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0058 TRACEY ROAD - Health
58 Tracey Road Cotuit A = 005 — 056 L3Massachusetts Department of Environmental Protection Bureau of Resource Protection rn rfJ Well Completion Reports Well Driller Please specify work performed: Address at well location: ............ New Well Street Number: . Street Name: 58 TRACEY ROAD Please specify well type: Building Lot#: Assessor's Map#: Irrigation 5 Assessor's Lot#: ZIP Code: Number Of Wells: 56 02635 CitylTown: Well Location BARNSTABLE In public right-of-way:• GPS t"Yes t'":No North: West: 41.60013 70.45860 Subdivision/Property/Description: Mailing Address: click here if same as well location addres ..............._....___..................._..._............_..........--........ Property Owner: Street Number: Street Name: LUSSIER 58 TRACEY ROAD City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: ` 02635 Board of health permit obtained: G.Yes €"'Not Required Permit Number: Date Issued: W2020 20 07/13/2020 _.............................................................. y� M&WOMassachusetts Department of Environmental Protection Bureau of Resource Protection-Well Driller Program Well Completion Reports(General) rl` Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger Choose Bedrock-- WELL LOG OVERBURDEN LITHOLOGY i l _ Drop in drill Extra fast or slow Loss or addition j From(ft) i To(ft) Code Color Comment stem i drill rate of fluid 0 20 Sil Sand Brown ! Fast °Slow ►iL _ .� ! YES NO i __ _ Loss Addition _ r- -- i ( r 20 35 S!Ly Sand 1 Brown ' • r Fast r Slow - ! � --- ?� YES NO Loss Addition ;? 40 Medium Sand Loss Addition j Brown ! ! Y:. f Fast Slow I! ES NO ! ......... _ ...... r f°`: {" 40 50 (Fine To Coarse S i ! Brown Fast( Slow �i� Fin. ... . �t. .........._.. .. � ��� Y tt i E Loss Addition _....................................... S NO WELL LOG BEDROCK LITHOLOGY _..... ................_..__.........._.._-:....................................................................._...._......_.._.. .............. Loss or Extra i Drop in i Extra fast or i Visible Rust From(ft) I To(ft) Code Comment addition of i Large . ! drill stem I slow drill rate fluid Staining Chips ! P EYESN f Cf Fast Slow Loss Addition ADDITIONAL WELL INFORMATION Developed f�Yes f No Disinfected 0Yes r No __ Total Well Depth 50 Depth to Bedrock Surface Seal Type No.. � racture Enhancement Yes No CASING Is Casing above ground? i From To Type Thickness Diameter Driveshoe I _ . .. _ 0 47 Polyvinyl Chloride Schedule 40 T (4 i i( ( L.......VJ.................... Yes i .. ....._................_: (............................... SCREEN Ir-'No Screen From To Type Slot Size Diameter I 47 50 Stainless Steel Well Pont .T.........................._..._...1_ .................-."::.-"'..,-`:.':....".."":..." ........_.._......._..= ...................................._.................................................................................................................................................................................................; WATER-BEARING ZONES r -DR WELL; !From To Yield(gpm) �_ 33 -' PERMANENT PUMP(IF AVAILABLE) 2 Wirt •e Constant Speed Pump Description Horsepower Submersible 3/ Massachusetts Department of Environmental Protection Bureau'of Resource Protection—Well Driller Program a ` .. Well Completion Reports(General) Pump Intake Depth(ft) 45 Nominal Pump Capacity(gpm) 15 ANNULAR SEAL/FILTER PACK ----- -..._..__....-_..._.............._-....-...._.._...._........ - - - ------ From To Material 7 Weight Material 2 Weight Water ;Batches Method Of (gal) '(count) Placement Choose Material ( Choose Material Choose One WELL TEST DATA Time Pumped j Pumping Level(ft j Time To Recover Recovery(ft Date Method Yield(gpm) (HH:MM) 1 BGS) (HH:MM) _ BGS) _ ....... 7/29/2020 Constant Rate Pump 1230^m 34 0:01 !33 ; WATER LEVEL i Date Static Depth BGS(ft) Flowing Rate(gpm) Measured 07/29/2020j 33µ COMMENTS , WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. WILLIAM Monitoring[M] Supervising Driller DESMOND, DrillerURQUHART Registration# 877 Signature PATRICK, DESMOND WELL _ Date Job Complete Firm DRILLING INC. Rig Permit# 0551 `09/17/2020 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. ENMOTECHLABORATORIES, INC MA CERT. NO.:M-MA 063 8 Jan Sebastian Drive Unit.12 Satuhvich,AM 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Desmond Well Drilling Location Address PO Box 2783 58 Tracey Rd Orleans; MA cotuit,MA 02653 Lab Number DW-202535 Collected By: Iwo Date Received:: 07/30/20 Sample Type: Irrigation Well Specs: 50733' ��4 ��gLQC[t/1011 SptGe �s Zlrrte CUTI Ge ed,��Tiire Callec%mod � �� `� � �- �omments ���Y`a��� r07/29120 Analysis Regitested Units Reconnnended Limits AtialysisLRestr/t Met/ror! Date;Ana/yzed Ana/yzed By Total Coliform CFU/100mL 0 0 SM022B. 07/30/2020 RL @ 18:00 -- pN pH units . _ 6.5-&5 6.17 SM 4500=H B 07/30/2020 SD —. — Specific Conductancen umhos/cro 500 132 EPA 120.1 07/30l2020 SD __.._._. -....... .... Nitrite-N mg/t 1.00 SO.00ti EPA 300.0 07/31/2020, ILL_ _ _._ Nitrate N mg/L 10.0 4.20 EPA 360.0 07/31/2020 LL _ ......... Sodium. mg/L 20.0 9,9 EPA 200.7 07/31/2620 KB _ _........... -..... _ Total Iron mg/L 0 3 002 EPA 200.7 07/31/2020 KB _...._... _ Manganese mg/L 0.05 0.038 EPA 200.7 07/31/2020 KB Comments: pH is below recommended limit and may have corrosive characteristics. All samples were analyzed within the established guidelines of US EPA approved methods with all'requirenie_nts met, unless otherwise noted at the end of a.given sample's analytical results. We certify that.the following results are true and accurate to the best.ofour knowledge. Water meets EPA standards and is suitable for drinking for parameters tested.* ' --'� Date 8/3/2020 ..............--..—__._.,..............._._...._.__._-.....................:._._. Rona d J.Saari Laboratory Dir ctor BRL jYeloidReporlable Limits 'See Attached Page 1 of 1 oCertification is lot available.for this ahalyte_(or potable water samples.. No. d @ ;o Fee9 BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou _for Vern Cougtruction Perron Application is hereby made for a permit to Construct O(1, Alter( ), or Repair( ) an individual well at: 5 8 "�cteL24 A, CiWk 515� Lo ion-Address Assessors Map and Parcel Lk,�.ss;cc P- So. 1o0a , C,0+k A-1h A sD243S Owner Address De-SVY'Nb \gyp\\Q:& z71b3, nfkAhs o7M3 Installer-Driller Address Type of Building Dwelling X Other-Type of Building No. of Persons Type of Well S C►A4b VI C Capacity i Si M m Purpose of Well �f Cl'q��Cl�bin Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certifica a of Compliance has been issued by the Board of Health. Signed r a 424) Date Application Approved By m ate Application Disapproved for the following reasons: Date Permit No. �j Issued 7 Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed()4, Altered( ), or Repaired( ) bY- 51-�cs,-�� \�j \� �t<�\�rw lint Installer at c jp CVki- has been installed in accoAlance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. d G a" Fee BOARD OF HEALTH " TOWN OF~BARNSTABLE 01ppricatiou _for Yell Con5tructiou Permit Application is hereby made for a permit`to Construct( Alter( ), or Repair( ) an individual well at: i. Loca ion-Addresses Assessors Map and Parcel C-0+t1,► ,MA c�Z63S Owner Address Installer-Driller Address Type of Building Dwelling X IV Other-Type of.Building L :,. _-. . ,_ No..of Persons Type of Well t, S C;\��(l� V A C Capacity Purpose of Well ,{-o-qc*rr, --,� .. � '� C}F fir Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a CertificaK of Compliance has been issued by the Board of Health. Signed XA i3 241D L //�� Date Application Approved B d /L,1 / v61 PP PP Y ate Application Disapproved for the following reasons: Date Permit No. O o Issued %� Date _ BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed N, Altered( ), or Repaired( ) by ,p Installer at has been installed in acc r ance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE -N)-erf-Cougtructi-ou Permit- No. I } 7 ' y Fee v- t Permission is hereby granted to j,)UV-,,6r4 Installer to Construct(IQI, Alter( ), or Repair( an individual well at: No. S% Tc a uA, )?\A , r,o,"�-` Street as shown on the application for a Well Construction Permit No. ,Zo Z° ' Dated Date ��( � ,�. y Approved By h � � / I COTUIT o U�S PARCEL ID: / N69. 004 05/55 N / D �' 20 TP.ACEY ROAD \ I `'0c' i LOCUS '1 00 PR pp 710 LOCUS MAP / _ELEC. .: .PLAN REF: LCPJf11260-0 .TITLE REF: CTFP 195424 PARCEL ID: MAP 5 PAR. 56 ZONING: "RF° SETBACKS: 30'f— 15'S— 15'R WATER " 37.6' WITHIN 1 MILE WIND DISTRICT: EXP. 8 .�, MAX. BUILDING HEIGHT: 30' is 'iir.. •i - ,FLOOD ZONE: "X" Q � / #58 "eCk�.''. COMMUNITY PANEL, 25001C0752J DATED:07/16/14 45.3' 3DWELL�GM CERTIFIED PLOT PLAN / 3 GAS, <; , , (FOR GARAGE ADDITION) LOCATED AT: 0 58 TRACEY ROAD co COTUIT, MA. i PREPARED FOR ' SEPTIC o� o PER TIE CARD GUY P. & JOLYNN M. �! O LUSSIER o/ JUNE 5, 2015015 PARCEL ID: .... / 05/56 PARCEL ID: / AREA=20,2503 S.F,, 05/18 Sgg 28 °o£ MacDougall Surveying & Associates GRAPHIC SCALE 13soo P.O. Box 2428 I 20 o 10 20 b Mashpee, Ma. 02649 PH. 508 419-1086 PARCEL ID: fax (508)419-1087 ( IN FEET ) 05/57 email: 1. inch = 20 tt„ - mocdougallsurvey@comcast.net 1 SHEET`.I OF 1 .i#1756 I, Commonwealth of Massachusetts --- Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's°Name iequired for every —y is re Cotuit MA 02635 Jul 1, 201`1 page. City/Town State. Zip Code Date of Inspection: Inspection results must besubmitted on this,form.Inspection forms may not:'be altered'in-any way. Please see completeness checklist at the end of the form. Important:when A. General Information: filling out forms on the computer, �t use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return key. Name of Inspector Eco-Tech Environmcntaf Company.Name 43 Triangle Circle Company Address Sandwich MA. 02563 City/Town State Zip Code 508 364 0894 1,328 Telephone Number License Number` B. ;Certification . certify,that I have.,personally,inspected;the sewage disposal system,at this address and that the information reported below'is true,accurat&arid 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(310CMR 15.0.00). The system: 0 Passes ❑ Conditionally Passes 0.7Ftails E Needs Further Evaluation by the Local Approving Authorityr t C j d!y 11, 2011_ Inspector's Signature Date —t The system inspector shall submit a copy of this inspection report to the>Apptoving Autllorityoard f of Health or DEP)'withinW days of completing this inspection. If the system is.a shareWsystem or has a.desig'n flow of 10,000 god or greater, the inspectorand the system owner shall submit-the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use atthat time.This inspection does not address how the system will perform in the future under the same or.different conditions of use, y t5ins.•.09/08 Tdle 5 Offcial InspeUiori Fo�m::;SubsuAace Sewage D' 'sal System• age 1 of 17 Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a, 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's.Name _ information is Cotuit MA 02635 July 1, 2011 required for every, page. City/Town State Zip Code. DaWof Inspection B. Certification (cont..) Inspection Summary: Check A,B,C,D or E/always complete al of Section D A) System.Passes:. Q I have not found any information which indicates that-afly 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; r Inspector's Note==> A septic system is deemed to pass this Rear Estate Transfer Inspection if it does not trigger any of the failure criteria listed'below.-The septic systeen has been evaluated according to the,conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes ❑ one or more system components as describedin.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 extiltration or tank failure is imminent. System will pass in if the existing tank is replaced with a complying septic fank as approved by the Board of Health. *A metal septic,tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available ❑ Y ❑ 'N ❑ ND(Explain below): t5ins•09108 ritle 5'Ofrdal Inspection Form:Subsurface Sev3age Disposal System•Page 2 of 17 Commonwealth of Massachusetts: Tithe 5 Official IhSpecti'®n Form Subsurface-Sewage Disposal System Form -Not for Voluntary Assessments 58 Tracey Road Property Address Paul and Diane Foster Owner Owners Name- information is Cotuit _ MA 02635 Jul 1, 2011 required for every y page. City,Town i State Zip.Code Date of Inspection B. Gertification :(cont) B) System,CoAditionall Passes cont,, y (cont.): ❑ Observation of sewage backup or breakout or high static water level inth6 distribution.box due to broken or obstructed pip.e(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health); ❑ broken pipes)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ N'D (Explain below): ❑ distribution box is leveled.or replaced ❑ Y ❑ N ❑ ND (Explain below) ❑ The system reglured.pumping more than 4 times a year,due to broken or obstructed pipe(s). The system'W'ill pass inspection`if(with approval of the Board of Health)- t ❑ broken pipe(s)zre replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction'is.removed ❑ Y ❑ N ❑ ND (Explain below); G), Further Eva luation'is Required by,the,B.oard 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 riot functioning- in a manner'which will protect public health, safety and the environment: - ❑ Cesspool or privy is within 50 feet of.a surface water W... Cesspool.or privy is within 50 feet of-a bordering vegetated wetlandor'a salt-marsh t5ins-,09V08 Title official Inspection Form:Subiurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts -_ Title 5 Official Inspection Form. Subsurface.Sewage Disposal System Form-Not for Voluntary,Assessments 58 Tracey Road Property Address Paul and Diane Foster Owner _. Owner's Name information i required for every- Cotuit MA^ 02635 July 1, 20:11 page. City(Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in-a manner that protects the public health, safety and environment: ❑ The;system has a septic tank and soil absorption system (SAS)and the SAS is within 100.feet ,f 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 y tem'lias,a septic tank and SAS and the SAS is-within 50 feet of a private water supply well ❑ The system has a septic;tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if;the well,water analysis, performed:at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than ppm, provided that.no other fail ure,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 ElBackup of sewage into•facility or system component due to overloaded or clogged SAS or cesspool ❑ . z Discharge or ponding of effluent to the surface of.theground or surface waters due.to an overloaded or clogged SAS-,or cesspool ❑ Q 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:lessIhan 6 below invert or available volume is less than '/day flow 15ins-09108 Title 5 Afficial Inspection F.ofm:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts. __ -- Title 5 Official Inspection Form Subsurface Sewage Disposall System Form- Not for Voluntary Assessments 58 Tracey Road Property Address Paul and Diane Foster` Owner Owners Name_ information is Cotuit MA 02635 Jul 1, 2011' required for eue y page. ry .c4trown state Zip Code Date of Inspection B: Certification (Copt:) Yes No ❑ M Required pumping:more than 41imes intheaast year NOTdue.to clogged or obstructed pipEl(s). Number of-times pumped': ❑ Q, Any-portioh of the SAS,,cesspool or privy is below high ground water elevation.- ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary,to a.surface"water supply. Any`portion of a cesspool or privy is Within a Zone 1 of a public well, Apy portion of a.cesspool or privy is within50 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 at DEP certified ' laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to orless 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.] ❑ E The system is a:cesspool serving a facility with a design flow of 2000gpd- 1`O,000gpd. o 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,1.5,000 god: For largesystems;you must indicate either''yes"or-"no"to-each of the following, in addif on 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 EJ 'the:system'is located in,a nitrogen sensitive area(Interim Wellhead Protection Area—IWP,A)or a mao'pe d.Zone II of a public water supply well If you have answered "yes"to any question in Section E,the sy'stern is considered a significant':threat; or an veered "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 a 69/08, Title 5 Officia6.Inspech' Form:Subsurface Sewage Disposal System•Page,5ofa7 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments 58 Tracey Road Property Address p Y Paul and Diane Foster t Owner Owner's Name information is required for every Cotuit MA, 02635 July1,2011 page. Gityrrown 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health' ❑ 0 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) Z ❑ Was the facility or dwelling inspected'forsigns of sewage back up? 0, ❑ Was the site inspected forsigns 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 sizeand 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. ElDetermined in the:field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of.bedrooms (design)' 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203.(forexample: 110 gpd,x.#'of_bedrooms): 330 g s 15ins•09/08 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth-of'Massachusetts j Title 5 officiall Inspection Form. — Subsurface Sewage Disposal System Form-Not.for Voluntary Assessmenfs w _ 58 Tracey Road Property Address .Pb.ul.and Diane;Foster Owner Owner's,Name. information is Cotuit MA 02635> 1, 20.11 required for..every ' ., 'July—_ page. Cltyrrown State Zip Code Date.of Inspection; D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes M No Is,laundry'on;a-sepa"rate sewage system?(if:yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes. 0 No Water meter readings, if available last 2 ears:usa a d ):. 104`gpd g ( Y 9 (gp )). Detail: 2009-2010 sump pump? ❑ Yes No Last.date of occupancy: current Date Commercial/Industrial Flow Conditions: _T.ype of Establishment: Design flow(based on 310 CMR 15.203) Gallons per day(gpa) Basis of design flow(seats/persons/sq.ft_etc.): Grease trap present?' ❑ Yes ❑ No Indusfrial_waste holding tank pre8eni:7 ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes• ❑ No Water meter;readings if available; i5 ns a09108; Title'5 Official Inspecdon Form;Subsurface Se wage;Disposal System-0a90 o!17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_ 58 Tracey Road Property Address Paul and Diane Foster Owner V Owner's Name Information is Cotuit MA 02635. July1, 2011 required for every page. City/'Town State Zip'Gode Date of Inspection D. System Information (con..) Last date of occupancy/use: Date Other(describe.below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes 0 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.IIA system by system operator under contract ❑ Tight tank. Attaeh.a.copy of the REP approval.. _._ ❑ • Other(describe): 15ins,39108 Titlei5;01ficial Inspection Foam:,Subsurface Sewage Disposal System•Pago B,of 17 Commonwealth of Massachusetts: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's Name information is Cotuit MA 02635. Jul 1, 2011 ; required for every y 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: Ageyears. Certificate of Compliance dated 9/10/1984(.p'ermit 84-629).: Were sewage odors detected when arriving at:the site? ❑ Yes JZ No Building.:Sewer(locate on site'plan): 3 Depth below grade: feet Material of construction: ❑ cast iron 0 40 PVC ❑,other(explain): .Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc:): Sewer line app.ears.structurally sound with no;eviderice of backup orleakjagle-into dwelling. .Septic Tank(locate-on-site plan)- 2 Depth below grade: feet Material of construction: E concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If'tank.is metal, Fist age: years Is,age confirrrted;by.a Certificate of Compliance?(attach a copy of certificate) ❑ Yes El No Dimensions: lo 85 ft x 6 ft x 5 ft(1000 gal) _ Siudge depth:. 4 In 15ins•.09108 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System•Pege:9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's Name information is required for every Cotuit MA 0263'S July 1, 2011 page. Cityrrown State Zip Code Date of Inspection D. System. Information (cont.) Septic Tank(cont.) Distance from tap of sludge to bottom of outlet tee or baffle 30i in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet.tee or baffle 74 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet:and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time but maintenance pumping is recommended within and every two years. Inlet cover is under brick patio and not accessible for inspection. Outlet cover has riser for pumping access. Tank appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan),- Depth below grade: feer Material of construction-.. ❑ concrete ❑ metal El-fiberglass ❑Ipolyethylene ❑ 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 15ins;•09108 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 10rof 17 Commonwealth-d Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments. 58 Tracey Road Property Address Paul and Diane Foster Owner Gwner's:Name information is Cotuit MA 02635 Jul required for every y1, 2011 page. Cityrrown 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' 0 polyethylene ❑.Other.(explain):, -- _ Dimensions: Capacity: gallons Design.Flow: gallons per,day Alarm present: ❑ Yes ❑ No Alarm level` Alarm inworking order; ❑ Yes ElNo "Date of last pumping- Date Comments,,(condition of alarm and float switches etc•):: `:Attach copy of,current.pumping contract,(required,). Is copy attache d? ❑ Yes ❑ No 15 ns>;09/08 Title 5 Official Inspection Form..Subsurface;Sewage,oi5posal System•Page 11 of 17 ,ti Commonwealth of Massachusetts - _ r Tithe 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments — 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's Name information is Cotuit MA 02635 Jul 1 201.1 required for every y pager Cltyrrown 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of-solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage'in or out. Some solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leach pit. Pump Chamber(locate on site plan,): Pumps in working order: L ❑ Yes ❑ No Alarms'in working order: ❑ Yes. ❑ No Comments(note condition of pump chamber, condition of pumps.and appurtenances,etc.): — I Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: t5ins•09108 Tille 5 Official Inspection Form[Subsurface.SewageDisposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol untary,Assessments, 58 Tracey Road. Property Address Paul and Diane Foster Owner _.: 'owner's'Name requirati is.for-every Cotuit MA 02635 Jul. 1, 2011, . re wired _ page. City/Town ,State Zip Cotle' Date of Inspection D. System Information (cont) Type; 0 leaching pits number: ❑ leaching chambers number's EJ leaching,galleries number;; Iraching-frenchee 4• - - `, number;'leng h; El leaching fields number; dimensions: overflow cesspool number: -0 innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level ofponding,.damp soil; condition of vegetation, etc.): Soils above'leaching pit appear unsaturated. Nq evidence of surface ponding, breakout, lush vegetation, or:other evidence of hydraulic failure was observed:A bucket of water was poured into, the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down-into the leaeh pit: Cesspools (cesspool must be pumped as-part of inspection) (locate on site�plan): Npmber and`coce guratton Depth--top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of`construction u�_ „Indication of,groundwater inflow.. .. ._ . _ _ ._ .__ Q Yes. ❑ No iSins•Ogl08 Llle 5'Offcial Inspection Form:Subsurface Sewage.0isposai,system ?age:13 of 17 Commonwealth of Massachusetts: u• v Title 5 Official. Inspection 'Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's•Name information i e COtUit MA. 02635 . Jul 1 2011 required for every y page. Cityrrown state Zip`Code Date of Inspection D. System Information (cont.) Comments(note condition,of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 official Inspection Form:Subsurlace.Sewage-Disposal System;Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official InspectionForm. R — s Subsurface Sewage,D sposal System Form -Not for Voluntary. ssessments 58 Tracey Road Property Address Paul and Diane Foster Owner -- - Owner's.Narne information is Cotuit MA 02635 Jul 1, 2011 required for.every, y page. Citylrown State Zip Code Date of Inspection. D System. Information (cont) Sketch Of Sewage Disposal System: Provide a view°of`be sewage disposal system, including ties to at least two permanent reference..landmarks or'benchmarks Locate all wells within 100 feet. Locate where public.watersupply enters the building. Check one of the boxes below; hand-sketch.in the area below ❑ drawing attached separately' v 'A 3 7%Z Q I�r�2 I- N W t5ins-69108 Tide 5 Official Inspection Form:Subsurface Sewage Disposel System Page,15.of 17. Commonwealth of Massachusetts Title 5 Official Inspection (Form s a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Tracey Road Property Address Paul and Diane Foster Owner Owner's Name information is required for every Cotuit 'MA 02635 July 1, 2011, ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam! R. Check Slope ❑ Surface water Check cellar Shallow wells Estimated depth to high ground water: 19 ft feet .Please indicate all methods used to determine the high ground water.elevation: Obtained from system design plans on.record lf'checked,date of design plan reviewed: 8121184 Date ❑ gbserved 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: Barnstable GIS Department records You must describe how you established the high.ground water elevation: Septic design plan shows bottom of leaching pit to be.2.5 feet above the bottom of a witnessed test pit in which no groundwater was observed. Town of Barnstable GIS Department records indicate that the property is 19 feet above.neaeby Shoestring Bay. Before filing this Inspection Report,;please see Report Completeness Checklist on next page. t5ins r og/68 a - .. 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 Assessments Tracey Road Property Address Paul and Diane Foster Owner ' _ � ._ - • __., . .. Owner's Name information is required for every Cotuit MA. 02635 July 1, 2Q11 page. Cityrrown State Zip Code. Wte of.lnspection E. Report Completeness Checklist Inspection Summary: A. B, C. D, or checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information Estimated doPth'to high groundwater Sketch of Sewage Disposal.System either drawn on page 15 Or attached in'separat i file. 15ins•09108 a, Tide 5 Official Inspectionform:Subsurface.Sewage Disposal:System .page 17.of`17 " 005 ' t' � M 4 COMP�tONWEALT.r,�'OF ASSACHUSETTS {` 9 d ExECUTIVE OFFICE OF ENVIRONMENTAL q IRS s V �f IS DEPARTMENT OF ENVIRONMENTAL TEC'D1 d ONE WINTER STREET. BOSTON. MA 02108 617-29 -rF 001104 1997 � H�ciyoFsrAB[E N WILLIAM F.WELD Pr UDY CORE Governor ` Secretary ARGEO PAUL CELLUCCI �+ y AVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 53 Tracy Rd. Cotult, MA Address of Owner: care Date of Inspection: 5/22/97 (If different) Name of Inspector: Fr_,r-jprj dc Kiejy I am a DEP approved system insnectnr nurcuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Fx itainsttal Reclamation, Inc. Mailing Address: PO Box 3596 Wa uoit MA 02536 Telephone Number: — CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XXX Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 6 I n The Svstem Inspector shall submit a copy of this ii.6;ction 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 office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 3, C, or D: A] SYSTEM PASSES: I have not found anv 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. COMMENTS: The system is well constructed and has been properly maintained 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Paqu 1 of 10 OEP on the Wond Wide wed: htmwwww.magnet.state.ma.uwdeo l�.� Pnnted on Recyced Paoer � a it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,.r CERTIFICATION (continued) Property Address: 158_Tlacy-and. Cotui t Owner. Mr. Menze Date of Inspection: 5/2 2/9 7 BI SYSTEM CONDITIONALLY PASSES (continued) v Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed WA _ pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: WA Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 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 ate less than 5 ppm. Method used to determine distance approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 j r fr SUBSURFACE SEWAGE DIiPOSAL SYSTEM INSPECTION FORM PART A t - CERTIFICATION (continued) Property Address: 58 Tracy Rd. COtuit - Owner: Date of Inspection: D) SYSTEM FAILS: N/A You must indicate ei:!•,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply ` the system is located in a nitrogen sensitive area (Interim Wellhead.Protection Area,- IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements,of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 L } SUBSURFACE SEWAGE &ISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST L Property Address: 58 Tracy Rd. Cotfiit Owner: Date of Inspection: Check if the following have been done: You must indicate either "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 _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates duri ng g that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been obtained and examined. Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components, excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) page 4 of 10 ( r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION 'Property Address: 58 Tracy Rd. COyuit Owner: " _Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 660 p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder (yes or no):aa_ Laundry connected to system (yes or no):__yes Seasonal use (yes or no):__Yes Water meter readings, if available (last two (2) year usage (gpd): minimum Sump Pump (yes or no):j.-_,aQ Last date of occupancy: current COMMERCIAUINDUSTRIAL: N/A Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_yes If yes, volume pumped: unknOWTtallons Reason for pumping: ganara 1 ma i nta i nanra TYPE OF SYSTEM XXX _ 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: installed On 9/05/84 Sewage odors detected when arriving at the site: (yes or no)no (revised 04/25/97) Page 5 of 10 t • f. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 58 Tracy Rd. Cot�uit Owner: Date of Inspection: BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:24 (locate on site plan) Depth below grade: Material of construction: X concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 5.6 x 1 0_h Sludge depth:N� Distance from top'of sludge to bottom of outlet tee or baffle:.U(g 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 How dimensions were determined: builders plan / site inspection Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: _concrete _metal =Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (ravimad 04/25/97) Page 6 of 10 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 2 PART C SYSTEM INFORMATION (continued) Property Address: 58 Tracy Rd. Cotu.it Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology:- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) tic signs of break=aut-or ponding CESSPOOLS: NSA (locate on site plan) Number and configuration: Depth-top of liquid 'o inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: N/A (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.) (revised 04/25/97) Page 8 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "RT C SYSTEM INFORMATION (continued) Property Address: 58 Tracy Rd. Cotuit Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) N/A (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) D- box is level and shows no sign of solids PUMP CHAMBER: N/A (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 / f J '1 SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 58 Tracy Rd. Co_tuit ' Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revimed 04/23/97) Paqu 9 of 10 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 58 Tracy Rd. Cotuit Owner: Date of Inspection: Depth to Groundwater?r; Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) X Determine it from loral conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers X _ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 2Ie FrcpErty is located within the 30 foot elevation on the USGS Cotuit Quad 1974. During the site inspection it was noted the the basement of the home was dry enough to store Books without a dehumidifier- (revised 04/25/97) Page 10 of 10 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Frederick Kiely 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 21A of the General .Laws. Issued by The Department of Environmental Protection. to Poll Control December 12 ,1995 Acting Director of the ton OF Wa r ution ont of 1. ©, TOWN OF BARNSTABLE LOCATION D �RAC `f �® SEWAGE# 'V} VILLAGE Cal V t ASSESSOR'S MAP&PARCEL S S 6 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 a g i n, LEACHING FACILITY:(type) P (size) l�b NO.OF BEDROOMS OWNER `I��UL. l),we �p5 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ECO TECK T-ADSP '711N 714 n vi cia d . P W 7 x 2 } t r _J b m C f�1 v _ m z H g � 3 V J 3 Cl N 20 - C v v v � t z v .- __ :r,.,. d (� Cs e�i�, k �� t i ���j n �, � �,. 1cI /�1�� � �' �� �. '�� �' ��2 � '��. R, , t a No .-. .. Fw$...::r.............. Pars _ THE COMMONWEALTH OF MASSACHUSETTS ` BOAR® OF HEALTH A;i;t irafilan for 1 sVoii l Works Tontitruttiun Prrutit Application'is ,hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............. .ca. .... ........T-R- cey.....Ad.......... .................................................................................................. Locatie -Address / l. _t .5_ - ?S FAQ Kctr .. .or _ ---• •-------••--------• --• Cz Owner Address Installer Address Type of Building Size Lot_._.__..__________________S . d yP g q feet Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( ) a14 Other—T ype of Buildin g ____________________________ No. of persons............................ Showers ( ) — Cafeteri� ( ) dOther fixtures ...----••------------------••--.....------------_...-.------••-----------------•-•-•--•--•-••----•-•-•••------------------•-----------•-•........---- W Design Flow................%m�...............gallons per person per day. Total daily flow.......Z, ......................ga)ons. WSeptic Tank—Liquid capacity." ..gallons Length._1 _.. Width:i97~ .._ Diameter________________ Depth__. ....... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter'.................. Depth below inlet....../_1......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-----•----•----•-----------------•------•-----••------------•--•-•---_.. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •••-•-------•-•----••--•-------------------------••-•----------....•-----............_...._............---•------.._...._....-----........-------•••-•------. ODescription of Soil........................................................................................................................................................................ x V ............•--•-----•-•....---•.....................•----------•-------•--....-----•••----••----.......-----------•------•--------------------------•---•---------•----------...--•--------•------------ W U Nature of Repairs or Alterations—Answer when applicable.--_.......................................................................................... .......-•-•--•----•---------------------------------------•---------------•----•--•-----------------••-••-•---•---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board 01 oIf heal. gned•--....--- .......-�C�_v ---•---- --------• --------------------- Application Approved B - -•--- -------- Date Application Disapprove r t e following reasons:-----•--------•---------------------••-•----•-----------.....---------------•--------...._...--•----.......---- •------ ---------------------•------------------------------------------------------------•--------------•---•--- -------------- Date PermitNo.......................................................- Issued....................................................... Date Devartment of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT ` WELL LOCATI N Address 0 - rA c l -� City/Town rAlCifrt M, G.S.Quadrangle Map Grid Location Madr Q OwnerTLA.) MC SAatiC Address /V QN ouG tn90 2'uN' WELL USE CONSOLIDATED WELL 'Domestic R Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones Method Drilled Qu�e 1) From To J 2) From To Date Drilled Q ' 31 From To -- - 4) From To ,CASING Depth to Bedrock Length a/^/ Diameters_ Type UNCONSOLIDATED WELL STATIC WATER LEVEL, Water-bearing Materials Feet below land surface San :d fine❑ medium[�coarse� .Date measured Gravel: fine❑ medium❑ coarse❑ Screen: GRAVEL PACK WELL Slot# /0 length 3 from 'n 'to S� Yes ❑ No ❑ 'Split Screen (or 2nd screen) WATER QUALITY TESTS MADE Slot# length from to Chemical [ Biological ❑ Depth To Bedrock PUMP TEST �y Drawdown feet after pumping• days /. hours at- O GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To � o m n. _T DRIL Cz LER m Firm G 2 Or - e aAddresseb. ,(O -I^6 e City 4 CLI Registration o. S of Operator's ig ature ea�print CUSTOMER COPY 15M-2 84-176471 No................. ... �._ f FE$.......................... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH a ..........................OF...................................................... ° .... .................... ppliration for Uiipoiaal Workii Tonstrurtion .rranit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...-•--••---•---...............•--.........•--.......--•--.....----------•-•--••-•---•----•--•... ......•-•---....------......-----••--•--------......••----•-•-----•---......------..........------ Location-Address or Lot No. .........................O r........... ..........--..------.........................--- css................---------...............--- W Owner Address a ---------------------•-••--•-----•--•••••----•-•-...----.....:...._......•............._....••••.. ------......--------..........-----------•--•-...-----•........................... ••---.....---- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p.I Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) d Other fixtures ---•-----------------------------••----•-----•--- ---------------------------------------- ------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_-__-___.._.___- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage.Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .--••-------------------•----•-........•------•----•••.....--•--•-•---------•-••------•--------------------------------------- •----------- --------- •--------- 0 Description of Soil........................................................................................................................................................................ x V .....-••--••-••--•-•-•-•....•-•---------------•-------------------•--••-•-----------••-----------•-----------•••--•--•-•-----•-•-------•-••----•--•••---------•--•-••--•---------....-------------------- W ---------------------------------------------------------...................................---------------------------------------------------------------------------------------------------.------ M. Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------•--------------------------•---------------...------•-•--...------------...---------------------------------------------------------------------------------------...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... Date ApplicationApproved BY.................................................................................................. Date Application Disapproved for the following reasons:.............................................................................................................. - ..............................................................................------...•-•--------•-•--.......-••----------•-•---•--•-••--•-----------------•--•-------•-•......------••-•-•----._..... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..............................................................I...................... CInfifirtt#e of Tontpliatta THIS IS T CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) b . .R. ........................................... ...... ................................................................................................................. ram^" Installer at._.. . ...::�. ----------------------••.-----------------------------------------------•--------------------------------------------- has been installed in accordant wtl the provisions of TITe,y 5 o Th State Sanitary Code as described in the application for Disposal Works struction Permit No..__._ ..� .�........ dated.............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................................... Inspector...................-- ---------------•----•-•---------•--•------............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH fr/ ......................................OF..................................................................................... �G 1 No...... .... L FEE... ............ �i��o��l� �k� �on��rnr�ion lerani� Permission is her granted...... .....-------•-•------------ -..•--- -----•••-y-----•-•....---•-----------...-•-•-•......•---•-....•--•.................... to Construct o it i al S.wa oral System Street as shown on the application for Disposal ` or Construction Perm N;..:.. ............ Dated.......................................... ----------- ------ -------------- Board of Health DATE FORM 1255 A. M. SULKIN, INC., BOSTON • I.----a---1 < ' III - .. z ' , I I - . . I I I I 14' 6 X. J 1r_6"-- � �Z d Ll -- m ® E 9'-0 314" - - - a I 10, Kee 3'-0.3/4" - - - — - ---,' - + 21' 1 -DESIGN BY: 0 13 Thankful,Lane, Cotuit, MA 02635 L ssie r Nome Renovations tel 508-428-4097 fax 508-428-7709 Wednesday,June io,2oi5 email lagcon@capecod.net- www.LagadinosBuilding.com -------------- R X -i Q ` �Q S m 3 R - X roZ D _ zpi m D C,2 4'-0 3/8"] NA j rn rp m� x A _ t DESIGN BY: 13 Thankful-Lane -Cotuit, MA 02635 Lussier, Home Renovations tel 508-428-4097 fax 508-428-776 Wednesday,June io,2oi5 9 x email lagcon@capecod.net . www.LagadinosBuilding.com Gnca SrWen t� - , QL 906D - iL--- --- } I • I I OH]bIB A°F461D A°M161B — w 5'-4 9/16,, N �2'�j -TI ° 3° 1/2" 3r-9 3/4" j a s N , 15'-1314' I - = 3'-1 1/4' LO m - m - ° a /12-'I"� 2'-9 ,- 4-4 3/4" 4'-V l'-9 1/4" 2'-2 3/4" 5'— 2'- 15'-11 1/4" f „ m c 9'-0 314" -10, - - 42'o j • goo m m b, 2 EF S � Grox5ec4on l: } 3 fl.. r w, m o m o O m _ O _ - - O - - i 1 - IM I DESIGN BY: # 13 Thankful-Lane { Cotuit, MA 02635 .�.USSier Home''Renovations, tel 508-428-4097 ,fax 508-428-7709 Wednesday,June>o,20>5 ` email lagcon@capecod.net www.LagadinosBuilding.com 21, - 6'-'f 3/8" 20'-4 5/8" 6'-2 5/8" 14'-2" - Al*2648- - -------- ----- ------ -1 _ I Zo ! 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