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HomeMy WebLinkAbout0041 TOPSAIL CIRCLE - Health 41 Topsail CrCa�, A=018-096-003 — - i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA• 02635 1-19-13 page. City/7own State Zip Code Date of•Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information ( - lU . 1. Inspector: Shawn Mcelroy ` Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 Eval tion by the Local Approving Authority 1 1-19-13 -„ (nspector's Mgnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority f and of Health or DEP) within 30 days of completing this inspection. If the system i 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 Q.stem caner 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. 3 t5ins-11/10 Title 5 Official Inspect F Subsurface Sewage Disposal System-Page 1 of 17 I 1 Commonwealth of Massachusetts � Title 5 Official Inspection Form l; o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 page. City/Town 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. Comments: System is in good working order with no sign of failure. 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 t 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): r F t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 OfficialInspection F.orml Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments �M 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13, page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System.Conditionally Passes (cunt.): - ❑ 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,repiaced_P ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection .Form o Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 page. City/Town 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 than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 page. Cityfrown 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. w ❑ ® 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 r 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 El E 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 4 . necessary to correct the failure.. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D.-- • : - - Yes No ❑ the system is within 400 feet of a'surfacedrinking•wate'r`supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El the system is located in a nitrogen sensitive area (Interim Wellhead Protection El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 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? . F . ® ❑ 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. s ® 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): „ 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts '_ Title 5 Official Inspection- Form m a Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick 6 r Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 page. City/Town 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? [if yes separate inspection required] ❑ Yes ® No 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: 10-2012' • � 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal p g System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 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: p 9 Source of information: N/A 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts ,z :. w _ �•' Title 5 Official Inspection Form r :. Subsurface Sewage Disposal System Form Not for,Voluntary Assessments r M 41 Top Sail Cir f Property Address .4 E Paul Myrick Owner Owner's Name information is Cotuit MA 02635 1-19-13' required for every ry ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �s : Septic Tank(cont.) +t. - ,► Distance from top of sludge to bottom of outlet tee or baffle " '20" W Scum thickness :- - t- 0 Distance from top of scum to top of outlet tee'or baffle 61- Distance from bottom of scum to bottom of outlet tee or baffle. 16" How were dimensions determined? Tape . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. } Grease Trap (locate on site plan): Depth below grade: - feet Material of construction: fi_ _ _ ' L a ❑ 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-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank and pit .1980's with new pit added in 1996. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 30" 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24"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 12" Sludge depth: t5ins-11/10 Title 5 Official Inspection 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 1 41 Top Sail Cir , Property Address Paul Myrick Owner Owner's Name information is required for every COtult •,� ., MA 02635 1-19-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present 0must be opened)(locate on site plan)'! Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pits. Pump-Chamber(locate on-site plan): Pumps in working order: ❑••Yes ❑ No Alarms in working order: ElYes' ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 . 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.): 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form h s Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments- M ,. 41 Top Sail Cir Property Address Paul Myrick , Owner Owner's Name information is Cotuit MA 02635 1-19-13, required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal H-20 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure; level of ponding, damp soil, condition of vegetation, etc.): Leach pits were empty at inspection with stain line in new pit at 36"below 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-11110 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 page. City/Town 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.): t 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts • , Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 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 G'r.ro- c ,r. - c v a OG €a _ -- New and Q" 6 -0' — 43 r 35. r � t t5ins-11A0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts } W Title 5 Official Inspection- Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 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: 20 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 and town maps show groundwater at 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form SL Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Top Sail Cir Property Address Paul Myrick Owner Owner's Name information is required for every Cotuit MA 02635 1-19-13 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir { Property Address - Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448). Owner Owner's Name . information is Centerville MA 02632 1-19-13 required for every - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information U , 1. Inspector: Shawn Mcelroy ' Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr ,. r.. Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification . F 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 (77 --� 1-19-13 � - Inspector's Signature Date - The system inspector shall submit a copy of this inspection report to the Approving Authority (Bod of Health or DEP) within 30 days of completing this inspection. If the system is a shared System has a design flow of 10,000 gpd or greater,the inspector and the system ownerlshall subtir>tt thet" report to the appropriate regional office of the DEP. The original should be sent o the sy9t^em ogger and copies sent to the buyer, if applicable, and the approving authority. t ****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. it,5-/1 1 t5ins•11/10 Title 5 Official Insp Vorm: surface Sewage Disposal System•Page 1 of 17 r r Commonwealth of Massachusetts Title 5 Official (inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 0' 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 page. City/Town 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: ® 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 is in good working order with no sign of failure. 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 t Y 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. El ❑ N . ❑ ND (Explain below): r t t" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of MassachusettsT Title .5 Official Inspection Form IR Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 I-19-13t required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 4 B) System Conditionally Passes (cont.): . o , ❑ 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 D (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The Y q P p 9 Y 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): r 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. 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 t5ins-11/10 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 1-19-13 required for every ' page. City/Town 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-'13 . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes - , No a ❑ ® 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. ❑ 0 , Any portion of a cesspool or,privy is within a Zone 1 of a`public well. r ❑ ® `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- 0 ® .`10,000 pd.- :, The system fails. I have determined that one or more of the above failure ❑ ® ' ' ` tcriteria 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 t, 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 Il of a public watersupply 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13- 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): 5 e Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 1-19-13 required for every 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? [if yes separate inspection required] -- ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? f ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: r . Sump pump? _ ❑ Yes ® No Last date of occupancy: 2012 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-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 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: N/A 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 �I ❑ 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-11110 Tine 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 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate.1-800-966-2448)r, t Owner Owner's Name information is Centerville, { required for every MA 02632 1-19-13 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan):- Depth below grade: 2411 feet Material of construction: ❑ cast iron' ® 40,PVC, ❑ other(explain): Distance from private wate'r'supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of.Compliance? (attach a copy of certificate): . ❑ Yes ❑ No Dimensions: 1500 Gal Sludge depth: , 12" t5ins-11110' Tide 5 Official Inspection Form:Subsurface Sewage Disposal Systrn-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•°�< 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) . Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 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 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" • Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address r Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is ',: required for every Centerville MA 02632 1-19-13 page. City,/Town State Zip Code Date of Inspection D. System Information (cont.) 1 4 - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert; evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: t +. : k• 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 page. Cityrrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type _ F ❑ leaching pits number: ® leaching chambers number: 5-Cultec's ❑ 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.): Leach chamber field in good condition with no sign of back-up into d-box or surrounding stone. 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-11110 ;. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 page. City/Town 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 .(I site i an)' Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form: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 M 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate Ir800-966-2448) - Owner Owner's Name information is Centerville required for every MA 02632 1-19-13 page. City/Town 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 ' - t racA _ A 'D-27' 13^D_36' •ter- 3?' f3 - Y1? ' y . F . t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 94 Monomoy Cir Property Address Bank Owned (Contact Dennis Falvey @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Monomoy,Cir Property Address Bank Owned (Contact Dennis Falvey @Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-19-13 • 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION m � yea TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner's Name:. MR.BOYLE Owner's Address: 41 TOPSAIL CIRCLE MARSTONS MILLS, 2648 Date of Inspection: 8/6/01, C9� h Name of Inspector: (please print) JOHN GRAC Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICK 6 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 as n, _ Needs Further v nation by the Local Approving Authority ; Fails Inspector's Signature: _ Date: 8/6/01 The system inspector shall submit a cop f this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. I he system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM USEFUL LIFE. ****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 th4e system will perform in the future under the same or different conditions of use. Title 5 Incnrrtinn Fnrm 6/1 ;'1?0 0 i'i 1 f Page 2 of 1 1 4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM { PART A ;4 CERTIFICATION (continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR. BOYLE Date of Inspection: 8/6/01 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 not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM USEFUL LIFE. ` B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair„as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits 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 mote thar?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 _obstructiowis removed ND explain: n/a 'E Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR. BOYLE , Date of Inspection: 8/6/01 `' 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(l)(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 ,t 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 defermine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, fo'r coliform bacteria and volatile organic compounds i4cates 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 , t Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ':"'CERTIFICATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR.BOYLE Date of Inspection: 8/6/01 D. System Failure Criteria applicable.to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool .. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NO-1—due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or~privy is within a Zone 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 tha'f 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 flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of atributary to a surface drinking water supply _ X the system is located in,a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. ,y If you have answered"yes"t any question in Section E the system is considered a-significant threat,or answered "y@§" in 5e0ion A Above the large§y§tam`Jimfnilt±d:The owner or operator of any large§y§tern eon§idered a§ignifiennt 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. A 6 a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR. BOYLE Date of Inspection: 8/6/01 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.componentsgumped out in the previous two weeks? r, 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 ? 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 t, X Existing information. For`'examble,'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)] ti? �J Yt4 k Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR. BOYLE Date of Inspection: 8/6/01 FLOW CONDITIONS RESIDENTIAL t, 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: 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): NO Seasonal use: (yes or no): NO 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 t. .' Design flow(based on 310 CMR.15:203):,n/agpd Basis of design flow(seats/personsAgft,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 x4 OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) t _Tight tank Attach a copy of the'bEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 15 YEARS Were sewage odors detected when arriving at the site(yes or no): NO A Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR. BOYLE Date of Inspection: 8/6/01 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron.X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc,): TOWN WATER ; ;T ' SEPTIC TANK: X(locate on site plan) Depth below grade: 24" 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: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32". Scum thickness: 1" 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: 17" 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 SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete metal fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom'of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc::): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR.BOYLE Date of Inspection: 8/6/01 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_metal3_fibergiass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must,be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND ALSO APPEAR_ S TO BE FUNCTIONING PROPERLY. 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 I,., r R I Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR.BOYLE Date of Inspection: 8/6/01 l - 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: 2 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 s Type/name of technology: n/a Comments(note condition of soil,signs'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PITS APPEAR TO BE STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. THE NEWER LEACH PIT HAS NEVER HAD MORE THANTWO INCHES IN IT 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 laver: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a < Indication of groundwater inflow(yes or no):NO. 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 .r i Page 10 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR.BOYLE Date of Inspection: 8/6/01 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. V/ ' n of 4 (� FS 17. , CT Alew Qo� AC N AJ 3) j �E Yl CC 3� Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "'SYSTEM INFORMATION(continued) Property Address: 41 TOPSAIL CIRCLE MARSTONS MILLS,MA 02648 Owner: MR. BOYLE Date of Inspection: 8/6/01 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: 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 dzcavators, 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 fib •�. ; ,� Y I a - 11 . . ... ��� (39co No. z1_ Fee 0.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for 3Di!9poga1 *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or RepairXg)D an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.,rar q A "0677 41 Topsail Circle Cotuit,Mass . Jean Rogers Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J.P.Macomber Jr. J.P.Macomber J.P.Macomber Jr. 508-775-3338 Box 66 Centerville,Mass . ,02632 Box 66 Centerville,Mass . 02632 Type of Building: Dwelling No.of Bedrooms 3 Garbage GrindeA) ) Other Type of Building RES No. of Persons 1 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3x1 1 0 gallons. Plan Date 3729/96 Number of sheets Revision Date Title Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Adding an additional 1-1000 gallon. leaching pit to an existing tank & p't V4,e 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 Certifi- cate of Compliance has been issu d by this B and f H th. Signed Date 3/29/96 Application Approved by Application Disapproved for the following reasons 47 Permit No. /,�.��`K Date Issued —a ——————————————————————————————————————— Mf n. •-+ .y.•. * .. '�.r . w.. 1 t Fee$ 40.00 • _ ' - THE'COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Migoml *pgtem Con9truction Permit a Application is hereby made for a Permit to Construct( )or Repait((XX)an On-site Sewage Disposal System at: r Location Address or Lot No. "s Owner's Name,Address and Tel.No.swQt q p#a —0677 41 Topsail Circle Cotuit°,Mass . Jean Rogers r .1e Got'lit Mass , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J.P.Macomber Jr. 508-775-3338 J..P.Macomber Jr. 508-775-3338 Box 66 Centerville,Mass . 02632 Box 66 Centerville,Mass . 02632 Type of Building Dwelling; No.of Bedrooms 3 Garbage Grindetwo ) Other Type of Building RES No.of Persons 1 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3x1 1 0 gallons. Plan Date 3 29 9 Number of sheets Revision Date Title Description of Soil Sand i Nature of Repairs or Alterations(Answer when applicable) Adding an additional 1-1000 gall1n leaching nit to an existing tank & pit A!1 s!�U4 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 Certifi- cate of Compliance has been issued by this B ard:"f He lth. Signed ,Gl p Date 3 129/96 t Application Approved by Application Disapproved for the following reasons Permit No. `K Date Issued THE COMMONWEALTH OF MASSACHUSETTS 'PU 'LIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS ,E Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced)(X)D)gn by J.P.T4,a.c�ntnhar Jr. ! for Jaan Roaprit as 41 To,T)Nail Circler \ i v has begn constructed in accordance with the provisions of Title 5 and the for Disposal Systern'Coni truction Permit No. - `� dated .o...- - Use of this system is conditioned on compliance with the provisions set for •elow: Ael No. �` ! Fee $ 40-00 F,. THE-COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTHDIVISION - BARNSTABLE,;MASSACHUSETTS s r 30ioogal *pgtem Construction Permit } Permission is hereby granted to J.P.Maeomber Jr. to construct( )repair�(Xj an On-site Sewage System located at LL 1 Topsail Chi r e 1 e C o to i t Mass and as described in the above Application for bisposal System Construction Permit.The`applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ; All construction must be completed within two years of the date below. S Date: IV°"`' Approved CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) d I, Joseph P. Macomber Jr., hereby certify that the application for disposal works construction permit signed by me dated 4,/1 /96 , concerning the property located at 41 Tn:Ga; 1 ri rel Ei Cotilit Mass meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • . The observed groundwater table is 1.4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED DATE: 4/1 /96 LICEN SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 1 licensed installer sesses a certified lot plan, [Attach a sketch plan of the proposed system. Also if the ce sed sta po p p , this plan should be submitted]. U •H t l et O 44 bL Y A F rx {r 95 l ..i S � .\.•� iNkP ENT re 1 '9 k ,yS zN�+'.• �Y ����4.i7 Ji,'r`�ks �t� t �• �. � 5 V �'G��:,f a E d�[}'s Py ,s". 3.:k �A• ✓f f sJ �� � ' rt �},� �F".".k��k'' �, �"f. .. >'+ �... a t � N t1�''f t" 'i'�r.' ••o' ;'+ `�1,5�•�t�� a � °fit sitr,�)F 1 �.. •,�� •li,- Y'� Ji t��'i..S 4:'m.F� � I. L `$+ Y 'ITi.,�lr''i��J�T•FJ • d - s' •� v e i F V' N P� `' AA th �. �`"''+f s } '�j��i•f ,44 Y);���y�b �i{J}�'((��g<�"•'' fp y N ` .�ay,��:t. ,` /� /� • ��5it�3t+ Tr x �•i r 7�-1 YA• e° t.b� a �C}�' t' t R I •+�' O � \7 rw A CIOp yX as xati a .x CNO � tiny � 0 �. 4 ; S NCB � y O �c,s7«rg ow Jed T r6�o� gT 7a* �' ��, . �� I I { ���� � � { _�; r S Commonwealth of Massachusetts ,zt Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe oo»tnoe �,y Arge0 00w Paul Celluocl David B.Struhs U. e 6orm�belorwt l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Ax" Property Address: 4 1 Topsail C i r c 1 e C o tui t,Mass . Address of owner. Date of Inspeogon:3/2 2/9 6 (If different) 9g6' Nam e P. Macomber Jr. ,.- '�, ' �,. Company Name,Address and Telephone Number. • ��� � � �f; , J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 . 4 CERTIFICATION STATEMENT 508-775-3338 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes eeds Further Evaluation By the Local Approving Authority V Fail, Inspector's Signature: /G''�� LcY Date: The System Inspector submit a copy of this inspection report to the Approving Authority within 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 shall submit the report to the appropriate regional oMce of the Department of Environmental Protection. The original should be seat to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A.B,C,or D: Al SYSTEM PASSES: AL I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: -- 4 One or more system components used to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If'bot determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial inflltratioa or exfiltration,-or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved �J by the Board of Health. (revised 11/03/95) I One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-sm %7_Printed oA R-r-W Paper SUBSURFACE SEWA09 DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddresu 41 Topsail Circle Cotuit,Mass . Owner. Jean Rogers Date of Inspeo4ow3/2 2/g 6 B]SYSTEM CONDITIONALLY PASSES(continled) e 'j Sewage backup or breakout or 0 static water level observed in the distribution boat Is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution bar. The system will pass inspection it(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumper more than four times,a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 60 feet of a surface water .4)4 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE:ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic is nk and soil absorption system and is within 60 feet of a private water supply we]L The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water supply well,unless a well water analysis 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 6 ppm. 3) OTHER r (revised 11/03/95) 2 U6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Propertynddresw41 Topsail Circle Cotuit,Mass . Owner. Jean Rogers Date of Inspection:3/2 2/9 6 e e DI SYSTEM FAILS: • V I have determined that the system violates ono or more of the following failure criteria as defined in 310 CMIi 15.903. The bassi for this determination is identified below. The Board of Health should be contacted to determine what will be neoessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of sfiluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level �t�distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in oesspeei is less than 6"below invert or available volume is less than lJ2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(+). Number of times pumped-- A0 Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface.water supply or tributary to a surface water supply. 4W Any Po P� P portion of a cesspool or ri`7 is within a Zone I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. �Q Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 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 Systom)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply Q 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Auther information., (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddrem 41 Topsail Circle Cotuit,Mass . Owner. Jean Rogers Date of Inspeotion:3/2 2/9 6 • Checjc it the following have been done: 2Pumping information was requested of the owner,occupant,and Board of Health. 6 2None of the system components have been pumped for at least two weeks and the system bas been receiving normal flow raise during that period. Large volumes of water have not been introduced into the system recently or as pant of this inspectim j,As built plans have been obtained and examined. Note if they are not available with N/A. ,�Tha ''ty or dwelling was inspected for sagas of sewage back-up. The system does not receive non-sanitary or industrial waste flow 4zT%s site was inspected for signs of breakout. , All system Components, cluding the Soil Absorption System,have been located on the site. ,ZThe septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of bames or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum jLThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non•iatrusive methods. . !'hs facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddressr 41 Topsail Circle Cotuit,Mass. Owner. Jean Rogers Date of Inspeotlon:3/2 2/9 6. s FLOW CONDITIONS RESIDENTIAL- e Design flow:_JID gallons e Number of bedrooms: ' Number of currant residents:_L Garbage grinder(Yes or no):_0 Laundry connected to (Ye.or no)Yes Seasonal use.(1w or no)•,� Water meter-readings,if available: w E �O 6 S = + Last date of occupaary: zor l� COMMERCIAL NDUSTRIAL• . Type of establishment: 4>A Design flow: MA,gallons/day Grease trap present:(Yes or no),a,�} Industrial Waste Holding Tank present: (yes or no)& 4 —� Non-sanitary waste discharged to the Title 6 system: (yes or no)" Water meter readings,if available: 1014 Last date of occupancy:_&q_ OTHER(Describe) 1�\Cl Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS d source of information: System pumped as part of inspection:(yes or no).VS if yes,volume pumped: '!0FDA eallons Reason for pumping. TYPE 0�'SYSTEM _L/ septic tank/distribution boz/soil absorption system . A)V) single cesspool -� Overflow cesspool ' Privy t� shared system(yes or ao) (if yes,attach previous inspection records,if any) Other(explain) APPROIQMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site:(yes or no) (revised 11/03/95) 6 b . • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) y prop0rty,daes. 41 Topsail Circle Cotuit,Mass . . Owner. Jean Rogers. Date of Inspection:3/2 2/9 6 SEPTIC,TANL-1_-14VP4 aV /' • ' • (locate on site plan) Depth below grads: Material of,construction:Zooncrete_metal_FRP_other(ezplain) Dimensions: ' e LIZA& Distance from top of sludge to bottom of outlet tee or baffle:�_ b Scum thic]mess: 6 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baiMe:�_ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence ofleakage,etc.). •Pump tank once every 2-3 'vim PArR j n»t1 Pt t•PR i n -in Pl n na And is str11n •. l ll y AOl1n�etnnA Wq i i i a nvar t.-h� i nl a+_n^niraz of t1" sBUtic tank;Astmd on the _ C —Structurally oyaZ should be rn sound: o eVi ence of leak GREASE TRAP:&rl�• (locate on site plan) Depth below grade:, Material of construction:4ficoncrete_metal_FRP­other(explain) Dimensions: AA Scum thickness: Ma Distance from top of scum to top of outlet tee or baMe.__A & Distance from bottom of scum to bottom of outlet tee or bame:_A)A Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of ,etc.) i (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 41 Topsail Circle Cotuit,Mass . Owner. Jean Rogers Date of Inspection: 3/2 2/96 TIGHT OR HOLDING TANK;j&/{, • Gocat•an site plan) • . Depth below grad•:. Material of construction:49oncrete_metal FRP_other(explain) - __ A7ft Dimensions-_ ,0-4 Capadty:_ AJA gallons 6 Design flow: nsiday + Alarm level:_ 10 A _ comments: (condition of inlet tee;condition of alarm and float switches,etc.) .�n �DrLti4?��tlTs DISTRIBUTION BO&.k/ (locate on site plan) Depth of liquid level above outlet invert:Ya.5 Comments: (note if level and distribution is equaL evidence of solids carryover,evidence of leakage into or out of box,etc.) Distribution box is .level;has evidence of solids carry over;No leakawe in or out of the box. No repairs needed at this time. PUMP CHAMBER-ail (locate on site plan) Pumps in working orden(yes or no)_41 Comments: (note condition of pump chamber;condition of pumps and appurtenances,etc.) (revised 11/03/9S) 7 SUBSURFACE SEWAOI; DISPOSAL SYSTEM INSPECTION FORM SYSTZ..: Property Address, 41 Topsail Circle Cotuit,Mass . n Owaen Jean Rogers' Date of itaspeot" 3/2 2/9 6 SOIL ABSORPTION SYSTEM(SASX, . Oocab an sits plan,upotsibls;sacavatioa not r$quiil,but may be eppmsimated by non-intrusive mothads)' It not determined to be ps$sant,,,plain: Zee: leg Piv�numbsr,L�a p�T.. a .. •.:• . • .. • ..... .::. .. 18"hing 6=1bers.uumbll�ln 3saching trenches,nt"r,length:- leaching Gelds,number,,dim$ kus: overflow cesspool,cumber. Comments:(note condition of soli,signs of hydraiWa failure, lam.r':of M^.a n�, condition of vegetatio etc.) Soils Sand;no signs of hydraulic failure •No . si ns of on In All vegetation normal; Pit filled to capacity with water over e' Inver ai p e_ Water 4 . ndi ng in collars on the leaching Bi„ t_System muot e ' up�raded dding an additional leaching pit. CF�BPOOL9t� .. (boats on site plan) Plumber and coudguradon• Depth-top of liquid to inlet invert: Depth of solids lsy$r: Depth of scum layer: Dimsnsious of cesspool: Materials of construct10: 3A1 Indication of groundwater. ASA • inflow(cesspool must be pumped as part of inspecta,;r) A> Comments:(not$condition of soil,signs of hydraulic failuro, ,-r condition of vegetation,su.) __AIo C.�,ytX-1P_wn; PRIVY, t yez: (locate on sits plan) Materiels of au� {on.• .lJ� Dima,ukas: i(%� ' , Depth of solids. - --- Comments:(acts condition of 94 signs of hydraulic faiiuro, .:oa of vegetation,etc.) (revised 11/03195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Topsail Circle Cotuit,Mass . Owner: Jean Rogers Date of Inspection:3/2 2/9 6 ® ; SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Cotuit Water Company 428-2687 7. 'r 1 DEPTH TO GROUNDWATER .'!. Depth to groundwater: 12 1 + feet method of determination or approximation:S' 'e pales 5A & 2B Permit # 86-760 lre 95) 9 / 88 3. THE BOARD OF f _ MHEN CONS TRUC TO BACKFILLINC 4. ANY CHANGES it BY THE BO4AV [ Zo SURVEYING Co., 5: MATERIALS AND 49, 2(jam-- '� _ ZZ CaWLIANCE MI7 Z 4 CODE - TX TLE 6 RULES AND AEGC /'' V• ;'� ram-2�0 ;+ y -' . . ,� 6. NORTH ARROW I,� IS NOT TO BE L 2� 7. FLOOD HAZARD MA TER SUPPL Y .L 0 0 \ s 3 ,o `moo. Qv �- : :•.: 52.50 - sEao.s5 LEGEND 28 05 DI LE, ` C9 SE rti JRP1 R ' .. 28 • - P•5 TOWN OF BARNSTABLE LOCATION`Lo f Sr bP s i SEWAGE - 74 VILLAGE ... ASSESSOR'S MAP & LOT ,INSTALLER'S NAME 6 PHONE NO. C/I y 2Es �SEPTIC TANK CAPACITY /b Oo S • . n LEACHING FACILITY:(type) (<00 L P Off`AA,& (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE�t-' BUILDER.'OR OWNER DATE PERMIT ISSUED: f 0 G DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ! y^•nnnrr•-nrr�--�-•nrrmr•n.aria•-nrt•+nrs+a:•n.-+-+mn+sri*ems m-n•v*rs.-a*rer.+rn *n's*s+sT+nra�•rmrr-�+-.Zrr-.env.r-•.•--^-- l '!'UHN OF Barnstable BOARD OF HEALTH j h•.•41ry-'..-:.•-'."r-.SUIfSUfiFACF 9EHA(;F DISPOSAL SYSTEM IN�S(�T�CTION FORM - PART U^ CF,11,rl FICATIUN� - -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 41 Topsail Circle Cotuit Mass ASSESSORS MAP, BLOCK ANll,PARCEL # 18-96. 3 OWNER' s NAME Jean Roors PAI.?Z' D - CERTIFICATION I NAME OF INSPECTOR _ Joseph P. Macomber Jr.. COMPANY NAME 'J.P.Macomber & Son Enc. COMPANY ADDRESS Rnx A6 Gentervilla Macs Q263.2 Street To-wi or My State LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage diaposc41 system at this address and that the information reported is true , accurate, and complete as of the time of :inspection . . 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 oil- site sewage disposal systems . Check one: System PASSED ; The inspection I+hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. XXXXXXSystew FAILED* The inspection w)lich I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 - 303, and as 'specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 27 6 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF 11BAL-111. * If the inspection FAILED, tMe owner or"'•oporator shall upgrade he within one year oP tl�e date o1' the inspection, unless allowed ortrequiredm otherwise as provided in 310 CHR 15 . 305 . y. --- -- - -- 141 1upsall l; , 'lil e - Cotuit, Massachusetts Large sprawlipg custom ranch. Walk to Loop Beach. r j" Taxes: $3,711 Acreage. 1.13 Assessment: $291,300 ('94) Price: , . O BEROOM#2: (11'x 1T)Wall to wall FOYER: Oak Bruce Wood flooring, carpet, 3 Anderson permashield • \� coat closet, French doors leading to Dining Rootn Thermopane casement windows,wall to wall carpet,sliding door closet with lights LIVING ROOM: (14' x 21)Wall to wall BATH#2: Full,porcelain cast iron sink, carpet, glass enclosed fireplace, e fiberglass shower with seat,ceramic tile Anderson case. ,g floor, lar a linen closet thermopane windows,sunken Livhl g Room, chapel ceiling 1. BEDROOM#3: (11'x 12') Oak parquet DINING ROOM: (13'x 14')Wall to wall floor,six Anderson Permashield carpet, glass enclosed fireplace,mantel, casement-windowsdoors tth lights built-in china closet,view of Japanese closet with sliding Garden BATH#3: Half,porcelain cast iron sink, FAMILY ROOM:° (24'x 13') Oak floor, oak vanity cabinets,ceramic floor 3 Anderson casement windows plus BEDROOM#4: (11'x 12') Oak parquet double French doors, ash cabinetry, floor,three Anderson Permashield views of natural woodland casement windows,custom built-in KITCHEN: (17' x 13') No-wax bookcases,closet with lighting congoleum floor, ash.cabinets, formica countertop, GE self cleaning stove with ATTIC: With pull down stairway hood, Ainana refrigerator,Maytag BASEMENT/UTILITIES: Bulkhead dishwasher, three casement windows, access,circuit breakers,town water, porcleain cast iron sink Titles Septic,275 gallon oil tank located BREAKFAST AREA: Overlooks deck in furnace room,extra flue,central with natural setting MUD ROOM: Pocket door between EXTERIOR: Front porch, 12'x 45'deck, O Berkshire hurdle fencing,stone wall Kitchen and Mudroom, ceramic tale floor, anese Garden, architect window seat,two closets, double bifold shaker shenclosiningled roof,redwood clapboard door pantry in inudroom sidewalls LAUNI?RY ROOM: Seperate,Maytag GAGE: Automatic opener,circular washer, door leading to deck , driveway with natural stone MASTER BEDROOM: (16' x 13)Wall FT, 1985; 3,000 +-s.f. to wall carpet, sax Anderson Permashield AGE/SQ. Thermopane=casement windows, triple Map 18,Parcel 96.3 O bifold door closets with lights,oak vanity ALL INFORMATION CONTAINED HEREIN IS OBTAINED FROIT ' OWNER AND IS ASSUMED TO BE CORRECT.ALL MEASUREMENTS ARE APPROXIMATE AND ALONG WITH THEWPORMATIONCONTAINED cabinets linen closet with built-in hamper HEREIN,IT IS BELIEVED TO BE ACCURATE BUT IS NOT WARRANTED. \� MASTER BATH: Porcelain cast iron ALLBROKEHEMAESPERSONSREPRES IONANNT THE SALER,N07THB BUYER.IN ERNE MARKEERNON NEOUTI S1 AND SALE OP PROPERTY, UNLESSOERNERWISEDISCLOSED.HOWEVERTHE Carosel sink, porcelain cast iron BROKP.RISAIESPERSON HAS AN ETHICAL AND LEGALOBLIOATIONTO SHOW HONESTY AND FAIRNESS TO THE BUYER IN ALL O oversized Whirlpool tub, ceramic tile TIwsAcnoNs. floor and walls (,�ofton REAL ESTATE -9115 or (800) 851-9115 8S1 Main Street, Ostemille, MA 026SS Phone (S08) 428 THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 2.1A. of the _ General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' '•ion of water Pollution Control a TOWN OF BA)RNSTABLE .00ATION y� 0 D'64 �`� SEWAGE # tiLLAGE cy f"k A:SSESSOR!S DAP&LOT ___..._ NSTAir IXPUS-NAB&PHONE NO. _ 'EPnC TANK CAPACIT"x �000 a -av ,EACMG FACILITY- (type)LEI; (size) d®.OFBEDR.00MS-, ..y.-..W..........._. , MILDER OR OWNER.._ E1MITDA.7'E: _. _-,C:OMPLIMCE DATE: separation Distance Between the: daximum Adjusted Groundwater IMIc to the Bottom of Leaching Facility met �ivate Water Supply Well and Leaching Facility (if miy%As exist on site or within 200 feet of leaching'facility) idge of Wedand and➢,caching Facility(If any wetlands exist within 300 feet a leaching facility) urnishcd by `_�� - r r CIS w 1 V 91ZU c5 n cnl � �► w � SLi � cry 'iOWN OF BARNSTABLE 1,C)CATION y f i4 S/�/�L �i' /�GL"Iz. SEWAGE.# V e 4T9 w%Q .4A 1/I C V>Z;LAGETsx-v--�9» —�-� ASSESSOR'S MAP & LOT INSTALLER'S NAME P ONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 feet of leaching facility) Feet Furnished oy C- w o w . rn ❑ o 0 -r-1 TOWN OF BARNS'TABLE L- r'ATION '7// �t�✓� S��li SEWAGE # V-TLLAGE Co f ASSESSOR'S MAP & LOT' "= n-iSTALLER'S NAME&PHONE NO. YYl/� 1 b e Soh h`- SEPTIC TANK CAPACITY 100 0' i LEACHING FACILrI',Y: (type) - (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: ��"�/� CO IANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -� ;� T' \\r �.� \`� � ��� � ��� � (� ,--- , , n -� l \� � I �� �� � � � � ©�.a � � �,'� � ' � _ � /�/ �'l � � �. �v � �� 1 TOWN OF'BARNSTABLE L CATION �1� S �6P SAGA L, .��. SEWAGE # 740 ASSESSOR'S MAP 6z LOT �6 NSTALLER'S NAME & PHONE NO. Gf a//y 'SEPTIC TANK CAPACITY /b 0o s k LEACHING FACILITY:(type) 600 L P p"e`"�(size) ONO. OF BEDROOMS 3 PRIVATE WELL O UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: CO/ /f6- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes I e�No _ _ �� . � �r � �{�. � -� . `J' t- a � • I:,.•.�.-----� ^^� No...`//�� :'.....1�� .40 Fics... _. ... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................OF.......... f .f.. /'� ApplirFaiion for Disposal Works Toustrurmitt Prrutit Application is hereby made for a Permit to Construct ( )K) or Repair ( ) an Individual Sewage Disposal System at: Location-Ad��� �,� or Lot No. ....... i��1. .......... ................... ................."-•- ..... ..... wner Address - - a .......................................... ... -"fir#-' ---•••--._...._..•. .................... ............ ................... Installer Address Type of Building Size Lot_ __=Sq. feet Dwelling--No. of Bedrooms..........._-3_.......•...............Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------•-•--••------•-- ----•---------------------------------------------------•--••------..--...------ W Design Flow........................!s.. ..........gallons per person day. Total daily flow.....................;U.O-............gallons. C>a' Septic Tank—Liquid"capacitye ! .gallons Length ._. Width. `.Y_v�Diameter________________ Depth�.......... Disposal Trench—No. .................... Width.......... t-........ Total Length.......a_�......_. Total leaching area....................sq. ft. Seepage Pit No------/------------ Diameter.Z�(__�?---. Depth below inle ---•-2 ..._ Total leaching area._�Y.F..sq. ft. Z Other Distribution box (-;c) Dos in tank aPercolation Test Results Performed by. _k) ::e�'_e7r/�_ _._ Date.Z- ...... .�_f`,-•6.. a Test Pit No. I.....�.....minutes per inch Depth of Test Pit...YY--------Depth to ground water__�w'^'L fX Test Pit No. 2................minutes per inch Depth`of Test Pit.................... Depth to ground water-___.._____-___-...____- 04 ® � ��� ---------S---�saA.1.... ------- ----------------------------------------------- ...-.----- Description of Soil -.._s �l�!` ............./l t.c�------. W ------------------------------------------------•----------------------------...------...-------------------------------------...----------------------•------•---•-----------••--••••-•------•---•••. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------------------------------------------------------------------------------------------------•-•••-••••--••-•-••-•--••••----••••-••-•••----•-•-----•---------•-----••-••-•--•------••--•--•----•••-- Agreement: The undersigned agrees to install the aforedescribed Individual S e Disposal System in accordance with the provisions of iI"TL Z 5 of the State Sanitary Code he un sl d further agrees not to place the system in operation until a Certificate of Compl' ce has be bo Pr Signed ` .... [ ���C (� " / Date r Application Approved B ._. PP PP Y --.......... ............ I Date Application Disapproved for the following reasons:__..._'. ....................................................I.=-............................................... Date Issued Permit No......................................................... ....................................................... Date _ F 'w 4" t -1 No................_....... Fps............................. l THE COMMONWEALTH OF MASSACHUSETTS -- � BOAR® OF HEALTH .................OF........ ..�s.'! �j{� Appliration for Disposal Works Tonfitrurtinn ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: 77 --- ..... ........... ..... ......... Location-Aq�s s or Lot No. �C Sl e •-•---..... --••-._-- ... .............................................. .................................................................................................. Owner ............................................ Address Installer Address d Type of Building Size Lot .__ ----Sq. feet U Dwelling—No. of Bedrooms............�............. _Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................ . Design Flow........................ ........gallons per person per day. Total daily flow...................3_7 Q.._........._gallons. 9 Septic Tank—Liquid'eapacity/U __gallons Length P:-. .r Diameter................ Depth_ _'._._ .. W Disposal Trench—No..................... Width................. Total Length................. Total leaching area------------ ____sq. ft. x Seepage Pit No..... ............ Diameter. ?..__"o.._. Depth below inlet ._____.-..-... Total leaching area..z Y. ..sq. ft. Z Other Distribution box (X ) Dosin tank ) '-' Percolation Test Results Performed by._____ � `__.. r ` Date. ..__l.. - - - ,� Test Pit No. 1....2-.._._minutes per inch Depth of Test Pit...�`+� ._.._.. epth to ground water......................... Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O x Description of Soil----.. ........................t- r---C-------_. r=' c, W .00 VNature of Repairs or Alterations—Answer when applicable._.............................................................................................. ------------------------------------•----------------------------------------------.........---------------------------------------•----------------------------------------------------............... Agreement: The undersigned agrees to install the aforedescribed Individual S ge Disposal System in accordance with nTmi 5the provisions of ii: �, of the State Sanitary Code he un rsl d further agrees not to place the system in operation until a Certificate of Com li nce has be d e bo a , - Signed.......... ...... llolleo 1Z vDate �7 Application Approved By................................... ............. --• ----- ....... -- Date Application Disapproved for the following reasons_________ ................................................................................................... -•--------------•-------•-•...-•---•--••-•----•--•.....•-----------•-•---.........•----•-------•--•-•--•-I---------------•-•-----•-----•---•-----•---------------•---•-•---------•--•----•-••----•-•-•--- Date PermitNo......................................................... Issued...................................................... Date S THE COMMONWEALTH OF MASSACHUSETTS �lL BOARD OF HEALTH C�rrtifirate of Tontlrlianrr THS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired ( ) by .... .lQ•. ..7�✓ -----....---••--•-------------------•----------.......------•----............................•-•-----------....----••--•...---•-•--•---. Installer at............ � ' 1 �' �. 1- --•--------Cp.± 1 ............................................................... has been installed in accordance with the provisions of TI i iE 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 CONSTRUE®,AS A GUARANTEE THAT THE _SYSTEM WILL FUNCTION SATISFACTORY t DATE..... . . t, Inspector... ........................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF- HEALTH ��j�6 a ....., .... ..11!r!............OF.............: ���.. .-............................................... � �© No..... .... FE ........ ......... �i���a��t1 nrk� �nn�#rnr#Uan erntit Permission is hereby granted......... --49. ... ��_ 1 : _1�_1...-----•--•--...-•---•.................................••-•-•-•--. = to Construct ( ) or Repair ( ) an IndividuafSewage Disposal System at No.. �Q..... ...7`?t�..._.C_� G:� .---..... f v r--X------------- ---•­---------------------------..-----.---- Street q _7&O as shown on the application for Disposal Works Construction Permit No..................... Dated--___--___._-7..__.._.. ._........ -----------••........................•-------• - -- --�- ••---------•-_---------_ ,,�Q L Boa f Heal b DATE ). �...--••---•-U-------------•------------.-.. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS S YS TEM PROFILE NOT TO SCALE TOP FON. FINISH GRADE — 50 FINISH GRADE OVER .o.•• e , FINISH GRADE OVER �-� DIST. BOX � _`5. � FINISH GRADE OVER SEPTIC TANK ' -�� - LEACHING PIT 2 fs. VARIES o . o.:a: a o:e e.•..°....e:• e. :.. e: ; . . ..° 3" OF 1/B" - 1/2" 12" MAX ••0• :o• •o::'.e•:.a:..•:e.:t:'o:�:�..:":::d•:s:• '•:o•: a;d.•e,�e:i �O :s , :•:t'' " e •: ° PRECAST CONC. OR ASHED PEA STONE Q.t'.:° :;-: •' : BRICK 6 MORTAR 3 OUTLET PIPE LEVEL .: TO 12" BELOW GRADE • 4 FOR 2 FT. MIN. p• .q o:••a: o. e.; O O d Q•. :: o': A.: :e c i 2{ pick i.. i Nt= :°o:.b: A C. I. OR PVC TEES o.o;e. ' :'•o: .Q "0 :q p "•0'. .• a A. cl BSMT T. FLR. GALLON n o•:::•°•• ':: DJr S TRIBU TION BOX EL . 'Z 0 o INS TALL ON LEVEL BASE PRECAST CONCRETE s/4 ro 1-1/2 PRECAST /0 REINFORCED WASHED CRUSHED H— CONCRETE •e•.•a.'.o•.'o'.:°'.•.: '.. a 'i :I a a: e o:e' o:o-q;o:..°:o:: o :o• '.c e:c•. p.:a:o p'.e:. :.` ::6. '0. a o.:'o: STONE y b::o: o. °..o.°?.o.o p•.o.o.o:. c:•a .�.o •o;a o.0 0.• :o. . o . o b:o• 9 H— l 0 REINF. SEPTIC TANK INSTALL ON LEVEL BASE !7 ° °° ° • e ° ° a' ° NOTE.' EXCAVATE TO ELEV. ; .4 _OR e .°.°. .••o; a. • . L OWER TO REMO VE AL L IMPERVIOUS MA TERIA L BENEA TH THE L EA CHING AREA '- 0* -O' REPLACE EXCA VA TED MA TERIAL WI TH -O CL EAN, CL A Y FREE SAND O" EFFECTIVE DIAMETER 00 GENEF.°A L NOTES L EA CHING PIT n L© t 1 . ALL EL EVA TIONS SHOWN ARE BA SED ON INSTALL ON LEVEL BASE 2. ALL PIPES IN rc S YS TEM MUS T BE CAS T IRON ' OR SCHEDULE 40 PVC. hr r A J1 LION PI T 3. THE BOARD OF HEA L TH MUS T BE NO TIFIED \ �8 WHEN CONSTRUCTION IS COMPLETE PRIOR Y' TO BA CKFIL L ING PERCOL A TION RATE.' _; S7, 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED 2 MIN./IN. BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WI TNESSED BY"" SURVEYING CO., INC. T. MCKEAN Lo` cj / Za 5. MATERIALS AND INSTALLATION SHALL BE IN 49, 215 t 6F - - 22 COMPLIANCE WI Th THE STA TE SANI TARY BARN, BRO. OF HEALTH DESIGN DA TA CODE - TITLE V - AND LOCAL APPLICABLE DA TE.' F��. 64�i,�� RULES AND RE'GULA TICNS 6. NORTH ARROW IS FROM RECORD PLANS AND NUMBER OF BEDROOMS 3 IS NOT TO BE USED FOR SOLAR PURPOSES TOPSOIL G GARBAGE DISPOSAL NO 7. FLOOD HAZARD ZOVE c� DA I L Y FL OW 330 GAL . B. WA TER SUPPLY suesorL SEPTIC TANK REO 'D. 1000 GAL . SEPTIC TANK PROVIDED 1000 GAL . .-A L EA CHING REGUIRED 330 GPD. G�', MEDIUM SAND SIDEWALL AREA S. F. S. F. X 2. 5 G/S. F. = 3_7 SPO %. �� �''j A i2o•�5 \ BOTTOM AREA = 1 1 3 S. F. RPM / LEGEND 11—SS. F. X 1. 0 G/S. F. = 1 ( 3 GPD LEACHING PROVIDED 4-50 GPD PROPOSED EL EVA TION _ n A, , `z -- � � — — EXISTING CONTOUR `O OBSERVA TION PIT ❑ DIS rRIBUTION BOX 11CHAa4j PROPOSED SENA GE DISPOSAL S YS TEM sE,29891 O � AND �ga�a LEACHING PIT PREPARED FOR o o SEPTIC TANK WILL G JEAN ROGERS (RP l RESERVE � LOT 5 TOPSA IL CIRCLE �' � BA RNS TA BL E — MA .O: PIPE INVERT EL EVA TION cr k _ CAPE 6 ISL ANDS SUP VE YING, INC. PLOT PLAN \ IsF �fl.y- SCALE AS NOTED P. D. BOX 334 SCALE.* 1 . '` PLAN NO. S 2 � �J TEA TICKET, MASS. MAP SEC PCL LOT HSE 2