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HomeMy WebLinkAbout0225 SCHOOL STREET - Health 2 25 S(7-ilO L STREE`I' ORilt A'= 020 09b' No. C) h i Fee t J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for Disposal 6pstem Construction Per:ki i Application for a Permit to Construct( ) Repair(o�grade( ) Abandon( ) ❑Complete System l Components Location Address o Lot No. 7Z S" ,Sc1_o m f S� Owner's Name,Address,and Tel.No. o)w I- B f p �!-F Assessors Ma 1�1 t.�+► Map/Parcel Installer's Name,Address,and Tel.No t Designer's Name,Address,and Tel.No. O'la",n sw 5 e�� ��✓<, 7" Type of Building: A J Dwelling No.of Bedrooms ✓" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revisig Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4gw14,e`G 0,15 Date last inspected: be,— Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 2 Application Approved by Date _ Application Disapproved by Date for the following reasons Permit No. �_ �� Date Issued •ti No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes. PUBLIC HEALTH DIVISION -"TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Disposal 6pstem Construction Vertu Application for a Permit to Construct(, Repair Upgrade( ) Abandon( ) El Complete System Individual Components a � Location Address gr Lot No. 27 S_f 57Z,4 o o/ s'Y Owner's Name,Address,and Tel.No. X0jf B� Assessor's Map%Parcel Installer's Name,Addreess,and Tel No. Designer's Name,Address,and Tel.No. /I- a ILIX0. 90� /�.." v tZ s L. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) t gpd Design flow provided ' gpd r Plan Date Number of sheets Revision Date i Title i Size of Septic Tank Type of S.A.S. Description of Soil i t Nature of Repairs or Alterations(Answer when applicable) j"j�JG c`C )j�✓� f/ '— •�^ d 7� I r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. �..►— Signed,$ Date ' \ a / Application Approved by Date Application Disapproved by Date w for the following reasons Permit No. C — Z Date Issued THE COMMONWEALTH OF MASSACHUSETTS ((,^, BARNSTABLE,MASSACHUSETTS Certificate of Compliance rc I i VI`�x i Q THIS IS TO CERTIFY,that the On-site Se/wage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by pi(3wan at 2 S C l 5 -- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. pj — Wdated Installer Designer #bedrooms /l/ �Ll Approved design flow ,� gpd t The issuance o this pbrmf it shall not be construed as a guarantee that the system will ctio llas design,,A as �/ Inspector �1�� �� i p V ---------------- -/--- ------------------ '-------------— ---------- ----------.---— -----— --------- - - _ No. r) 1 2 Fee �3 THE COMMONWEALTH OF MASSACHUSETTS . PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstrm (Construction J9Ermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construct r)71P[ completed within three years of the date of this permit. Date Approved by ::k. AsBuilt Page 1 of 1 LOCATION > f SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED S . v V http://issgl2/intranet/propdata/prebuilt.aspx?mappar=020098&seq=1 6/27/2016 Town .of Barnstable- MAS& Regulatory Services Department '°j fa rub" Public Health Division 200 Main Street, Hyannis MA'02601 . Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 � Z Thomas A.McKean,CHO ib Feb 6, 2007 - G 2� Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground I - ❑ Pumping more than 4 times during the"last year not due to clogged or obstructed pipe ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation . ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution), TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool a 0 Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation ' of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid,level, <12"below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at.or above.the invert pipe (per Town Code §360-20 h) _ OTHER �04d Repair deadline: kO-e[„/' Q:\SEPTIC\DEADLINES TO REPAIR AILED SYSTEMS.doc Commonwealth of Massachusetts v�b�o98 , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st z Property Address rQ Robert and Margaret Orlando Owner Owner's Name �7 information is required for every Cotuit ✓ Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection Lo W 47 i 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 filling out forms A. General Information -6 on the computer, / ly use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector i key. DiBuono Sewer and Drain ,Q Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Cityrrown State Zip Code 508-364-9587 S103522 Telephone Number License Number 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. 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: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/27/16 Inspector' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 vs �yg� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments :;. 225 School st Property Address Ro bert and Margaret Orlando 9 _ Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 a e. Cityrrown State Zip Code Date of Inspection,. p g p =; B. Certification (cont.) 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 15.303 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . cG 22 ,M 5 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): System contains a 1,000 gl septic tank a concrete Dbox and a 1,000 gl leach pit. System is in good shape with only a foot of standing water in bottom of pit: Distribution box is rotted and in need of replacement. ❑ 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): 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 abordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. Cityrrown State Zip Code Date of Inspection 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. ❑ 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 day flow than 1/2t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 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 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo rm Not for Voluntary Assessment s "^M 225 School ool st SV•'' Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1,000 gl septic tank a concrete Dbox and a 1,000 gl leach pit. System is in good shape with only a foot of standing water in bottom of pit. Distribution box is rotted and in need of replacement. Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 189gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/industrial Flow Conditions% Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 31 Years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.5 Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System vents through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 GI 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form (m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Traplocate on site n( teIpa ). Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r — Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection 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.): Tees are in place and levels are normal. 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form �A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st M Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Rotted and decayed 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma ' 02635 6/24/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number.- El 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. Cityrrown State Zip Code Date of Inspection 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: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 School st Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft 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: Usgs maps indicate Ground water at app 18+ ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 16 of 17 6/27/2016 Assessing As-Built Cards a 3 LOCATION SEWAGE PERMIT NO. VILLAGE 7 L ,r/ INSTALLER'S NAME & ADDRESS I U I L D E R 01 OWNER S�/yam DATE PERMIT ISSUED 0(7_ PAT E COMPLIANCE ISSUED V r http://www.townofbarnstable.us/Assessi ng/H Mdispl ay.asp?mappar=020098&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 225 School st 7M Property Address Robert and Margaret Orlando Owner Owner's Name information is required for every Cotuit Ma 02635 6/24/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Parcel Detail Page 1 of 4 Elk �4 } I•A ^ i ` ` �.i/'Y:r�� i''S #fit .y, Logged In As: Parcel Detail Monday,June 27 2016 Parcel Lookua Parcellnfo Parcel ID 020-098 � � � Developer Lot�LOT 23 Location '225 SCHOOL STREET Pri Frontage 1104 Sec Road aCROCKERS NECK ROA! sec Frontage 200 Village jCotUlt ) Fire District FORTiff f Town sewer exists at this address NO I Road Index 11433 I Asbuilt Septic Scan: Interactive Map - 020098_1 ' i6 s Owner Info owner ORLANDO, MARGARETI Co Owner _ streets 225 SCHOOL STREET (street2 . . ..m _- city ICOTUIT __ ) state MA zip 02635 -... f Country Land Info ------ --- - _._.. ........_....._ ......_.__ _.. _ __..... Acres 0.66 I use :Single Fam MDL-01 zoning RF (Nghbd 0108 Topography 1,Below Street Road jPaved utilities(Public Water,Gas,Septic Location olf Course Construction Info Building 1 of 1 Year�1900 Roof,Gable/Hip E� Wood Shin le ! Built Struct wall g tl Living t. Roof AC r""•-""�"-"�� Fg ` I'- - Area 11924 cover,Asp�Is/Crop Type I,None 2 ` Style Conventional I"t Plastered Bed 3 Bedrooms ens ` r' Wall,. Rooms - Model Residential '"t Pine/Soft Wood Bam,'2 Full-0 Half i 26 Floor, Rooms d Total Grade, Type Aver _Hot Water ( Rooms Rooms 6 a 12 , Stones i2 StOr12S Heat Ga Found- Stories Ft9S "'°Kze - Fuel ation GrossArea + - Permit History Issue Date Purpose Permit# Amount Insp Date Comments 5/20/2009 Wood Deck 200902203 $1,000 6/30/2009 18X30 REPL WDK 12:00:00 AM 11/2/2001 New Roof 56925 $7,350 1/23/2002 STRP OLD 12:00:00 AM http://issgl2/intranet/Propdata/ParcelDetail.aspx?ID=926 6/27/2016 Commonwealth of Massachusetts/ Title 5 Offic al-Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orlando Owner Owner's Name information is required for evert',/Cotuit MA 02635 04/26/14' page. City/Town State Zip Code Date of Inspection i 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.formss fs WhenA. General Information fillingng out on the computer, use only the tab 1. Inspector: «.. key to move your cursor-do not Kevin Cochran use the return Name of Inspector key. �� Aardvark Environmental Inspections ITV Company Name P O Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 13356 Telephone Number License Number 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.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 Tide 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Fu r Evaluation by the Local Approving Authority ' 04/29/14 s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 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. t5irr.•3M3 Title 5 offi Form:S ubartaosSewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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. m - 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-W13 Tim 5 Offidal hspechm Forth:Subsudeoe Sewage Disposal System•Page 2 of 17 r ' 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owners Name information is required for every Cotuit MA ' 02635. 04/26/14 Cityfrown State Zip Code Date of Inspection page. P pe B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): 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 t5ins•3113 Tide 5 Official bspectim Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Owe Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is Cotuit MA 02635 04/26/14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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: 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. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 '/day flow t5ins•3113 Tice 5 OfficW hspectrw Form:SWMA&a Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every 02 Cotuit MA 635 04/26/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility'with a design flow of 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 lBoard 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. 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. t5ins.3f13 Title 5 Official m Form:Subsurface Sewage Disposal System-Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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 t5ins•3/13 rifle 5 Official Uispection Form:Sut%w faoe Sewage DisposalS Page 6 of 17 System• ag 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 03/14 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-W3 Title 5 Official Uispection Form:Substaface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every cotuit MA 02635 04/26/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system s ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval: ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information required for every Cotuit MA 02635 04/26/14 page. Citylrown State Zip Code Date of inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: 08/17/83 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evident of leakage, etc.): t Septic Tank(locate on site plan): Depth below grade: 0.9 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: 1000 gal .. Sludge depth: 41- t5ins•3/13 ,�, Title 5 official trvpedion Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts { Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (corn.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" 2„ Scum thickness 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 15" 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 tank was sound and tight with tees in place and liquid at outlet invert Grease Trap(locate on site plan): Depth below grade: feet Material of construction: Elconcrete ❑,metal ❑fiberglass El polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Forth.SubsuAaos Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando r , Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code, Date of Inspection D. System Information (cunt.) 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: S Capacity: gallons Design Flow: gallons per day f 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.): k *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 rifle 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's(dame information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Even 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.): The box was level and tight with no sign of carryover. t Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order:, ❑ Yes ' ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Trte 5 Official In spection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: El 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.): This system has a 6'x6'precast pit surrounded by a foot of stone. There was 2.2'between the liquid and the inlet invert. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disp osed posal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•3113 Title 5 Official htspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 't 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Citylrown State Zip Code Date of Inspection 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: ® hand-sketch in the area below ❑ drawing attached separately rear 23. 18 50 40 60 51 t5ins•3113 Title 5 otfidal hA)ecbm Form Subsurface Sewage Disposal System•Page 15 or 17 •' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope 0 Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water. 20.0 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: pate ❑ 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: USGS maps show an elevation of over 20.0 feet. x Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3113 Title 6 OI(idal trtspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 225 School Street Property Address Margaret Orando Owner Owner's Name information is required for every Cotuit MA 02635 04/26/14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file � S ' t5ins•3113 Title 5 Official Irupection Form:Subsurface Sewage Disposal System-Page 17 of 17 L O CATION SEWAGE PERMIT NO. VIILLAAGE INSTA LLER'S NAME i' : ADDRESS BUILDER OR OWNER DA T E PERMIT ISSUED DAT E COMPLIANCE ISSUED _J � � .. (; . � , � -- �� �� �� � z ,� � �� aa� � �� �hl � _h �J ,\ , �� ��, �J ' ������ No... ..... ..1� FRs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................O F.................................................----•-••---------...............--------- Appliration for E ,5vnsttl Works Tonstrnrtion Frrmit Application is hereby made fora Yermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: /,_2,4 "- L as on �f. ... -Ad .e o r Lddotr eNso. ....................... •, .� wW - w Installer Address .m� Type of Building Size Lot.__ 57IM....sq. feet U Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ply Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) aOther fixtures ......................... .............................................................. w Design Flow...................................: - gallons per person day. Total ly flow__.__.._.___.._.____..._..__......____._._._ga1B ns� G: Septic Tank—Liquid capacity.r�!.�.gallons Length... ........ Width... ........... Diameter................ Depth... Disposal Trench,—No. .................... Width.._ ..._.........__ Total Length............... .... Total leaching area....................sq. ft. Seepage Pit No.___--.--/-_.______ Diameter.. °.... Depth below inlet.... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil -•---= •------ - -------------- 1.._ /�.�--••--....ry.............� -- ... ----...----• x �� U �' c� UNature of Repairs or Alterations—Answer when applicable...................... ...._...._..._..__.................._..................._............. ---------------------------------------------------•----•--•---•--------•-------•---....-•-•----••--•---•----...--------------------------•--------------------------------------------................. Agreement: The undersigned agrees to install the aforedescribed Qividual Sewage Disposal Sys m in accordance with the provisions of TITLE; 5 of the State Sanitary Code under ' further ee to place the system in operation until a Certificate of Compliance has been is ed the b Signed...........-- .......... ............. ------. ..------ ......._............ .. � Date ApplicationApproved By....................................................... ....................................... ........................................ Date Application Disapproved for the following reason s................................................................................................................ _ ....................................................•----.....-•--•---••-•--••------^-•---...-•-•--•.......--------••--•-----............................ . ..._........ ......---•-•. Date PermitNo......................................................... - Issued_........................................................ Date --------------------------------- -- ------- 7 Q �- No._.Q- � FEs...!/.10 .....__..._.•-_... ............... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ....-......................................OF.............................--... Appliration for Uispwial Works Tonitrnrtiort ramit Application is hereby made for a ?ermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1 / RNG/lr sr Aleeiij .............................. ......... ------------------------------------------------------------------- Loca ion Ad re - - -• ,or Lot No. a ...... fi! N ,1+ �✓ ''•--._...___•_ --•--� /� � ddress . ................ Installer Address �r Type of Building !� Size Lot__.rer - Q .....S f U Dwelling No. of Bedrooms._rr�______________________ ._.__Ex Expansion Attic q �-+ g— --•------ p ( ) Garbage Grinder 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................... Design Flow................................ gallons per person day. Total ly flow.............................. -gallons .WSe tic Tank—Liquid ca acit Len th__ .__._ Width... Diameter__ .____._DPtha _ x Disposal Trench—No ____________________ WidthV�---- ____..._.._. Total Length.._._-_....__�.___ Total leaching area..................:.sq. ft. Seepage Pit No........ ........ Diameter._ Depth below inlet.....4._______._. 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........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----------------------- .............................:........ . ....................r;­.....................................I......... O Description of Soil ------------ 4 .......................... ✓ /o J ) V Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -------=•--••----•••••-•-•--•••••__....••••-•••--••---•••••••••••••-•-••••••-• ••----•-••---__••••-••••••••••...-••---••-•----•-•••-••••-••••-••---•-••-•••__...__...••••••••-•.............•----•-•-••- Agreement: The undersigned agrees to install the aforedescribed n id ivual ewage Disposal Sys min accordance with the provisions of TITLL 5 of the State Sanitary Code under ' further e to place the system in operation until a Certificate of Compliance has been iss ed the b Signed. ••-•. .. --- ...... . ..V ......... .,,. Date Application Approved B ` Date Application Disapproved for the following reasons:..........................................................................................I..._..••••...--•..._.. G Date PermitNo......................................................... Issued-........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Tomplittnrr T�k.S IS TOPCRTIlrYT a the Individual Sewage Di osal System constructed ( ) or Repaired>(by - if� ••....... ........at•••3fit.. _..-•••-- -••-• = . has been installed in accordance with the provisions of TITLE j of The State Sanitary de s de j4 in the application for Disposal Works Construction Permit No.... . _.....�_ f_ ........ dated......... P. ..... ....................... THE ISSUANC9 OF THIS CERTIFICATE.SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM! I F CTION SATISFACTORY. DATE d �2 Inspector_.... v .._.. ------•-•_______________________________________•-------•-•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........................................•--•-••-......_....__.........___............ (� No�........... - FEE........7............... ioor �T#ttr ion rrmit Permission is h reb ranted ` to Constru ) o Repa an div' ual Sewage ispo yst at No _ , s -__•-- •- --_'.� _•. -••-- -- •-•-• --•.............••• .. -•-•--- ---•••-••••._...-••-••--••_..__. _.....•••-•---•••-••--•--•-••-........•-•- Street as shown on the /11iica ' n for Disposal Works Construction Permit No___ _ _________ Dated.. ____..__._...-._.__________.__....... ............................ .................................. .............................. J� FBoard of HealthDATE. ((Qll ------•------ r ,�t� FORM 12$5 A. M. SULKIN, INC., B /,OSTON rp: ty