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Home My WebLink About0701 SANTUIT ROAD - Health 701 Santuit Road ` Cotuit E A = 006 024 - 1 SEWAGE INSPECTIONS °LOCATION701 Santuit Road DATE 4/25/03 i 4rMLAGECotuit.Mass. 02635 ASSESSOR'SMAP & LOT 006-024 -'INSPRCTORJoseph P.Macomber Jr. SEPTIC TANK CAPAcrrYNone. Split System Rear 6 'X8 cesspool & 1 -LP-1000 overflow. Eastside 1 -6 'X8' LEACHING FACILITY: (type) (size) galleps NO. OFBEDROOMS 3 as overflow. BUILDER OR OWNER Eleanor Fernanda OWNER MAILING ADDRESS Same y P ,� 1 � Z1oo \ 1 � 1 o� IN _ �.�OC-AT1.O_N : SEWQG�E_PERMIT 1`►0.. 1-N-S�ALVER �- -I- -D-E-R�-�S��-A-►vl-E- -A D D R E_SS 7� •t- C.._ ' .. �� .,�b , . .. ..._, _ . . t . (F3) - L 0 CATION .� SEWAGE PERMIT NO. VILLAGE r INSTA LLER'S N ME 1► ADDRESS - 1t OR OWNER It -ell _ DATE PERMIT ISSUE ` _ DATE COMPLIANCE ISSUED �Z ,--/ ., ' l �� _� o � ,� � �� . - . , v � No........ �......... .......... THE COMMONWEALTH OFMASSACHUSETTS BOARD OF HEALTH ................. ` .....OF...........� �. Appliration for Elisp.oiial 19orko Tonstrurtion Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , � � --...-- ............. --•••--•--- •-•....................•-• •----.........................._------•-- Location:Addr ss or Lot No. . ............................... ...........................................-...--•-------_-. ......... ......... wn Ad s ...... +fig='eA !�-�.e +Cl?�� a Installer Address d Type of Building Size Lot. �. ��. .Sq. feet aDwelling LNo. of Bedrooms._..........................................Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. - ------------------------------------- W Design Flow......_._. �j......................gallons per person per day. Total daily flow______._......UC!........•..........._._gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter-._.._-___.____- Depth................ x Disposal Trench—No..................... Width......_.-__-.___-_-_ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._, _____________ Diameter_.__._�a___-____._- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-•--•---_____________-. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---••---•-••--------------------------------------------------------- --•----------......------- O Description of Soil-- -•_ -------------•-•--------------•--------........-------------------------------•---------------•------------------------•---•----•-•--•- W •--•-------------•----••---•---------•-•-•-•---••---•-------•--------•••-•--•••--•------•----------•-----•--. ---- --------- UNature of Repair Alterations—Answer when applicable..._._,Q'0�.. ........:...... `._____.____ _._...._____..__......__..._..__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board�oh • tSigned.. :._.._ = ` -- •-•-•-••• ......•--•-•----•• - -l- Date Application Approved By-•--•... •--•AG-•-•=-••-••--•---•......--•--•••-••--•------•--••---•---••-•----•----•.•_... --_-_-_---- 15r --- Date Application Disapproved forte following reasons:-----••-----------------------------------------------------•--•-•--•-------•----------------•---•-••---....... •---•...................••---........-------•---------------•----•-......------------.....---•--•---------•-------•-•-•-•-•--•--•---•--•--•-•----•- ------- -----......... •..... .............. `Nate Permit I`To. `S ......---•----......-•------------•--- --•--. Issued �� --�-`--------•---•--••---- Date 0 THE COMMONWEALTH OFUMASSACHUSETTS BOARD C 1�.'{ ` '.....OF........... .e A IzJ f9!e c ........... ............................................... Appliration for Biapoiial �irkti (nomitrurtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at , r 'tilt/ }', r ( art f�� r .:................_.._,............- --..........•...._..................... .............. .........._.....---------•••............------..............------••.............................. location•Address or Lot No. .._. ............................... ............ ..- ............ } r Wr-a J...I.r .f t..✓..... .r.�.�.... ."..../..mot..'k..n e�e r(.j.'C..✓..'.... Ad�dCres��O ................................ ....... ................... L•'e _ { f6f Jd_. ..."ter. Installer Address Q Type of Building Size Lot.!.�L.CQ_C:.. n_Sq. feet Dwelling ZZNo. of Bedrooms.........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------- ----------------- _ �� ...............gallons per person per day. Total daily flow_....__—°`... 4......................_.gallons. W Design Flow...........:....�-..--_--_-• g P P P Y•. Y WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. ___--_-___-- Depth below inlet.__.._._._.__._..___ Total leaching area..._....._.._....sq. ft. Seepage Pit No...o�-.•............. Diameter-____�- Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ s ._ ODescription of Soil--=,. '(' -------------- -----------------•.... ........------------....---------------- ----•--•----•--•-•----•--------•------•-•-------..-•_--- x ------ ------- - -------------------- --- --- --- ---- U -----•-•---•---•--------------••----- ------------.......---------------._..................-----••--•--•••---------•---•--••------•-----•-•-•----•------•--•-•------------------•--•------------------- W ------------------------------------------------------•----------------------•-------------------------------------------------•----.... --------------------------•- UNature of Repairs or Alterations—Answer when applicable...... 0 ZZ .....1 "�1 r .......................... Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Cert_ficate of Compliance has been issued by the board of health. .. . Signed__e._..__. ✓� d ,t r .=11 -----�......---- _ Date ApplicationApproves BY................................................................................................. ............... Date^ �' Application Disapproved for the following reasons--------------------------------------------------------•----------------...:....----••-•-•-•----•--- -----•-------•------------•--•---•--------------------------------•----............-•---...---.......--------•-•---...-•--•---------------------•-----•-----••••---•-•---•••-•--•-•-•-----......_...... Date • PermitNo... ................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... .........................OF.......... ................................................. �rdifira f f��rtt� list re THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) f t l t t! ..........�:,111`//! /fit by ......... ......... -•--------...---------------------------------------........------..............................-----•----------•••------•---•••... Installer at----------- .!ri_/.:.......)1 k- -(1/,r.......... ............— li,! has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......�`��............................ dated......._..... ......... % ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH ..................... ......................OF........:.....::......r...................:_........................................ f C No........::............... FEE--__.••-=---........... %potia1 Marko Cnonstrurtion ramit Permission is hereby granted......�:�L:'-P.-I.,..Z..I f'(='// 'i:: �z ... -----•- to Construct ( ) or Repair ( ' ) an Individual Sewage Disposal System atNo........... :... r.L A. . r'` f.. ?-� .=-....---------....................---....................----•---------...------•----••-- Street o as shown on the application for Disposal Works Construction Permit No.............I...... Dated....... ........... ............................................... .. Hf h='===-• -. �� ., -----........... BOfiTd DATE................................................................................ °> FORM 1255 HOBBS & WARREN, INC.• PUBLISHERS Page 1 of 1 ► y s _ ex�s-h` Plour p lard NEW 3 C� 1 http://www.-town:bamstable.ma.us/sketches04/114_119.jpg 1%28/2004 pQ�THE COMMONWEALTH OF MASSACHUSETTS MAP :..�.,� BOAR® OF HEALTH PARCEL OF..................... LOT•---. - Appliratiou for Dispoii al Workii Toutitrurtivaa Famit , Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal f stem Sy 6 at f ............................... ..........& __----_ ------------------------------------------ �.. _ cs.QLocation-Addres or Lot No. �'�V '.-Vt r -----------•----•-- .................... ele - ress Installer Address U Type of Building Size Lot_ ....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria 0.' Other fixtures ................................................. --------•-------•------------- -----------------------•---------•----•••-------•-•--------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching.area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................-•--------------------------------------- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water____________________.._. f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' r ...... ........................:........................................................................................ ODescription of Soil-•---- _:.__ --•----•-••-•---•--••-------------------------------------------------------- x U -------------•---------•-•-------------......-•-----•------•---•-•••-•-•-------------•--•--•-------•.....--•----------•----•----------•------•-•••--••--••--------•---------••-•-----...---------•------ W ---------------------------------------------------------------------------------------•••--------•----------------------•-•--- ---- U Nature f Repair, Alterations—Answer when applicable.____=_/Df� ---------• = -------------------•-----------•-----............__..._._.._.....---------------------------------------------------------....-----..................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by he board 4// ealth. 1 'GL filC� .� igne- x ---- - .....• ��•-----•-----------•------•-- l j Date Application Approved By,, ---- - "_r .." Date Application Disapproved for a following reasons-................................................................................................................. f� --------------------------•-------------------_-__---------------------------- : ..._ Date PermitNo.............................:........................... Issued._..-----...-----------•-------_•__- Date No.... --- 2 Z2 FE.B..Z.�................... ... THE COMMONWEALTH OF MASSACHUSETTS: BOARD OF HEALTH .....................................OF............................._......... Appliration for Uhqpoiial Work.5 Tonstrurtion thrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 12ei.................... ........................ .................................................................................................. ocation-AddressJ4 , or Lot No. ... .. ............................ k...................... ..................... ....................... ... ....zc ....... --- --------------- 1-s ..... . .... ...................... . . ........... - ------------------------------------- ,&......... .......... Installer Address U Type of Building Size Lot__.... feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder `4 PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures .................. ...............................................................I............................................................. Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. 1:4 Septic Tank—Liquid*capacity............gallons Length................ Width.._.__.......... Diameter-_._____.._..... Depth___..__......... Disposal Trench—No. .................... Width.........._____._... Total Length.......__..._....... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter..___.._._...._..... Depth below inlet........_........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................... Test Pit No. I................minutes per inch Depth of Test Pit...........__....... Depth to ground water-..----_---__-__---_- - �-4 �14 Test Pit No. 2................minutes per inch Depth of Test Pit...___......_....... Depth to ground water.___._.............._... .............................................................................................................. 0 Description of Soil........ ............................................................................................................... U ......................................................................................................................................................................................................... ................................................................................................................ - --------------- ------- U Nature of Repair o Alterations—Answer when applicable...___7 A�. ......y.............................. o......... . ....... ........................11 ............................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T1T1L; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by)he bo d - health. igned ....... ....................... . ............................. -/_2 ............. ate Application Approved By..... ............................................................................... -2- ........................................ Application Disapproved f.o�rt e following reasons:.............................................................................................Date........ 41- /.2''- r.? ................................................................................................................................................................................................... Date PermitNo....................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF. ................................... V Tntifiratr of- Tompliana, THIr9 TQ�ER Y, That the IndividuA Sewage Disposal System constructed or Repaired by------. ------ ""......... .... ................................T................................................................................... at.... ...... ....... .. . . . .. Installer. . .... .........t.................................................................... has been instilled in accordance with the provisions of TITrE 5 of Th%State Sanitary Cod as -ibed in'the application for Disposal Works Construction Permit No............*3 ................ee?......... date,--................................................ CONSTRUE®THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C' ,ZS A GUARANTEE THAT THE SYSTEM WII.3/FUI�tTION SATISFACTORY. DATE....... .......................................... Inspector... ... .................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................OF..................................................................................... FEE......................... fit Permission is hereby granted-.--., . ...........................................................................7................................ to ConstrucL, 011) or Re_ it.,4an divia 'Sewage.Disposal System at No..--.._#.....A Z....... ..... ............ ............i...............................Street........................................... . .........as shown on the application for Disposal Works Construction Permit No..................... AV.tF.................................. .......................................... -- --------------------------------------------- alth DATE............._................................................................. 'FORM 1255 HOBBS & WARREN. INC., PUBLISHERS < . k DATE: Lz5Jo3 _-- PROPERTY ADDRESS: 701 Santuit Road ----------------------- -- Cotuit 0241 ---------------- od6 " *Mass 02635 On the above date, I inspected the septic system at the above address. This system consists of the following: RECEIVED 1 . 2-6 ' X8 ' block cesspools. 2 . 2-1000 gallon precast leaching pits. 4 2003 3 . This is a split system. Cesspool & pit in rear and a cesspool on right side of house. TOWN OFBARNSTABLE Based on my inspection, I certify the following conditions: HEALTH DEPT. 4 . This is not a title five septic system. 5 . This is a sewage system that has had leaching pits added as overflows. 6. The two sewage systems are in proper working order at the present time. 7 . Pumped cesspools at time of inspection.No signs of water intrusion. 8. Cesspools are presently structurally sound. � - SIGNATURE: Name:-J.P. Macomber Jr__ ` Company: JosePh_P_ Macomber_& Son, Inc . Address: Box 66 Centerville , Ma_-02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE%A GUARANTY OR WARRANTY r JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds j Pumped & Installed 1 Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:701 Santuit Road Cotuit Mass 02635 Owner's Named anor P rnandc Owner's Address: Box 2032 r ni-iii t Macs n2635 Date of Inspection: C 2 5/n 3 Name of Inspector: (please print) Joseph P. Macomber Jr. Company Name: Joseph P. Macomber & Son Inc k Mailing Address: Box 66 C'_entervillP Ma 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: _Zt/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: `—� ; The system inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 701 Santuit Road cotuit Mass Owner-E anor Fe_rnands Date of Inspection: X12 5/p 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S ste�Passes. NO 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 sewage systems are in proper working order aT THE PRP.RP.NT TTMF_ B.�lie) Conditionally Passes: ,ye) 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. �y�he 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 eNisting 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: 11�We—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 x obstruction is removed distribution box is leveled or replaced ND explain: ten 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: I Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 701 Santuit Road Cotuit Mass Owner: Elanore Fernands Date of Inspection: 2 5 0 3 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: A,V 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. /UD The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 40 The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. /VU The system has a septic tank and SAS and the SAS is less than 100. eej�feet or more from a private water supply well". Method used to determine distance t "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. T 3. Other: • This is a split sytem. Cesspool & pit in the rear. Cesspool & pit on the right side of house. Cesspools act as ' septic tanks Cesspools contain solids in pinc-e And allnwg the effluent to pass over to the two leaching pits. 3 Page 4 of 1 I OFFICIAL INSPECTION FORM —'NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:701 Santuit Road Cotuit Mass Owner:Eleanore Fernands Date of lnspection:,41' 25/03 D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no" to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool A1601, 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-!i day flow Required pumping more than 4 tirpes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped� � r?�1y `�/fi.✓r 7 _ 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 ater supply. ry portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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. [Tbis system passes if the well water analysis, performed at a DEP certified laboratory, for collform 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 )O (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 flow of 10,000 gpd to 15,000 gpd• ). You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes now r/ 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(]nterim Wellhead Protection Area— IWPA)or a mapped Zone 11 of a public water supply well F If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:701 Santuit •Road Cotuit Mass Owner: Eleanore Fernands Date of Inspection: 9j' 2 5 10-1 Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No� Pumping information was provided by the owner, occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks _ Has the system received normal flows in the previous two week period ? r/ Have large volumes of water been introduced to the system recently or as part of this inspection ZWere as built plans of the system obtained and examined?(If they were not available note as /A _ Was the facility or dwelling inspected for signs of sewage back up z _ Was the site inspected for signs of break out? Were all system components,eluding the SAS, located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of thhee 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: Yes no / _ �/Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CIAR'15.302(3)(b)] s ' 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_ M PART C SYSTEM INFORMATION Property Address: 701 SantLi t Road rottli t MARR Owner:Fl aanora Farnanr]g Date of Inspection: ."/2 5/0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):__2 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 0A1.) Number of current residents: # Does residence have a garbage grinder(yes or no):�a Is laundry on a separate sewage system'(yes or no):A)b [if yes separate inspection required) Laundry system inspected(yes or no): A5 Seasonal use: (yes or no): 4VD Water meter readings, if available(last 2 years usage(gpd)): 07-r��(,, � Sump pump(yes or no):A),* Ir Last date of occupancy: COMM ERCIAL/INDUSTRIAL Type of establishment: q)i¢ Design flow(based on 310 CMR 15.203): AM gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): .V/4 Non-sanitary waste discharged to the Title 5 system(yes or no); Water meter readings, if available: 2A Last date of occupancy/use: OTHER(describe): A4 GENERAL INFORMATION Pumping Records Source of information: Pumped at time of inspection. Was system pumped as part of the inspection(yes or no). If yes, volume pumped: Lbp allons--How was gu,anhty pump d determined? Reason for pumping: Sim ud�S �c'Jp.✓,� �yY.: T - TYPE OF SYSTEM /l� Septic tank,distribution box,soil absorption system p Single cesspool 5 X Overflow-."spoW td Privy ND Shared system(yes or no)(if yes,attach previous inspection records, if any) 470 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) !!O Tight tank W,,4 Attach a copy of the DEP approval NA Other(describe); , Approximate age of all components,date install (if known);and source of information: Were sewage odors detected when arriving at the site(yes or no): �✓D i 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: 701 santuit Road Cotuit Mass Owner:Eleanore Fernands Date of Inspectiont�f 2 5/0 3 BUILDING SEWER(locate on site plan) Rear=4" ' orangeberg pipe & fittings From house to cesspool Depth below grade: $i AP. m%' Side=Sch. 40 4" PVC pipe & Materials of construction:_✓/east iron 1/40 PVC�ther(explain): Distance from private water supply well or suction line: Ad�t a ' Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tight-No evidence of leakage The sy-stPm—a-_re vented through the roof vents. SEPTIC TANMAV4(locate on site plan) Depth below grade: 40 t t Material of construction:A/4concrete AftetalA/Afiberglass�/r¢Polyethylene itl!)other(explain) ,11A If tank is metal list age:_1!,4 is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: !4 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ 11too Distance from top of scum to top of outlet tee or baffle: 4� Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: "ta Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): Main cesspools should he piirnptmrJ jevery 2-3 y ars . GREASE TRAA:�.[. Locate on site plan) Depth below grade: 4/4 Material of construction:,0,4concrete,,t/N metal*M fiberglasWApolyethyleney.4 other (explain): xloA Dimensions: 1f201I Scum thickness: Distance from top of scum to top of outlet tee or baffle: afi9 Distance from bottom of scum to bottom of outlet tee or baffle: oefiQ Date of last pumping: 4W Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels• -as related to outlet invert, evidence of leakage,etc.): C;rpasp trap is note resent. 7 Page 8 of]] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACEW SEWAGE DISPOSAL S OSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 701 Santuit Road rotuit Mass Owner: Date of Inspection: s 25 03 TIGHT or HOLDING TANK ? (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: V0 Material of construction:4Aconcrete.VA metal A14 fiberglass V-4 Polyethylene.4)A other(explain): Dimensions: A Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): oW Alarm level:_� Alarm in working order(yes or no): 4JA Date of last pumping: AM Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION BOXL40,(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: t)4 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)s ribution box is not present PUMP CHAMBERiI Wrl (locate on site plan) Pumps in working order(yes or no): .f/A Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): piimp charnhc-r is not present 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 701 Santuit Road Cotuit,Mass, Owner: Eleanor Fernands Date of Inspection:C 2 r/0 3 SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) 2-6 ' X8 ' block cesspools & 2-1000 gallon precast leaching pits. If SAS not located explain why: T-Qgaced: See- Page 10 Type L�'-JD�Irs leaching pits, number: leaching chambers, number: O �leaching galleries,number: 0 UlJ leaching trenches,number, length: O o leaching fields,number,dimensions: 6 �JO overflow cesspool,number: Q_ n innovative/altemative system Type/name of technology. 81Vt1` 9 4A �d�� XA/ Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): i.namy sanr1 t-a fin oa sans.No signs of hydraulic failure n_r D nndi ncj qn; 1 �-' arp dry Veget'at-i on is normal Pumped main cesspools as part of inspection. No signs of water intrusion.The CjgS OOLSs &e presently structurally sound. (cesspool must be pumped as part of inspection)(locate on site plan) s--C Number and configuration: d� Depth—top of liquid to inlet invert: Jl Depth of solids layer: S;Id& Depth of scum layer: Az /Q11 Dimensions of cesspool$ dt } , Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Same as above. PRIVY,&,,(locate on site plan) Materials of construction: Dimensions: Depth of solids: AM Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present_ V - I 9 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: 701 Santuit Road Cntnit- ,MASS_ Owner. E aenor Fernands Date of Inspection:- %9 5./01 E 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 withi.n 100 feet. Locate where public.,Yater supply enters the building. ZT� D ( 5 �n fug -4 �o act �o+u t•1- �r -1 .iyr i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)' Property Address: 701 Santuit Road Cotuit,Mass. Owner:Eleanor Ferands Date of Inspection: _Ir 2 5/0 3 SITE EXAM r Slope Surface water Check cellar Shallow wells Estimated depth to ground water_'!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: TV A YES Observed site(abutting property/observation hole within 150 feet of SAS) NQ_Checked with local Board of Health-explain: NA yam_Checked with local excavators, installers-(attach documentation) YES__Accessed USGS database-explain:http: //town.barns table.ma.us. You must describe how you established the high ground water elevation: Used: Gahrety & Miller Mod 1 12/16/94 Ground water elevations above sea _I vel. Used: USGS: Observation wPl 1 data T,n,P 1 g_q2 Used: USGS- TPc-bnir•al Riil letin 92-000-1 P1atP 42 Annual ranneg of grnnnd . water LVPUi n Leaching l� ~ Pit ,eet, Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bonom r of the leaching pit and the adjusted groundwater table is feet. 11 rrnr-+.-nrl+�.'Pr'•rnrmr•ntnrnrr.rt a�rrrfttln7r+ts.rr�nr•�nnn ln♦TRZa Asltrrsn R't+ .. �• TOWN OF Barnstable BOARD OF HEALTH 3011SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CER'IIFiCATION •••T••t�T••••.•,—l.,R��Tr„1,1.1'n.'1►I T1TiR1fl11'tnT.�:7 P'IRT.Y 11RwP^TnR\nl�r r� I T/1n1TRIT1\TnTT7TT.• ••t I`T'T•1. �..A —TYPE OR PRINT CI.EARLY— PROPERTY INSPECTED STREET ADDRESS 701 Santuit Road Cotuit,Mass. ASSESSORS MAP, BLOCK AND PARCEL # 006-024 OWNER' s NAME Eleanor Fbrnands PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & Scfi • Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 street Town or city sc.t. COMPANY TELEPHONE (508 ) 775 - 3338 I1P FAX { 508 ) 790 _ 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at ®rlecommendations his address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was re ardi)I performed and any g u pgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Che orie : WSystem PASSED The inspection which I have conducted has not found any infon which indicates that the system fails to adequately protecto public health or the environment as defined in 310 CMR 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \con The inspection whichI have txcted has found that the• system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 - 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , i I ' XInspector Signature Date copy of this certification must be provided to the OWNERD ,re applicable ) and the OARD OF HEAL7111. the BUYER * If the inspection FAILED, the owner or"'operator shall u within one year of the date of the inspection, unless alloweddortrequiredm otherwise -as provided in 3.10 C�1R 16 . 305 . partd .doc