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1698 SANTUIT-NEWTOWN ROAD - Health
x[A024-039 698 Santuit-Newtori'� ��Cotuit) -u I I I' I'� LOCATION � �.� AGEER'IIT NO. VILLAGE A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE COMPLIANCE ISSUED r 1 3 L 0Qy C A[]7{Ty 1 O NJfp`" SEWAGE PERMIT N 0. VILLAGE. k . fNST LLER'S AME i ADDRESS A'Z, / � OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED G ,�yy Ify � -v '.fir•. I i4c Y e � y J't ti ' TOWN OF BARNSTABLE r 1 LACA N t) Newtown Road _: • SEWAGE # VIiLAGE Cotuit ASSESSOR'S MAP & LOT INSPECTED BY: IJfJJRkDdXRMVAME&PHONENOJ P.Macomber&Son, Inc 775-3338 SEPTIC TANK CAPACITY none LEACHING FACILITY: (type) 1LKHM'Pit (size)J000 gallon LPG-/ NO. OF BEDROOMS 2VzXUQR OWNER Estate of David Hall PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fee of eac ng fac ty) Feet Furnished by I I cm �l /h L �.. r... ra ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ................................OF...........................------.......------------------...............------........... Appliration for Diipos al Works Tontrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ......1.: .. _ _ .... -•......-•-------•••---•--••-•-•-•._....... -•••--.••...............••.--...........•- oc Address or Lot No. ... .._ ..... .. ......................................... _..___....... ..- Addre ��' a ............. --.- Installer Address d Type of Building Size Lot._7�/4!.6_®.Sq. feet Dwelling�o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 'k Other—T e 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................ 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........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit__-_____----__--___. Depth to ground water........................ a ................'' 4, O Description of Soil---- r --_� - - - - - -.......... x W ••••------------------------•-------------------------••-•-•....----••..........•••••••••-••--------------- r U Nature of Repa s or Alte ations AnswgrA hen applicable__ .C:____.4_____ _____________<% ......__. _._..._..._....___........... _-----•-----•-•---------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d by the board of h Ith. Sig................................... ed - � j --------- Date � LCo -"APPlication Approved BY - ..._. ..... ......---•--•----•---•--•---•-. ........................................Date Application Disapproved for the following reasons:.............................................................................................................. -----------------•------•-----•-------••-••--•-•••--•---•------------•-.....-•----------•-•--•••----------.._.._....---•-•••-•-••-----•--•-•-•-...----•--•----••••-------------•-••--•.._...-•--------- Date Permit No......... q -3 ..•.... .....-•••--------------•----.. Issued..-® L�......-----�-----•-------•---- Date No..............CY213 .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF...............---.................. ....... Appliration for Disposal Works Tonotrurtion Frrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: e�..... ................................................................................................. ------------ ...........Lm 01 ....Address or Lot.No. .. .... - -.......................................... ..........---- r re Ad�d --------------------- . .. ............ ...... .... . ............ 4 Installer Address 0 6q.Type of Building. Size Lot_��Oio.......... ..S feet DwellingONo. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons___.___._______________.____ Showers Cafeteria Otherfixtures .......................................................................................................................................0.....0.0...... 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. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutesperinch Depth of Test Pit__.__.___________._. Depth to ground water__-____________________. 444 Test Pit No. 2................minutes per inch Depth of Test Pit._____._.._________. Depth to ground water........................ ---------------------------------- ---------------------------------------0--------------0----------- -------- 0 Description of Soil ------'•z*'fu ..................................................................I..............0........ U .......................................0...................................................................................................................................................0............ ................................................................................................................. --- --- ......... . .. ...... .......... ............ U Nature of Re-pairs 07 Altqatiorissu AnswerAvhen apDlicable'-40a.. ..................I ............ ...............................................................................................0.............. ---------- 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?o h ltl. _/ Signed. ------- ...................... ...............6'... j *- Date Application Approved By......... ...................................... .. .............. .. .......................... ..................... A VV Date Application Disapproved for the following reasons:........................................................................................................... ...............................................0.................... .............................0..............................I..........................................................------- S Date Permit No... ..... .......... .. ......................... Issued.) ......S,1 ..4V ...... ..... .- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.................I............................ (Infifiratr of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by--------------------_-oo------------------------ --------------------------0----------------------------------------------------------------- ------0------0----------- :;, —_ , Installer at....0...........................1_67-------0.......... ........ -----------------------------------------*-------------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_________________________________________ dated-_._____.___-_____._-_____.__._______.______.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------- ........0....................... Inspector....0.4--_4............................................ .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH —9 7 ...........................................OF............-- . ..........................................OF..................................................................................... No......................... FEE ...................... Disposal Works ToUlnotrudion ";Vrrutit Permission is hereby granted.............. ....................................................................... to Construct or-Re air an Individual aa�a e Disposal System atNo................... ............7;;. /....... ........................................................ Street as shown on the application for Disposal Works Construction Permit No!iH._!?_�... Dated__. ....... .............. ........................................................................................ Board of Health DATE.................................................. .............. FORM 1255 A. M. SULKIN, INC., BOSTON .. _ _A No....8.5 ....... Fim$..... THE COMMON H OF MASSACHUSETTS BOAR® OF HEALTH Town. O F............Barnst.. abl..e ..................................................... Appliration for Bispnaal Works Tonstrnrtion rrmff Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .....169.$...Uewrt Lwn... oad-,...0 atu it.,_YA....026J.j---------- --------------------•-•---•---•---•----------•---•---•------------...........--------............. Location-Address or Lot No. .._.Alam-•B1amchette.......................................................... 1698__Dtelatolan..RDar3,._Cmtl�t,--MA___-Q435........... Owner Address ....A.Ali 3..Ce.aaPQol-.Sexv.Iaa,..ln............................. 12$.Bi shops..T�sra cQ, Q?-6Ql...-. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..2............................ .....Expansion Attic ( ) Garbage Grinder ( )U Other—T e of Building No. of persons......Z................... Showers — Cafeteria P4 1 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........................ _...__•----------------------------••-----..._•--••------•--•-•-•----------••-_.--------------------•---------------------------------- ------------ -......... 4 0 Description of Soil........Sand------------------------------------•----------•-----•-----•--------................................................................................ x W VNature of Repairs or Alterations—Answer when a plicable...installation cf a 1, 000 gal. septic tank, d-box and a 1 000 gi stone packed each pit. -- -----------------------------------------------------••-•-..------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board of health. —� 1/04-/85 Signed---••----• .............---•••-•-•--......•--•-••--••-•----•----••......•--•--•... Application Approved BY �1 .. .. -.- 1 04 Date Application Disapproved for th following reasons-----------------------•------------------------------...----------........................................... -----•-•-••-•-••-•-••--•----•--••----•--...•••--••-•--•••••••----•--••--•---•---•-••---......•••---•.....--••••......•-•-•••••-•-••••--••-••-•--•-•••--•-•--•---•----•--••----------•••-•-•-•-•---•----- Date Permit No....$..-.. . 5 ---------•----._.. Issued........ -Q4/8-�r---------------------------•--- loon THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................._..Toxn..---......OF...........Barnstable..-----------....-•------.....-••-••--•-------------- :_. ApplirFa#ion for Disposal Works Tonstru rtion "permit Application is hereby made for a Permit to Construct ( ) or Repair ) an'Individual Sewage Disposal System at: ...� ,gg.I�1 -•tea-, cor � b3 ••---•-•--- -•••--•-••......•----••---------------••-•--._...... ...._.... .....- .........._. Location-Address or Lot No. A3a Bla at t e........---•-•------...--=•-•--•-•---•---••--•--•--•-•----- 1698-•-Newton--Road,...C ot� �, �'�.....c)26M—---•-----_-- Owner Address A..&..B•-fasssgo©1•-Sersr�oe,.._Inc•.------•------•-•-----__----_ 128-_Bis-hops--T-exrare, Rysa isT.. � 026Qi... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms2.........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons___.2..................... Showers ( ) — Cafeteria ( ) dOther 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. I_-__.__.•....._.minutes per inch Depth of Test Pit____________________ Depth to ground water---------------------.-. Gt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ___________________•••-------_,______.________________-___.........____......_________•-•-_......_........................................................... DDescription of Soil.......50,.Ud....................................................................................................................................................... W V .___________________________________________________________________________________________________________________•••--•-•-------____.---•_•--- W UNature of Repairs or Alterations—Answer when applicable. nstallation_-of--a_ 1,000 dal. Septic tank, d-box and a-1.000__ ., st aria packed leach pit. - -___-_-•-----------------------------•---___________.._.._..•••-___. 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 b• n i sued by the board of health. •••____._-••_____________________ 1 Signed••••z��-�- 1/04/85 1 Application Approved By.... ................................ --•----1/ /�?e------•••••--• Application Disapproved for a following reasons:..........- -•-----••-•••___________________________•--__•_____.•---•__________.--•._ Date•••••--------- _ --- ........-•-••-••••••••--••---•--•--•-•--••••-•--••-•••••-•-•-•-••••-.....-••--••••.................••::- •••-••---••__--•______________•-•---•---_-... --•--••••••___ Date Permit No._$ry..�. .. IssueX - +1•04g5-............................... i1 Date !I THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH `ti' Tq .....0F..Barnstable Trriif itab of TontpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X) by.A..&..B.__C.esepaol-•Ser,v3,ce-,--•Iac.•r--128--BJslappa._Tarracs-,...H3a nn-is,..I.....A2601....._...-•---••-•----•----•-- Installer at---ifiga.Newt-own..B ca,.._C.Otnit_,...11T1.... 2l•35------Ala n-._Rlancbetts...................................................................... 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.--•_85_-............................. dated__1/04/85-_-.-_---------__-_-______-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... :f S._ ..............•••-••-•--•-....-•-•-•-•--• Inspector...•-----.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 8 Town Barnstable � 15.00 .........................................0 F................................-.................................................... No........ _____..... FEE........................ Disposal Works C�agnotra ion rrrmit A_ & Fs Cesspol Service, Inc. Permission is hereby granted._:_:: • ----••_-....... .-.....••------. ------- gepa� (� ) a.,t� p ��y tin to Co}IsXrct_( t)OWI3 R6afl� tiOtUlt,ndjYidu� SR�jages2R1osL�laYiCriette atN •____-- ___________________________________________ !"A O7 Street — � as shown on the application for Disposal Works Construct n Permit No 85— 1/04/85 Dated......... oar ealt J,., ----------•-------------•-------------- -FORM 1255 A. M. SULKIN, INC., BOSTON s ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: 1698 Santuit Newton Road Jrl Cotuit,MA. 02635 Owner's Name: Kaplan, 5h e44.Z f M Owner's Address: Same Date of Inspection: 05/26/2006 Name of Inspector: (please print) Brad J White Company Name: Windriver Enviromental Mailing Address: 107 N. Main Street Carver,MA 02330 . `: f� Telephone Number: (508)-866-2576 1 N) V- 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 rriy training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: f Date: 5/26/2006 The system inspector shall submit a copy f is inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this in ection. 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. 'I Notes and Comments 3 I System Passes. ****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. +•fe� ,'; Title 5 Inspection Form 6/15/2000 page I Page 2 of I 1 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System passes.Recommend regular service. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. 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. ND explain: 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 in if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced - ND explain: 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: Titles C Tnen f;— V—All",/IMA 2 . Page 3 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone l 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 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. 1 3. Other: Titles S Incr�artinn Fnrm�n�i�nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1698 Santuit Newton Road ' Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supplyror tributary to a surface water supply. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.1 _NO_(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) t yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone It 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. Tit1. Pn (./1 5/1M11 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Titles A/1 ;/700n 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330gpd Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):Yes Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): 143.27gpd Sump pump(yes or no):NO Last date of occupancy: Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after Inspection Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 1,000gallons--How was quantity pumped determined?Sight tube on truck Reason for pumping:Check for groundwater infiltration TYPE OF SYSTEM _ _Septic tank,distribution box, soil absorption system _X_Single cesspool _X_Overflow cesspool Privy No Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Cesspool appears to be original and leaching pit appears to be in the early 80's Were sewage odors detected when arriving at the site(yes or no): NO Titles G Tncnartinn Pn All G/7Ml1 6 . J Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 BUILDING SEWER(locate on site plan) Depth below grade: 3211 Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line:N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer is in good conditon. SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 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: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Titles G Tncf;t Rnrm 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Till. G 8` Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 Santuit Newton Road Cotuit,MA.02635 Owner: Kaplan Date of Inspection: 05/26/2006 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not.located explain why: Type —X leaching pits,number:_ 1 @ 6' x 6' pit is bone dry with no evidence of high stain leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Soil is dry.No evidence of hydraulic failure.Vegetation is normal.No ponding on the surface. CESSPOOLS:_X_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Standard Depth—top of liquid to inlet invert: I I" Depth of solids layer:4" Depth of scum layer:—2" Dimensions of cesspool:_6' x 6' Materials of construction:_Cynderblock Indication of groundwater inflow(yes or no):_NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):_Soil is normal.No signs of failure the cesspool is functioning as there is 3"from water to outlet line. PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): T;t1. Pn Ail;/Innn 9 € � w Page 10 of 11 �ti` ' . • ., ti�'�1 ° OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a .. PART C SYSTEM INFORMATION(continued) .r 4ir s f x � Property Address: 1698 Santuit Newton Road Cotuit,MA. 02635 4 4� .f Owner: Kaplan }` t Date of Inspection: 05/26/2006 u SKETCH OF SEWAGE DISPOSAL SYSTEM ..,,, 5a ' Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or r'. benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i i ; l r� v �a't+ is T.: ..R BA $b - 2 y , ,�, .. ,Ei L }' { t< T41P C� Tncnantinn Rnrm.(./15/7Ml1 10 if M t Page I 1 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 Santuit Newton Road Cotuit,MA. 02635 Owner: Kaplan Date of Inspection: 05/26/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to groundwater 14' + feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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:No indication of groundwater at 14'. There is a slope off in the side of the property no indication of groundwater @ 18' +. FTitle V inspection is often misunderstood to suggest that we are conducting amplete inspection of your system. A Title V inspection is limited to determining if, 1 at the time of the inspection,the existing septic system is functioning. The State of E Massachusetts has outlined specific tests that are to be performed,which will be completed during your Title V inspection. However, a Title V inspection,and the' ainspection that Wind River Environmental is performing hereunder,does not evaluate f if the system was installed correctly,has been engineered in accordance with state and local regulations, or whether the system will continue to function in the future. It also does not evaluate whether the system would meet the past,current,or future Board or Health or State DEP regulations. A system can pass Title V but still not meet state o -Iocal requirements or be suitable for continued use. If the customer would like a complete inspection of their system,including an evaluation as to the design and suitability of your system,Wind River Environmental can provide a quote as to the cost of such services. As well,Wind River Environmental strongly recommends persons interested in buying a home to have a full and complete system evaluation il before purchasing a new home. A new home buyer should not rely on a' itle.V P ill function in the future,and instead should inspection in determining if the system w commission a complete system inspection. f Titles G Incnantinn T7 r All 1;i11)nn l 1 WIND RIVER ENVIRONMENTAL,LLC 34388 , DATE INVOICE NO COUNT NET AMOUNT 06/14/06 KAPLAN 1698 Santuit Newton Rd 25 . 00 . 0.0 25 . 00 COMMENTle CHECK: 034388 06./16/06 Town of Barnstable CHK TOTAL: 25 . 00 y DATE:_1 Of 11 /00___ PROPERTY ADDRESS (� 1698 Newtown Road Cotuit, Ma. 02635 On the above date, I Inspected the septic system at the above address. This system consists of the following; 1 . 1 -5X6 cesspool 2. 11 000 gallon leaching pit Sawed on my Inspectlon, I certify the following conditlona: 3. This is not a title five septic system. . 4. This is a sewage system. 5. The sewage system is in proper working order at the present time. f SIGNATURE;. 4 — �G� Na me :_,L,_P �ApS.Qmttr-_,L�______ Company: Joa•ph_P � Hacomb.r�b Son , Inc . Address;_ Box-66- Centerville Nay 02632-0066 Phone:___ ------- THIS CERTIFICATION ODES NOT CONSTITUTE A OVARANTY OR WARRANTY 12!9W JOSEPH P. MACOMBER & SON, INC. Tjnks•C�s�poolI'LI"hfloIds Pumped L Instilled Town sower Conneotlons P,o. Sox 66 75•3338eY77, MA 02632-0066 �_ �'y 7 COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (817) 292•6600 TRUDY CORE Secretary ARGEO PAULCELLUCCI DAVM B. STRUHS Governor Cotttmiuione r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIACAnON Prop-Ty Aga; 1 698 Newtown Road Name of 0 Estate of-David Hall Cotuit Address of Oww: c 11 Da,of��:1 1 1 /nrove Street Narrw of Mtspoctor: (PQ"/" )9oseph P. Macomber 'Jr.� Worceggl6e� �I 0 01 605 I srn a DEP approved sysrtarrt trupector pursu+^t to Section 16.540 of Th3. ti(31 Cltt'i 1 Off) C,orT,par,t,Nam,@: Joseph P. Macomber & Son Inc. M.&ngA6.,a,; x , en�Servi e , Ma . 02632-0066 Tarephorw CExTLg4CA ON STATEMENT i cardry 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 dme of kupectlon. The Inspection was performed based on my tralrting and experience In the proper}unction and ma.nunance of on-site s wage disposal systems. The system: asaae Conditionally Psssas _ Needs Further EvsI stlon By the Local Approving Authority _ Fail •� , Data: l�D0. Inspector's siquturr. _ The System Inspect hall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wttNn thirty (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 mall submit the report to the appropriate regional office of the Department cKinvtronmentat Protection. The original should'be sent tovw system owner and copies sent to the buyer. If applicable, and the approving authority. NOTES ANO COMMENTS P.eetorll revised 9/2/98 �� rrinta0 on R.cyclad rapt, ,: ., SuiSURfAC9 SEWAGE DUPOSAL SYSTEM IN3PECTtON FOR>kl_ PART A CE3iT ACATION (oorftld u i rfop«rty Ada,.,,; 1 698 Newtown Road, Cotuit �TMr Estate of David Hall Dww of ltupocdon. 1 0/1 1 /0 0 eiSpeCr.oN susAwAnYr._ Ch«k A4 B, C, a Dt A. YSTt3d►ASSES:— . I havt' not found any tnformadon wNch lndlcstes that any of the f&1Iurs oonddons described 4t 310 CMR 14.303 •SUL Any rat crttsr(a not svaJuated are Indlutsd below, S. SYSTDA CONDMONAUY PASSES: One or mote system somponenu s.s desortbod In the 'Cortddortal/awe'section Hood to be roplaeod ar rop.alred. TAd oysum, v compisdon or the replaeemont a repair, as approved by the Hoard of Health, wW paaa, trtdicate yes, no, or not d•t•rmined(Y, N. or NO). Doscr(be bawls of detarminadon In all Wtanoos. If 'not dotsrminad', expraL+ why rat. The s•pdc tank sa metal, urJess the owner a oporow has Isrovldod the system 4upooto+whh o sopy of a Grvnute CompI&nce (attached)Indasdng that the tank waw kutallod within twenty(201 You#prior to the lots of th4 vwp.cvc the septic tank, whetter or not metal. Is stocked, otmetsually unwound, shows eubotandal Inftivadon or erftrVsdort. of f0we Is Imminent. The system will pass Inwpoodon If the oxJsdnp espds tank Is fspleood wlth a sornplytnp Fepd< L— approved by the Dowd of Health. �,06 Sewage backup or breekout or Ngh otade water level observed In the dlotrlbudon box la due w broken a obruvcud v or dvo to a broken, sstded or uneven dlatrlbutlon box. The system wW pass Irtapeedon If(wfdt approval of Vw soars c Hea)th)- broken pipe(+) are replaced obswcdon Is fomovod �w cU#vtbudon box le levelled W replaced /✓V The synsm fegt.*sd pumplr1t7'*n0ro ttwt'tourtmee*"ardus to broXMw obwo Mod pipe(sI. 7?►e vrwwm M'vyasr Inapotoon It(with approved of the Board of-Hsolth)l broken pipo(a) uo roplacid obswcdon is removed revised 9/2/98 nieierii r t SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM Sir PART A CERTIFICATION (corrdn ) f4operty Adbese: 1 698 Newtown Road, Cotuit Owrw: Estate of David Hall Dau of tnepectson. 1 0/1 1 /0 0 C, FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: A/b Condtfons sxlst which require further evaluadon by the Board of Health In order to detern—Jno If the System la t&Mng to protect the public health, safety and the environment. . 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETMMINES W ACCORDANCE WITH 310 CUR 16.=(1)(b)THAT THE SYSTEM I''''SMMMMNOT FUNCTIONING IN A MANNER W}iJCti W SAFETY LLI.PRQZECT THE PVSUC HEALT)iAND AMD TH8 90dBOkM6kL' /ILA Cesspool or privy is within 60 feet of surface water Cesspool or privy is wlthln 60 lest of a bordering vegetated wetland or a sell marsh, 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,U'ANY)DETFR104M THAT THE SYSTBA 13 fUNCTIONLNG IN A MANNER THAT PROTECTS THE PUBUC HEALT•ii AND SAFETY AND THE ENVIRONUZO: The system has a septic tank and loll absorption system(SA31 and the SAS Is wlthln 100 feet of a surface water supply or trlbvtary to a surface water supply. The system he* a septic tank and soil absorption system end the SAS Is wlWn a Zone I of a public water supply woll. The system he► a septic tank and soil eb►orption system and the SAS Is wlWn 60 feet of a privets water supply Wall. The system has a septic tank and soil absorption system and the SAS Is less then 100 feet but 60 feet or more trom a private wets( supply well, unless a wall water analysis for coliform bacteria and volatile organic compounds U%Wcatelk Mat tA. well Is free from pollution from that facility and the pree nce of smmonla nitrogen and nivste nivogen Is sWai to or talks than 5 ppm. Method used to determine distance (approximation not valld).- a) OTHER q/ The system consis 5 'X6 ' block cesspool.The cessia=1 ctULS as a se is cesspool. precast leaching pit.Which is an overflow for the main cesspool. revised 9/2/96 relic 3arlt SUBSURFACE SEWAGE DISPOSAL A YSTIEM INSPECTION FORM . PART CERT1RCATION (coardnuad) , p„pw y Ad&o&&: 1 698 Newtown Road, Cotuit Owner: Estate of David Hall 10/11 /00 p. SYSTDa FAILS: You must Indicate either 'Yes' or 'No' to each h the following: _ A I have determined that one or . The Board lof Health owing ishouldure nbedcontacted to dotermin ons axial as descbed(what will ben aural to �w V" t' determination Is Identified below Yes NO ootnpon•nt•doe[O on overloaded cr�clagg+d 841Sor•c949pod• n overloaded a dogged SAS o Backup 04 eowage Irno feclAty_wr•+Te�t Discharge or ponding of effluent to the surface of the ground or surface water$due to a '— cesspool. a Static liquid level In the distribution box above outiot Invert due to an overlosd•0 or clogged SAS or tees Liquid depth In cesspool Is less than fl' below Invert or available volume If loss than 112 day flow. Required pumping more th. 4 times In the lost year VM due to clogged or obsuuc ed plpol$). Number of times pumped• Any portion of the Soil Absorption Sy$,am, cesspool or privy Is below the high groundwater elevation. within 100 fast Of a surface water supply or tributary to a surface water supply. Any Donlon of s cesspool or privy Is Any portion of s cesspool or privy is•wlthln a Zone 1 of s public well. Any D n onion of a cesspool or privy la within 60 feet of a private water supply well. pty Any portion of a cesspool or privy is It$$than 100 feet but greeter than 60 feet from a private wawa au ate well wit! acceptable water quality analysis. If the well has been analyzed t.denluet•nluog•n.ach copy of wall water analya'a -coliform bacteria, volatile organio•compou mmO E. LARGE SYSTEM FAILS: You muat Indicate tither 'Yes' or 'No' to each of the following: The following criteria apply to large systems In addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system Is a signif ont weal health and safety and the environment because one or more of the following conditions exlIW yes �No _✓ the system Is within 400 feet of a surface drinking water $uDplY the eyatem•le witiSw 200 1#4t ol+M�utaayle wrf000 delr+kh4''�+�wf�y the system Is located In a nitrogon sensitive aroo(Interim Wellhead Protection Area+IWPA)or a mapped Zww It of r ._ water supply well) The owner or operator of any such system shall upgrade the system In accordance with 210 CMR 15.304(2). Plea+•conauft a'+ local oMce of the Department for further Inforgnstion. Pegg 4orit" revised 9/2/98 f SUBSURFACE SEWAGE DISPOSAL SYSTtDA INSPECTION FORA PART B CHECKLI3T P,op*tyAd&a": 1698 Newtown Road, Cotuit or+n.r: Estate of David. Hall Deu of U%aDoct 0n: 1 0/1 1 /0 0 Check If the following have been don@: You must Indicate either 'Yes' or 'No' as to each of the following: Yet No / Pumping Information was provided by the owner, occupant, or Board of Herllth. Norw of the aystsm<ornpoA&fAs haw:baut paw+p�d+toaacJaaat iwowwke e>itdtbe7ystases hubwowoala:+e. 0101W A rates during that period. Large volumes of water have not been Introduced Into the system recently a sa pan of uvs Inspection. As built plans have been obtained and examined. Note If they are not available with N/A. 4 _ The facility or dwelling was Inspected for signs of sewage beck-up. The system does not receive non•sarJtary or industrW waste flow. _ The eke was Inspected for signs of breakout. /f At/ All system componenU;r,aLGluding the Soil Absorptlon,$ystem, have been located on the site. /)evc- The septic tank manholes were uncovered, opened, and the Interior of the septic tank wee Inspected for condtlon of bet or tees, material of construction, dmenslons, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System On,the site has been determined based on: Existing Information. For example, Plan at B.O.H. e-1111 _ Determined In the Held (If any of the failure criteria related to Pan C Is at Issue, approximstlon of detanee If unaeeevtao 116.702(3)(b)) The facility owtw dlflar= lroauzwzw).Y{aJ4y:—ldad wI.Lh lnfnr—•tloaon��evnn.•rr,. r. r� SubSurface Disposal Systems. revised 9/2/98 Pageserll i 5 . t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. PART C SYSTEM WFORMATION PropwyAddraa: 1698 Newtown Road, Cotuit Owrw: Estate of David Hall Dou of hspecdon: 1 0/1 1 /0 0 FLOW CONDITIONS RES*UfT1AL: Dealgn flow:a�g•p.d./bedroo Number of bedrooms A000s SsLp Number of bedrooms(actual)l Total DESIGN , Number of current residents: Garbage grinder(yes or no): Laundry(separate system) ,1 or jP_, If yes, sep"suJrtspecdon.requlred /+�n_ (2_pa Laundry system Inspected y� i ,r no) 1 _ y( CAO40 G411*S6 Seasonal use (yes or no) J water meter roadings,If available (lost two year's usage NO): .2000=o ,CX <<, M•S '' 'v — - Sump Pump(yes or no): AJO ��.� // O D Lost data of occupency:Ak4G"� cpf.1MERCU►VWDUSTRU►L: � Type of establishment: Design now: ( Based on 16.2031 Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no)" Non•sanitery waste discharged to the Title 6 system: (yes or no)AL4 Water meter readings,If available: X� Lost date of occupancy: OTHER:(Describe) 101* Last date of occupancy: ' GENERAL INFORMATION PUMPING RECORDS and s�rce of I formation: J System pum ed as part of Ins act)on: (yes or no" If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/d(strlbutlon box/soll absorption system Single cesspool . Overflow etsapeel d2�7C�+.✓� �" .t/(J Privy ----� Shared system(yes or no) (11 yes, attach previous Inspection records,If any) I/A Technology,etc. Attach copy of up to date operstlon and maintenance contract , Tight Tank '4 Copy Q of DEP Approval Other A XlMATE E o all compo , date Instolledilf known)•and eouree ofJw(ormadon: -' � � Sewage odors detected when•orriving at the sits. (yes or no) revised 9/2/98 page 6ofII SUBSURFACE SEWAGE DISPOSAL'SYSTE164 INSPECTION FORM PART C SYSTEM INFORMATION(corrdr%nd) P.opwly Address: 1 698 Newtown Road, Cotuit - ournse: Estate of David Hall Dart,of Fnspecdw: 1 0/1 1 /0 0 BUILDING SEWER: (Local*on alto plan) - Depth below grads. ay Material of conatructJo : cgs r on f!40 V other(e�aln /,per d d a. - &";I - Di:tsnce hrp o ,9? ate water tuppl well or auction lineDimeter ��• Comments: (condition of Joints, venting, evidence of leakage,♦iC.) Joint S TANK: - hocate on she plan! Depth below grade:,&e Material of construction oEJ4c ncreta�,�metal,_d FlbergisaWIPolyethylene'&other(ezpialn) If tank Is instal, Ilst ape_ Js.a.pe.confwmed by Certificate of Compliance (Yes/No) Dimensions: AM Sludge depth: : Distance from top of sludge to bottom of outlet tee orbaffle:,Ql Scum thickness: AIA d Distance horn top of scum to top of outlet toe or baffle: 4 Distance hom bottom of scum to bottom of outl t tee or baffle: /¢ Mow dimensions were determined: Comments: (recommendation for pumping ondition-of inlet and outlet toss or-baffles, depth of liquid level In relation to outlet Invert. structuraf-integrity. evidence of leakage, etc.) tr a main cesspool 3 T e . GREASE TRAP: (locate on site plan) Depth below grade:-0/0' Material of construction:s{2iconcrstsNilmst&WA Fibs rglasa APolyethylene4&jother(e:plain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or batfis:Ad . Distance from bottom of scum to bottom of outlet tee or•beffte:A14 Date of last pumping: Comments: (recommendation for pumping condition of inlet end outlet toss or baffles, depth of liquid level In relation to outlet Invert, structural Integrity. evidence of leakage, etc.) Gr revised 9/2/98 hilt 7of11 SU93VOACZ SEWAGE D13POARs�C YST'EU Wsrf:1iT10N FOftfl SYJTDaA WFORMAT1,0141(oa1� Progw,Ty Adde": 1 698 Newtown Road, Cotuit . 0-.-rw: Estate of David Hall Dwa Vf "1 0/1 1 /0 0 n0NT OR HOLDWO TMKW,,�Le(T►nk rrwot be pumped prior to, or of time of, Inopecdon) I104e19 on site pion) Depth below prode:ZY Mote/W of conewcUon:,ldi concrete+&metiv.l�i�Flborpl�� /dY�wl�on�LLothorlozp)+Inl 40A1 Oosipn R000llonsldoy Alorm preAlorm levAlorm In orkinq order;Yes.4 Nod# Dote el provlovs pumpinol Commonu: IcondJdon el Ir1Jet tee, eondJtion of ►loan end Hoot ewitchee,otd.) 1111na Lanks a rez .,r+4- DLSTRISVT10N 1110X:&/Vf- 119coto on Ws plonl 0ep1h ol.liquid level obove ovdel Invon: � Commenu: (note 11 level end dlsulbvtion to egvoJ, ovldonoo 01 solids corryowr, evldo++ce of 1•okopo Into or out of►os, etc.) ion pVldp CMIABEAtAL" 110Ro1e on $eta pion) I Pumps In worklnp order:lye$ or No) 40 Alerms In worklnp ordol lye' or No1�0 Comments: (note condition 91 pump chombor, condition of pvmpe end SppurtonortM- etc.( PSI;sofIt revised 9/2/98 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART C SYSTEM INFORMATION(continued) PropwtyAd&*": 1698 Newtown Road, Cotuit owner: Estate of David Hall Data of r►specdw: 1 0/1 1 00 SOIL ABSORYTION SYSTEM(SAS):_ (locate on sit@ plan, if possible;excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: leaching pits, number:1 leeching chambers, number: leeching galleries, number: _10— leaching trenches, number, length:--Q leaching fields, number, di Ions:U overflow cesspool, number. Alternative system: J47 g Name of Technology: Comments: 1 ote condition of s d il, Igns of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy san to medium fine sand.No signs or pon ing Sol s are dry_VPQPtaTTQN TR MORMATit A .� CFSSPOO • (locate on site plan) Number and configuration: Depth-top of liquid to Intel)Fort: Depth of solids Isyer: a '/ Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) o signs ot water in Fusion Comments: (note condition of soil, signs of.hydraulic failure, level of ponding,condition of,vegetation, etc.) as a ove. PRfvY,rre, (locate on site plan) Maud als of consu cdon: /lf� Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) -Privy is not revised 9/2/98 Psat9of 11 3V&3UAFACI IIWAOI"POSAL IYAfTVA W3►EC110N Fo" VARY C '. SYSTUA WF*PJAAT10N(9-r& d) Ad& 1698 Newtown Road, Cotuit Or.W: Estate of David Hall 0.0 Wt`"Ppq'6—` 1 0/1 1 /0 0 SKETCH Of SEWAGE OLSPOSAL SYSTEM: Incjude der to et least two permanent reference Iandmuks or benchmarks locate IJI well► wlddn too' (locals whets publlo water supply comes Into house) 0(s NcuJ-(ova � � V New. . 'QCI YSr 1'�°�VQJ.A d. hit to of it revised 9/2/98 , SU93URFACE SEWAGE WP9M SY1TE7d WS/ECTION FORkil PART C SYSTOA 1}lFOR"nON (continued) I►�.rty Abdra+s: 1 698 Newtown Road, Cotuit owrwr: Estate of David Hall D•u of lewecdon: 1 0/1 1 /0 0 NRC$ Roport name SoU Type_ TyplcN depth to groundwater VsOS Dote webslte Allied Observstlon Wells checked Orovndweler depth: Shallow Moderate Deep _ $IT( EXAM Slope Surface water Chock Cellar 3hsJlow wells Estimstsd Depth to Orovndweler&Feet Piesso Indicate aU the methods vied to dotsrrrJne High Groundwater Vevotlon: 0 taln•4 hem Design/lens on record s d $Its (Abvtdn ro • bsorvstlon hole, basomeot sump etc.) Ostarmined from local condltlons Chocked with local {oard of health Chocked FEMA Maps �h cked pumping records Checked local escsvaton, Instollors Used USO3 Dots Doscribe how you established the High Groundwater Elovstlon, (HCt:1 be completed) Used; Water contours Map. Gahrety & Miller Model 1 2/1 6/94 revised 9/2./98 hill 1►•r11 f .'l..\T -111T^Tr\AIr A'I..rI/�T.11"IA./Rf nT�w�.�I••'Y.�.\.A AR��I AI'����w �-�"�\.-~�•.r� ) II'UWN OF BARNSTABLE 130ARD OF HEALTH -^^ . -• ,9Ul1SUItFACR 9EWA(;PI DISPOSAL SYSTEM IM�9P�CI'ION FORM - PART D •- CERTIFICATION � - I -TYPC OA, PAIFIT CI.[AILY- J PROPERTY INSPECTED STREET ADDRESS 1698 Newtown Road, Cotuit ASSESSORS HAP , DLOCK AND PARCEL i OWNER' s NAHE Estate of David Hall PART D - CERTIFICATION NAHE OF INSPECTOR Joseph P. Macomber Jr, COHPANY NAME Joseph P. Macomber &''`Son, Inc. COMPANY ADDRESS Box 66 ' Centerville MA. 02632-0066 straat Tovn or C ty state C r COMPANY TELEPHONC ( 508 775 3338 . , FAX CCR'rIFICATION STATEHCNT I certify that I . have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of �i.nspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one . r Syste_gi_PASSED k' ~ The Inspection ;+hich I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or, the environmc(It as defined in 310 CHR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form, System FAILED* The inspection which I have con acted has found that the system fails to protect the })ublic health and the environment- in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection form . Inspector 8ivn'ature--lz�d, Date ne' copy of this rtification must be provided to' the OWNER, the BUYER (where applicable ) and thm DOARD OY HEALTI(. yr I.. • If the Inspection FAILED, thb owner or oporator shall upgrade the system Within one ,year or the date of the inopection , unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 , partd .doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s DEPARTMENT OF ENVIRONMENTAL PROTECTION d 00 TITLE 5 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 w Owner's Name: MR SHELLEY KAPLAN p Owner's Address: 9 FAIRMONT AVE CAMBRIDG.E MA 02139 Date of Inspection: 6/12/01 ` Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 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: X Passes _ Conditionally Passes _ Needs Furt a Evaluation by the Local Approving Authority _ Fails - Inspector's Signature: �� Date: 6/12/01 The system inspector shall submi 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 «: t SYSTEM PASSES TITLE V RECOMEND RECOMMEND PUMPING EVERY ONE OR TWO YEARS TO MAINTAIN SYSTEMRECOMMEND REMOVING..BIG TREE REINSPECTION SHOWS NO INTRUSION BY THE TREE AT THIS TIME ****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 S tncnrrtinn I'nrrn r,%I snnnn Page 2 of 1 1 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria nocevaluated are indicated below. Comments: SYSTEM PASSES TITLE V RECOMEND RECOMMEND PUMPING EVERY ONE OR TWO YEARS TO MAINTAIN SYSTEMRECOMMEND REMOVING BIG TREE REINSPECTION SHOWS NO INTRUSION BY THE TREE AT THIS TIME 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. s Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a ' n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken.pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board'of Health): _broken pipe(s)are replaced _obstruction is rem oved ND explain: n/a Page 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 C. Further Evaluation is Required by the Board of Health: ' t z 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. I. 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS,is within 50 feet of a private water supply well. _ The system has a septic tank'and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a .y Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No - X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool - X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool - X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow - X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. - X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool Wprivy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be, attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each:of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - X the system is within 400 feet of a surface drinking water supply - X the system is within 200 feet of a tributary to a surface drinking water supply v. . - X 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. - ' w Page 5 of I I �!' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B a CHECKLIST p Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 J Owner: MR SHELLEY KAPLAN<'. n Date of Inspection: 6/12/01 p Check if the following have been done You must indicate"yes"or 'no as to each of the following:, a � a u Yes No X _ Pumping information was provided by the owner,occupant,or Board of,Health X Were any of the system componentfs pumped out in the previous two weeks`? ' X Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or:as part of this inspection ? <t4 Were as built plans of the system obtained and examined?(If they were not available note as N/A) w v e X _ Was the facility or dwelling jnspected for signs,of sewage back up X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? x a c n , The size and location of the Soil Absorption System(SAS)on the site has been;determined based on: Yes no " } X _ Existing information. For example;a plan at the Board of Health. X _ Determined.in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 1 - '� B v u r. Page 6 of 11 ;s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 f FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO , Seasonal use: (yes or no): NO l Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n%agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM s r. X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.-Attach a copy of the current operation and maintenance contract(to be obtained from — r system owner) _Tight tank Attach a copy of the'DEP approval - Other(describe): n/a Approximate age of all components,date installed(if known)and source of-information: 1915 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 BUILDING SEWER(locate on site plan) Depth below grade: n/a Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a ' Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 0" ' Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 5' X 5' BLOCK CESSPOOL" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a t.. Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 SANTUIT-NEWTON.ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a`; Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO " Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(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.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of l 1 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 r SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a y Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS NEVER MORE THEN HALF FULL-EMPTY AT TIME OF INSPECTION CESSPOOLS: (cesspool must be pumped as,part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a e4 Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a ' Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 1` 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 - Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1' Sae AA Ag 13 . � CA alp r DV chi ' (1 Page 11 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1698 SANTUIT-NEWTON ROAD COTUIT,MA 02635 Owner: MR SHELLEY KAPLAN Date of Inspection: 6/12/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: 11 NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET . t