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1682 SANTUIT-NEWTOWN ROAD - Health
1682 SANTUIT-NEWTOWN Imo, COTUIT -- -- - - A= 024 037 ' V--A� - i F 4 r 1 i r i. y LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS 0 U I L D E R OR OWNER DATE PERMIT ISSUED L-7 DAT E COMPLIANCE ISSUED�� 7,9 . � �� �<• �� m� Cs �__, .�_ , No........ .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LTH F.... . .................................................0 Applirdtilln for Uispuiial 19orkii Tomitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an In _ . ' pat System at: 1/1) Fisposal . ....................................................... .........:............. :j........................................................................................ . Location-Address or Lot No. ......... ......... ---------------------------------------- ------------------------------------- --------------------------------*--------- ---------- Owner Address .......... Installer Address PQ Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( Other—Type of Building ............................ No. of persons......_....................., Showers Cafeteria ( Otherfixtures ................................................................................. ...... ............................................................. 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. f t. Seepage Pit No--------------------- Diameter.__................. Depth below inlet.._......._......... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-----------------------------------_.._. Test Pit No. 1................minutes per inch Depth of Test Pit._______._.......... Depth to ground water......................... fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.____._....._...._.. Depth to ground water...................._... 9 ....................................................... .....................................................0......................................... 0 Description of Soil,.,4_ _a_t112......t::w... .................................................................................................. U�4 /......................................................................................................................... ............................................................................ W ------------------------------------------------------------------------------------------------------------------------------------ ........ ................ U Nature of Repairs or Alterations—Answer when applicable..._1t7"__ -------------------- .. ... .... . ................... ........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAI`;U, 5 of the State Sanitary Code— The undersigne7d further agrees not to place the system in operation until a Certificate of Compliance has,�en issued by the board of health. Signed��<J, �kele_r ------------------11------------------ ate ApplicationApproved By-------------------............................................................................. ...................................... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... I Date PermitNo......................................................... Issued----- ................... No....--��• ... b/ �'.Fss.. ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 1-IE LTH a i < Applirat ion for Disposal Works Tonstrurtion ramit :Application is hereby made for a Permit to Construct ( ) or Repair ( ) an In al age. isposal System at ...... . .... .... . � ....... �''.�............. .-----? Location-Address or Lot No. ...... .......................................................... .............................. ...... ...................... ...... a Owner ----------•-••------.--••.-.•.•—Address- :...:.......... .....�?.......... ..................-•--.............................. ........... ..........------.......................... Installer Address QType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—t11 Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) Q' Other fixtures ..................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons.• Length................ Width................ Diameter................ Depth................ xDisposal 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 ( ) 0-4 a Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... ' Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a . - ------- .. O Description of Soilrf " . � ... - ---- --.... - ............ .. . V -•••-•---•- -•------ ------------------•-------•--------------•---------------•--..._....-----------------------------•.......•---•----•----- W ------------- ------------------------------------------------------------------------------ U Nature of Repairs or Alterations Answer when applicable __,t'B lli . "+____.....�'��r�-�'....!.... ---- 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—Th' undersigned further agrees not to place the system in operation until a Certificate of Compliance has pen issued hly the board of health. Signed. .CA... 7 .. �- � ate" Application Ap roved B i Date Application Disapproved for the following reasons:--- •----------------------••----------------•--------•-------------•---------•-------------...-•----••--•---- .....................•----------------------------------------....---•-----------•-----.........------.....................------•-----------•---•-------............................................... Date .t�tS9 Permit No......................................................... IssuecL... ....... .A� 14,; ' tr• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF� HEAL H� 1 a� �. ; Trrtifirate of Toniphaurr TH I TOjCERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by G.......... ', Installer .-. at. " ' has been installed in accordance with the provisions of "' 5 of The State Sanitary Cod as described in the application for Disposal Works Construction Permit No._ ___..._.�_S'.` ........... dated__. �""..........................•..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYST�EA,+1 Wl ,L F NOTION SATISFACTORY. DATF,�'.Pl Inspector -' � �e J5� S- : THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL PH f� No......................... FEE ...:. ....... .� Dispos Not Tonfrudion Vrrmit f.y � a. Permission is hereby granted............ ................. `� ---------• ------ •---------•------- to Constryc or Repair e n Individual Sear g DispIsal S tdn at No...-!.. .....-------- Street as shown on the application for Disposal Works Construction VeSit q DATE...... ............................................... Board of ealth FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - TOWN OF BARNSTABLE LOCATION /' �,� /i�y�/c��� �� SEWAGE VILLAGE �Iz ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ,�,�i�E�'h /� (size) NO. OF BEDROOMS__.2 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: A1 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No' 1 `i 01119 �a a/ ASSESSORS MAP NO: No. a ' :rf.L2�.� PARCEL NO: Fps.... G.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4w.Yl....... .... .......OF.... ------- ------------------------------------------. Appliratilau for Uigvniia1 Works C omtrurtiun "truth Application is hereby made for a Permit to Construct ( ) or Repair (.K) an Individual Sewage Disposal System at: ..l�8z (on PJ dlu,4 .. ..... . ...... ----- --------- ----- ------------- Location-Address or Lot N ............... ..----••---•-...--•-•-.-•••--•.... 1.0 2.. e .. ...... ................................... Ow er A dress a 4 nno� - AFC C�neo .... e . Installer Address V QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) 'Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ................................................ W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................ xDisposal 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.................... Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0+ --------•--------------------------•--------------------------------------------------------•-------............................... .-...... ......... .._.... 0 Description of Soil........................................................................................................................................................................ x U ---•------------•------------------------------------------------------------------------ --••--------------------------------------------------- ---------------------•-••------------------------------- W ---------------- ---------------------------- --------------------------------------------------------------------------- ---- ---------- ----- - ----- --- -- UNature of Repairs or Alterations—Answer when applicable_:ny-----____-f9cO Y r......... �..._. .�............. rr =..................................................................................................................................................... Ag ement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI% 5 of the State Sanitary Code—The undersigned further agr es of to place the system in operation until a Certificate of Compliance has been issued the board of h Signed '�,e!� ur S � Date Application Approved By............... . +- ... -•--......°�° Date Application Disapproved for the following reasons----------------------------••-------•-----------------=•----------------------................................. ....-----•-••----------------•---•----------•-----------------------------------------......-•--•----•----------------------------- ------- ----------- ------ ----------------............. Permit No....... .��.-..1 t�r�................... Issued-------------------------------------------Date- ate..•••-- Date JV 5 No_e.{ .:"/.a1�..0 Yuic ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. c ......... ........ .............. ipliratilan for Uhipoii al i9orkii Clan.6trurtiun ranfit Application is hereby made for a Permit to Construct ( ) or Repair (�) an ,Individual Sewage Disposal System at: n ✓�!E U..s...................U..................................... ...............--•------....._•-----......--•--•-------••••..............-------•...............•. _ Location-Address y_ / or Lot No. -1 __..._.. .. . ... ........................................ ............ ........_....-•--• •----•----•-••--•-....__....._....................... r Owner � r " Address •, ���.+ .%+tee � � 7� IJ�Yin6 � 1 � �. p.!" �)J4' — � /,li�rE+�. Installer Address QType of Building Size Lot-------------_------------Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI .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........................................ Test Pit 'No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' --------------------------------- -•--.••------ --........ -..... .... •........... ..... ••--------- .--.-----.-----..---------•-------- ------------ .------ .•--- 0 Description of Soil..................................................................................------------------------------------------.....-----------------•----......----.----- x V .........--•--------•--••--•----------------------•--•----•-----••-------•-•--•--...------•-•-•---------•--••-----••-----•-•-••---------------•-........_.._..---.---.. ----W --------------------------------------------•-•-----•----------•••-------------------------------------•.....-•---------------------------•----------------------••-----...----•----.............. x ; , ` •. Novo :... /o . �rF :... ....,.< �..----•-. U Nature of Repairs or Alterations—Answer when applicable........._:-_':'________________r____..__._..._._._...__._._.__...._._.....______..._ . 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 issued by the board of health. Signed...................................................................................... ................................ Date Application Approved By............... -? ..... '`-"""'" ............................... --•---....y-.. .................. Date Application Disapproved for the following reasons-------------------------------------•--------------------------------------------------------------------••--•-- ..............•----------...-----------------•--......-----.....-•---•---.....-----•----•--•----------------•••-•-------------•---------------------------------------------------------------------•-- Date PermitNo....... . -----------•--••--- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF..... • .. �r 0rr#ifirFatr of ToutpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by----------------- .,:. ---.0 e.......----------...---...---------•-----------------------...------.......I-.:-..---------------------------------------.-..----------- //��'' nstaller at................. � ------/V_,.---- ------•- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------- -1 ...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �S .... OF........................................... n FEE.---- ................. Raposal Nab &TRnni#rnrtilan Vrrmit Permission is hereby granted .............P --------------------------•---•--------------...........-----•-----•-•-•-•-••-----•--- to Construct ( ) or Repair Q>4 an Individual Sewage D�1sp9_s_a1_ Sy ter atNo.---------. .................................. ------------------•----------------------------------•--•-----•-••---.... Street as shown on the application for Disposal Works Construction Permit No. -'� � Dated.......................................... .................................• -•-� ------.... . .....------•..............---- Board of Health DATE.............. 4T ' ................ ....... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t Commonwealth of Massachusetts 9 a U fig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE ' Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Date 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. Important:When A. General Information filling out forms on the computer, I D o use onlylythethe tab 1. Inspector. key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. ` A.B. CANCO � Company Name . 350 RT 28 Company Address , WEST YARMOUTH MA 02673 Cltyfrown State, Zip Code 508-775-2820 S-13381 Telephone Number License Number rD _.s ZZ B. Certification ; I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. TM inspection was performed based on my training and experience in the proper function and maintenance"of onstte sewage disposal systems. I am a DEP approved system inspector pursuant to Section i4.340 f Title 5(310 CMR 15.000).The system: AD ❑ ❑ aauuntu►n��,�� Passes Conditionally Passes tlsoF MgSS ,• •.. ......9c, �� ❑ Needs Further Evaluation by the Local Approving Authority MARK ''•y0% =o. WHITE ,-= ' SO* No.S13381 :c i J•• C �;•� w OCTOBER 26 2011 TIF .�`� spe or's Signature Date 1 NlStt"``�����` The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has.a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ""This report onlysdescribes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 1 of 19 ,1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26,2011 page. Citylrown State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 16.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are, . indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no.or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑, Y ❑ N ❑ ND(Explain below):" t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 19 Commonwealth of Massachusetts UOv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information.is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑. ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 19 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityrrown State Zip Code Date of inspection C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 13 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 19 Commonwealth of Massachusetts Title 5 official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Citylrown State Zip Code Date of Inspection 3. Other: D) System Failure Criteria Applicable to All Systems: r You must Indicate"Yes"or"No"to each of the following for all inspections: Yes No 0 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El © Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 © Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El x❑ Liquid depth in cesspool is less than 6° below invert or available volume is less than %day flow B. Certification (cont.) Yes No F1 F Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ px 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. O ® Any portion of a cesspool or privy is within a Zone 1 of a public well. E3 © Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins•11/10 Me 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'" 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityfrown State Zip Code Date of Inspection ❑ FX1 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,.performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. . E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ p the system is within 400 feet of a surface drinking water supply ❑ M the system is within 200 feet of a tributary to a surface drinking water supply ❑ © the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No p. ❑ 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? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluritary Assessments �y 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityfrown state Zip Code Date of Inspection ❑ © Were as built plans of the system obtained and examined? (If they were not available note as N/A)N/A © ❑ 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? ❑ ❑ 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? Z ❑ 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. Z ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance,is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): UNK Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): UNK D. System Information Description: Number of current residents: UNK Does residence have a garbage grinder? O Yes El No t5ins-11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•�y 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Date of Inspection Is laundry on a separate sewage system?[if yes separate inspection required] © Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Details2010 26,000 GAL 2011 20,000 GAL © Yes ❑ Sump pump?_ No SEALast date of occupancy: Date AL Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No . Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 8 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT-NEWTOWN Property Address STEVE MAYNE Owner Owner's Name inforrnation is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Date of Inspection General Information Pumping Records: Source of information: TOWN-PUMPED 6/16/03 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Reason for pumping: TO INSPECT CESSPOOLS 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/Altemative 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): THERE ARE 2 CESSPOOLS ON THE PROPERTY WITH EACH HAVING AN OVERFLOW PIT D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 19 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forma Not for Voluntary Assessments ..'° 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Citylrown State Zip Code Date of Inspection Were sewage odors detected when arriving at the site? ❑ Yes © No Building Sewer(locate on site plan): Depth below grade: 27"TO ONE PIPE AND 20"TO ANOTHER Material of construction: feet t • ❑cast Iron ❑40 PVC ❑other(explain): 1 IS ORANGEBERG AND 1 IS PVC Distance from private water supply well or suction line. feet Comments(on condition of joints, venting, evidence of leakage, etc.): RAN A CAMERA IN ORANGEBERG LINE AND IT IS IN GOOD SHAPE Septic Tank(locate on site plan): Depth below grade: 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: Sludge depth: 3 INCHES D. System Information (cont.) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 19 Commonwealth of Massachusetts Title 5 official Inspection Form own Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT-NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26,2011 page. City/Town State Zip Code Date of Inspection Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete 0 metal '❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness t5ins•11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 19 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. CitylTown State Zip Code Date of Inspection 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 D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): t5ins-11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 19 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Date of Inspection *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information cont. (cont.) , Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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.): 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 19 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Date of Inspection r Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type: ❑ leaching pits number:2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: . ❑ leaching fields, number, dimensions: overflow cesspool number:2 2-- 1000 GAL ❑ innovative/altemative system Type/name of technology: THERE ARE 2—1000 GALLON OVERFLOW CESSPOOLS ON THE PROPERTY. 1 FOR EACH Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 19 � J& Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityfrown State Zip Code Date of Inspection Cesspools (cesspool must be pumped as,part of inspection)(locate on site plan): Number and configuration 2 ....500 GALLON CESSPOOLS Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction THEY ARE BOTH BLOCK& BRICK. Indication of groundwater inflow ❑ Yes N No D. System Information (cont.)` Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): EACH MAIN CESSPOOL HAS A COUPLE OF BLOCKS THAT HAVE MOVED OVER TIME. THEY ARE STILL INTACT BUT HAVE BEEN MOVED A LITTLE BIT. Privy(locate on site plan): Materials of construction: Dimensions t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityrrown State Zip Code Date of Inspection Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: F hand-sketch in the area below ❑ drawing attached separately 5 t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 19 r �e J. Commonwealth of Massachusetts Title'5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE owner Owner's Name information is . required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Data of Inspection P►- q 1Cl r33 - � r= 6PUL H io its f��uw� D. System Information (cunt.) Site Exam:, O Check Slope © Surface water t5lne•11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 19 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner owner's Flame information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. Cityfrown State Zip Code Date of Inspection © Check cellar Shallow wells Estimated depth to high ground water: 14+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: Checked with local.excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: AUGERED THRU DRY PIT. BOTTOM OF PIT IS 9 FEET BELOW GRADE. AUGER HOLE IS 5 FEET Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 19 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1682 SANTUIT NEWTOWN Property Address STEVE MAYNE Owner Owner's Name information is required for every COTUIT MA 02635 OCTOBER 26, 2011 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑O Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D(System Failure Criteria Applicable to All Systems)completed © System Information—Estimated depth to high groundwater O Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 19 Comn-onweatth of Massachusetts .iolu><Grad Executive office Of Ef11/1fOnllleflt0! AffairsD.E.P. Title V Septic Inspector olepartmeint of P.O. Box 2119 D Environmental Protection Teat icket,MAo2536 (508) 564-6813 C a 6�q V0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO(Ift VPART AE'V-f4CERTIFICATION ES'Ap-n`•r waif P-4 41682 Ne ewn Rd. Cotuit t 1997Property Address: Address of Owner:Date of Inspection:7123197 (If different) AgIggName of Inspector:JohnGracl Jackson NDEPT, kv Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs F rthe Evaluation B the Local Approving Authority performing at the time of the Inspection. a longevity does Y PP tY not Imply any warranty or guarantee of the longevlly of the Fails septic system and any of its components useful life. Inspector's Signature: Date: 7123197 The System Inspector shall lubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A) SYSTEM PASSES: , X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) _ The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is Imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. x (revised 11/15195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,(continued) Property Address: 1682 Newtown Rd.Cotult Owner: Jackson Date of Inspection:7123197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply._ The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. " The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1582 Newtown Rd.Cotult Owner: Jackson Date of Inspection:7123197 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6,00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 1582 Newtown Rd.Cotult Owner: Jackson Date of Inspection:7123197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. r (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION Property Address: 1682 Newtown Rd.Cotutt Owner: Jackson Date of Inspection:7123197 FLOW CONDITIONS RESIDENTIAL: Design flow: a gallons Number of bedrooms: 2 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla ` Design flow:U gallons/day 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: n1a Last date of occupancy: nla OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was pumped last year. + System pumped as part,of l' section: (yes or no)Yes If yes,volume pumped: 1 J�gallons Reason for pumping: Maintenance. TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) X Other(explain) 2 cesspools with 2 overflows APPROXIMATE AGE of all components,date installed(if known)and source information: Cesspools original with new overflows Installed In 1988 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1682 Newtown Rd.Cotutt Owner: Jackson Date of Inspection:7123197 ` SEPTIC TANK: (locate on site plan) Depth below grade: nla Material of construction:X concreate_metal_FRP_other(explain) Dimensions: n1a Sludge depth:nla Distance from top of sludge to bottom of outlet tee or baffler n1a Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:n1a Distance form bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation.to outlet invert,structural integrity, evidence of leakage,etc.) Na GREASE TRAP:_ (locate on site plan) ' Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n►a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n/a (revised 11115195) • ti f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1682 Newtown Rd.Cotult Owner: Jackson Date of Inspection:7123197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches, etc.) nla DISTRIBUTION BOX: (locate on site plan) , Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order-(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 , i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ; r Property Address: 1682 Newtown Rd.Cotult Owner: Jackson Date of Inspection:7123197 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Na Type: leaching pits,number: 21,000 gallon leach pits leaching chambers,number:n1a leaching galleries, number: n1a leaching trenches,number, length: nla leaching fields,number, dimensions:n1a overflow cesspool, number:nla Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) The overflows are structurally sound and functioning properly. CESSPOOLS:X (locate on site plan) Number and configuration: two Depth-top of liquid to inlet invert: A:5'B:6" Depth of solids layer: A:2"B:5" Depth of scum layer: A'0 13:1" - Dimensions of cesspool: Both 6'x6' Materials of construction: block Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Main cesspools and all components are structurally sound.Recommend pumping systems every two years for maintenance. PRIVY:_ (locate on site plan) Materials of construction: nla Dimensions: n1a Depth of solids: nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla (revised 11115195) 8 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 3 Property Address: 1682 Newtown Rd.Cotuit Owner: Jackson G Date of Inspection:7123197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' V i ltl� ISJV 6 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts-12+feet (revised 11115195) ' 9 MOR TGA G-E INSPHC TIO N PLAN APPLICANT: MAYNE TOWN: COTUIT MAP & PARCEL 24--36 217.08' PER DEED MAP & PARCEL - ______ CONC. HOT TUB 24-82 --I —=-#1682-- 0o C r10 -==__=__=_= La Q' O ED z � rn m m ; m � d Q m m 0 m MAP & PARCEL D O 24-37 0 MAP & PARCEL D 24-83 ~' 217.08 PER DEED MAP & PARCEL 24-38 ` d STEPHEN i J. "' P 't DQl C � AL FLOOD PANEL: 250001 0021 D FLOOD ZONE: "C" DATE MAP REVISED: 7/2/1992 1 HEREBY CERTIFY THAT THIS MORTGAGE INWEC710H PLAN HAS BEEN PREPARED FOR: DATE: 12/27/11 SCALE: 1" = 40' THE CAPE COD FIVE CENTS SAVINGS BANK DEED REF: 10973-150 PLAN REF: NO PLAN THE LOCATION OF THE DWELLING SHOWN DOES NOT FALL WITHIN A SPECIAL FLOOD HAZARD ZONE. PER TAPED INSPECTION THE DWELLING APPEARS TO CONFORM TO THE LOCAL ZONING BYLAWS IN EFFECT THE STRUCTURES SHOWN ON THIS MORTGAGE INSPECTION PLAN ARE LOCATED BY TAPE SURVEY AT THE TAME OF CONSTRUCTION WITH RESPECT TO HORIZONTAL DIMENSIONAL SEBACK REQUIREMENTS ONLY. NO INSTRUMENT SURVEY WAS PERFORMED AND LOCATIONS SHOWN ARE APPROXIMATE. OR 1S DUPT FROM VIOLATION ENFORCEMENT ACTION UNDER MA GENERAL LAWS CHAPTER 40A AN INSTRUMENT SURVEY IS NECESSARY FOR PRECISE DETERMINATION OF BUILDING LOCATIONS SECTION 7. REFERENCE DEED SUBJECT TO AND VNTH THE BENEFIT OF ALL RIGHTS, RIGHTS OF WAY. AND ENCROACHMENTS. IF ANY EXIST. EITHER WAY ACROSS PROPERTY LINES. YANKEE LAND EASEMENTS, RESERVATIONS AND RESTRICTIONS OF RECORD, IF ANY THERE SHALL BE, AND INSOFAR SURVEY COMPANY INC. SHALL NOT BE HELD LIABLE FOR DAMAGES RESULTING FROM ANY USE AS THE SAME ARE OF LEGAL FORCE AND EFFECT. OF THIS PLAN FOR PURPOSES OTHER THAN MORTGAGE INSPECTION. TELEPHONE: 508-428-0055 YANKEE LAND SURVEY COMPANY, INC FAX: 508-420-5553 119 ROUTE 149, Morstons Mills, MA 02648 yonkeesurvey@comcost.net I www.yankeesurvey.com 81772 JM