adjusted Ocomdwm Table Ind Botmm of LAwhia3 Faeil ly aet Private Water ScpPly Well and Leaching Fadlity (lf my wells ewt 02 slte or within 200 feet of karhleg facibly) _ Edge of Wetland and Leaching Fuahry(tf&*wetlands exist wiWo 300 feet of leaching lbeiBey) _ Ew wed by _ T,EiraCL 81u Oz AC C g A 0 An 37 �1 ICY f$tY £A LL6G-LLb-809 sesildaelu3epmede0 e90:90'9L 6l;e0 L 6 abed xed dH ON 6 8 V 80 AON 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 g� abed xeJ dH 1,0:2 6 8 i3OZ 80 AcN 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 6 a6ed xez! dH 60:F I. 8l.OZ 80 AON 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 4197ED � AO 33 • fly � v` 9 Op 3 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 i �, J q3 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 l, a5ed xed dH OZ:1,1, 9 i3OZ bZ 130 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 Z a5ed xed dH 0E 6 6 81,0Z t Z 100 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 E a5ed xeJ did 0 66 ME bZ la0 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 t a5ed xed dH 02:66 81.0E bZ 130 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 9 a5ed xeJ dH 241, 860Z bZ 130 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 L a6ed xed dH 2:66 8IA2 bZ 100 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 9 a6ed xeJ dH 2:1,1. 9 60Z bZ 100 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 6 abed xe:1 dH ZZ:6 6 9 602 bZ 1:)0 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 5 l, abed xed dH VZ:6 6 8 60Z tZ l)0 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 9 abed xed dH bE:6l. 9I.OZ bZ PO TOWN OFBARNSTABLE 4A'CON it Q SEWAGE N ASSESSOWS fmgLLDL ASTAUSCS NAME&PRONENO. SFMM TANK CAPACrN J= LEACHING FAC(L:M:(type) (wu) NC.OFBBDROOMS_`7 BU LDFR OR OWNERffi-rhuielL PERMITDATE: COi1d UMCE DATE: S OWStion Disum Betwom the, Maximum Adjut W OMWWWK&Tetlt end BoCom of Leachibp Faaly Felt Ptivete Wakf S'PPIy Well end Laachieg Fatdliq (lf any walls edit oo+iu or within 2W fat of leeching fedlfty) Feet Edge of Wetland•nd Leeching FaIrty(if any wetlands post _ within dw het cf leachins facility) Fee Pumbhed by C ra 3 (44L �2� 1 TJ 49 o - �- 0 A0 , a Y (ic34� � +�3 £'d LL6b-LLb-90S SeSiidielu3 ep!Madeo ego:90'9L 6L 100 L abed )(ed dH bZU ME bZ 1a0 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� I;NAM a tRs r 0+ 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 u � 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. p I� U o C2� AA 3� � AB3� as AO 33 �N L ' ` 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