HomeMy WebLinkAbout0101 TROUT BROOK ROAD - Health 10 out Brook Road
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"L Commonwealth of Massachusetts
,Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
101 Trout Brook Rd. n
Property Address
Terri Smith
Owner Owner's Nam
in
formationevery Cotuit ✓ MA 02635 9/30/2016
required CityRow, State zip Code Date of inspection
w
Inspection results must be submitted on this form.Inspection forms may not be altered in ani"
way.Please see completeness checklist at the end of the form.
I ,r A. General Informationng out / ll 93g
on the ofurtputer, -
use only the tali 1. InspeCtOr
key to move your
cursor-do not Paul Martin
use the return Name of inspector
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Cape Cod Septic Services
Company Nam
350 Main St
Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
Telephone Number License Number
B. Certification
I cer*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:
® Pam ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1015=16
nspectoes signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the 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
at that time.This inspection does,not address how the system will perform in the future,under
the same or different conditions of use.
fto•3H3 Title 5 OfWW VqXbw Forth:&M face SmapeDisp and System•Pape 1 of 17
• Commonwealth of Massachusetts .
Q. Title 5 Official Inspection Form
a a Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
101 Trout Brook Rd.
Property Address
Terri Smith.
Owner Owner's Name
information is Cotuit MA 02635 9/30/2016
required for every 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 in working condition
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"_section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
f
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
101 Trout Brook Rd.
Property Address
Terri.Smith .
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑- Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ .Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
mom
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owners Name
information is Cotuit MA 02635 9/30/2016
required for every
page. CirylTown 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is Cotuit MA 02635 9/30/2016
required for every
page. Cityrr vn State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of.a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of.the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E). Large Systems: To be considered a large system.the system must serve a facility with a.
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered.a significant threat,
or answered"yes" in Section D above the large system has.failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 1.5.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is Cotuit MA 02635 9/30/2016
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® 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?
Z ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® 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):. 41 Ox4=
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owners Name
information is required for every Cotuit MA 02635. 9/30/2016
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2014=208gpd
9 ( Y g (gp ))� 2015=203gpd
Detail:
Sump pump? ❑ Yes E No
Last date of occupancy: Current.Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank.present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 , 101 Trout Brook Rd.. -
Property Address
Terri Smith
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
page. Cityrrown State Zip Code Date of Inspection ,
D. System Information (cont.)
Last date of occupancy/use: bate
Other(describe below):
General Information
Pumping Records:
Source of information: No Records
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 l/A system by system operator under contract
❑ Tight.tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M '< 101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
page. Cityrrown State Zip Code Date of Inspection
D.-System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Est. 1995-1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below grade: 1000
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, Fist age: years
Is age confirmed by a Certificate.of Compliance?(attach a copy of certificate) El Yes ❑ No
Dimensions: 1000Gal
Sludge depth: 6-8"
t5ins-3113 _ Title 5 Official Inspection Forth: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
101 Trout Brook Rd.
Property Address
I Terri Smith
Owner Owner's Name
information is Cotuit MA 02635 9/30/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom.of outlet tee or baffle
2-3,1
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good condition. Concrete baffles in place are solid. Tank at normal operating level.
Covers 16" below grade
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•3113 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
101 Trout Brook Rd.
Property Address
Terri.Smith
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
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 ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date`
Comments(condition of.alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M >.•''y 101 Trout Brook Rd. - -
Property Address
Terri Smith
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
page. City/Town 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
Oil
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.):
Plastic DB-3 box with 1 line in and 2 lines out in good condition. Box is clean and level with minimal
solids carryover. No sign of overloading or hydraulic failure. Cover 28" below grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
iI .
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form.
Subsurface Sewage Disposal System Form Not for Voluntary Assessments .
M •''r 101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is Cotuit MA 02635 9/30/2016
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits number..
2-6x6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of'soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-6x6 Pits with stone. One pit found dry with second found with 2'of effluent at time of inspection. No
staining above 3'. No sign of overloading or hydraulic failure. Covers 32" beow grade.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is required for every Cotuit MA 02636 9/30/2016
page. Cityfrown 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-3/13 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
,.•' 101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is Cotuit MA 02635 9/30/2016
required for every
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
t5ins•3/13 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
, 101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
page. Cityrrown 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: +15'
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:
Topographic grade changes. Propery situated on a hill with significant grade.drop. Max bottom of pits
is 9'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 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
101 Trout Brook Rd.
Property Address
Terri Smith
Owner Owner's Name
information is required for every Cotuit MA 02635 9/30/2016
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
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INSTALLER'S NAME&PHONE NO.
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SEPTIC TANK CAPACITY
LEACHING FACn=:(type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: #101 Trout Brook Road MAP
Cotuit,MA PARCEL
Owner's Name: Mark&Cindie Carney .
Owner's Address: 4101 Trout Brook Road LOT �-
Cotuit.MA
Date of Inspection: 9/18/03
Name of Inspector: (please print) Mr.Carmen E.Shay
Company Name: Shay Environmental Services.Inc.
Mailing Address: 34 Thatchers Lane
East Falmouth,MA 02536
Telephone Number: (508)-548-0796
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:
XX Passes 6; €
Conditionally Passes ZNOF�yjgS
Needs Further Evaluation by the Local Approving Authori
Fails o� CARMEN
o E.
Inspector's Signature: Date: 9/18/03 SHAY y
The system inspector shall submit a copy of this inspection report to Approving Authority(Board o VSPE�
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1 ,
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
5.5'Liquid observed in Leach Pit#1. 6"liquid in leach pit#2
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation.by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
XX Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
XX Any portion of the SAS,cesspool or privy is below high ground water elevation.
XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
XX Any portion of a cesspool or privy is within a Zone 1 of a public well.
XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No,
XX Pumping information was provided by the owner,occupant,or Board of Health
_ XX Were any of the system components pumped out in the previous two weeks?
XX _ Has the system received normal flows in the previous two week period?
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up?
XX _ Was the site inspected for signs of break out?
XX _ Were all system components,excluding the SAS, located on site?
XX _ 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?
XX _ 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
XX _ Existing information.For example,a plan at the Board of Health.
XX _ 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)]
f
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
{ SYSTEM INFORMATION
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 4
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):
Seasonal use:(yes or no): Yes
Water meter readings,if available(last 2 years usage(gpd)): 122,000 gallons—2002/127,000 gallons 2001
Sump pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: None Available
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX 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)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1976-original,- per Owner&BOH Records
Were sewage odors detected when arriving at the site(yes or no): No
T•., , . .,,.,.,. 6
f
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction: cast iron _40 PVC XX other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 24"to Top of Tank
Material of construction: XX concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 5'deep x 5'wide by 8' Iona (1,000¢allons)
Sludge depth: 4.0'
Distance from top of sludge to bottom of outlet tee or baffle: 2'
Scum thickness: % inch scum laver noted
Distance from top of scum to top of outlet tee or baffle: 8"
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.):
Structural intearity of tank was ok. No evidence of cracks, leaks,or water Infiltration/exfiltration 4" PVC Tee present at
inlet end. Outlet baffle present and In good condition Liquid level equal with outlet Invert
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): D-Box Present—two outlets,no evidence of significant carryover.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
f
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
XX leaching pits,number: 2
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:_
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): No evidence of hydraulic failure of septic tank or of leach either leach pit. 5.5' Liquid observed in
leach pit#1. 6" liquid in leach pit#2. Both Covers located and removed as part of inspection Riser present
Top of each pit is 18" below ground.
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 or no):
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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
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.
Swine Ties:
Cranberry Avenue
A- Tank In— 18.75'
B- Tank In—32.5'
A-Tank Out—23.4'
B-Tank Out—25.5'
Watir Line
A—D-Box-30'
B—D-Box—39.5'
A—Leach Pit#1 —41.5'
B—Leach Pit#1 —30.5'
A—Leach Pit#2—35.5'
B—Leach Pit#2—56.75'
Exist House
A B
0
Septic Tank
0 (1000 Gal.)
Box
0
OeLeach Pit#2
Leach Pit#1
T•., �, .,..,.,,, 10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #101 Trout Brook Road
Cotuit,MA
Owner: Mark&Cindie Carney
Date of Inspection: 9/18/03
SITE EXAM
Slope
Surface water -%:mile+/-
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 40' feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Ouadran0e of USGS Mao.
Per USGS MAP PLATE 2:
Elev.of Ground=60 Feet
Elev.Of Groundwater=20 Feet
Elev.Of Bottom of Leach Pit 50 Feet
Therefore: 50—20=30 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW29: 2.4 feet
Adjusted Groundwater Separation=50' +22.4' =27.6 feet
Grade=Elev.60 feet
Pit#2
Pit#1
Septic Tank
Bottom of Pit=Elev. 50 feet
Adj. Groundwater=Elev.22.4
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: _�Q wT � ]e3}� C�� �tl'(t� ` Lot No.
Owner: Address: :SQ(Y 2
Contractor: Address: rkQ
Notes: `-T�C�-� \J
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date � �®
mont /day year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well....................................................
OWater level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well
mon /year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 28)
determine water-level adjustment
STEP 5 Estimate depth to high water
by subtracting the water.
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ..................................................t............................. �a
Figure 13,--Reproducible computation form.
15
q
<000
COMMONWEALTH OF MASACHUSETTS �
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor `' Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: IOI TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Address of Owner: 16 KATHY WAY PITTSFIELD MA.01201
Date of Inspection: 8/18/00
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 608-664-7270
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 inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails P,
Inspector's Signature: �I= Date:8119100
The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If th 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.
NOTES AND COMMENTS .
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE EVERY NOW AND TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
i
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION(continued)
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES: q
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
ry
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.
DLa 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 complying septic tank as approved by the Board of Health.
oLe Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are.replaced
_obstruction is removed
_distribution box is-levelled or replaced
oLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if
(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
1
t '
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 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 or less
than 5 ppm,Method used to determine distance nLa(approximation not valid).
3) OTHER
n/a
T
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
» CERTIFICATION(continued)
Property Address: 101 TROUTBROOK.RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described 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
X Backup of sewage into facility or system component due to an 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 1/2 day flow, -
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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.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: =;,a
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large system`s in addition to the criteria above:
.rr
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection.Area-IW PA)or a mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 912/98 Page 4 of 11
>r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
+° CHECKLIST
Property Address: 101 TROUTBROOK RD COTUIT, MA 02636
Name of Owner: JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
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 during that period.
Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
r ,
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 liqr,.uid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
S
e
C
revised 9/2/98 Page 5 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00 ,
FLOW CONDITIONS
RESIDENTIAL;
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):
Total DESIGN flow: 440 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate 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 two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: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:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
t
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1976
Smige od6fa deteet@d Mimi affiving at ilia site:(yes 6f no): NO
revised 9/2198 i Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 22"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
is
Depth below grade: 16"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 6'7"W 4'10
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
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: n/a
How dimensions were determined: MEASURED
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL 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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n/a
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:NIA Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
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
revised 9/2198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18100
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type ,
leaching pits,number:(2)1000 GAL 6'X 6'
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,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS ARE STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE NEW PIT SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)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
revised 9/2/98 Page 9 of 11
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: 8/18/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
r
a
10
/4 13 a3
AID 3�
AC
3a�
revised 9/2/98 Page 10 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:. 101 TROUTBROOK RD COTUIT, MA 02635
Name of Owner JOHN AND SHAY KEENAN
Date of Inspection: • 8/18/00
k�A
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a r
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health,
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
F
revised 9/2/98 Page 11•of 11
TOWN OF BARNSTABLE
e ��U � 'L
LOCATION SEWAGE #
Vli LAGS �� \ ASSESSOR'S MAP & LOA� O�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS TeCA
BUILDER OR OWNER
PERMITDATE: 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
Q
s vw1 -C v.! IV M oc�
No....... ......... 110A.0.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. ._. ... _......... -- -OF....Barnstable.r...Mass. ....... .. ....._.....----
Appliration -for Uiapmal Worbi Tattotrurtion Puttift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
TroutbrookRoad -Cotuit Lot 29 - "AILLCREST"
_ _- __ _ _
-------------------------•-----•••••--•••...
Location-Address ` or Lot No.
S -LASE-•CDR�?O2ATION---------------------------------•---•- --P.O.--B07C--264x.-Sandwich---Mass.--°2563...........
Owner Address
,Wa Normax>_ yo�ts----------------------------------------------------•----• -- --------------------------------------
Installer Address
Q Type of Building Size Lot_22s2.59------------Sq. feet
Dwelling—' No. of Bedrooms__._-_WA------------------------------Expansion Attic (X Garbage Grinder ( )
per, Other—Type of Building ..........................•. No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures -----------•-----•--------------------- -
W Design Flow...... - ..•••.-....••.-•----^._gallons per person per day. Total daily flow._.-..-..•.-.yAQ....................gallons.
WSeptic Tank—Liquid capacitvl-4bjOgallons Length---------------- Width-------------_.. Diameter_----- ----_- Depth_-..__.._...
x Disposal Trench—No. ..................... Width...........-.._. ... Total Length------------_------ Total leaching area....----------------sq. ft.
Seepage Pit No.--_S--_-._------- Diameter._000.#�epth below inlet.................• Total leaching area..._._..___-__-scLit.
z Other Distribution box (ji) Dosing tank
Percolation Test Results Performed by----- lan__W.........Jones
............................ Date.APril _30 i 197.5---
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-_--------..-..-.---_-
a' - -- - -- #........ ----------- ;---= ----------------
Descri Description of Soil. ----------- ._ �r
O " mil
x
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance s eeLissued by the board of health.
Sign d . --- ••--•- --•-- P71
'v[ -7f
Dat
r V �'An -------------------------- - -Application Approved BY �s'1 - -- --------
Application Disapproved for the following reasons:............••.-.•...-
--••----------------------------------•--•----------...•.--.------. Date....--•----•--
...................................---------------------------•---------------•-•------•-•-----•----------------------------------•---------------------------.-----------------------------------------
Date
PermitNo......................................................... Issued... 9...°2' � `t............-........
Date
t
K��
1> ,
No......................... _ Fwic....$lo.00........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
_._... . ............OF....Barnstable.t...Mass.. _...........:..
Applirtation -for Bigpoml Workii Toaaotrurtion Vrrnift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.............Troutbrook Road----Cotuit--------------------------- ----Lot..2q "HILLCREST"
Location-Address or Lot No.
SEA-LAKE__CORPORATION----------------------------------•--...- P.O.__BOX_:26¢_.___Sandwich.....Mass.--02-563 -
Owner Address
a Norman Otte 1 6 Main St.___ dwich
? ----- �Bn -------. ..
......................................
Installer Address
Q Type of Building Size Lot 22.,254.............Sq. feet
U Dwelling—No. of Bedrooms------TKO.---.-_----------------------Expansion Attic (z ) Garbage Grinder ( )
aOther—Type of Building ------------------------_-. No. of persons._-___-.-.--_.-_._.-..-.-- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------ -
W Design Flow........... v.............. ........gallons per person per day. Total daily flow............. �U....................gallons.
WSeptic Tank—Liquid capacity�.:,. Ggailons Length---------------- Width................ Diameter................ Depth..--------------
x Disposal Trench—No....... ............ Width--------------
�.a-- Total Length-------............. Total leaching area----------:-------.-sq. ft.
Seepage Pit No..__r-�--_-..._..-.. Diameter:-./ U.U.s"llepth below inlet-4 /£- leaclea.3g.-.. sst�ft.
z Other Distribution box (y) Dosing tank )
Percolation Test Results Performed by..--Alan ... Jones ........... ............ Date.Apri1 30, 197 5
a ...
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
114 Test Pit No. 2......_-f_-..._.minutes per inch Depth of Test Pit.- epth to ground water........................
---qj�,_W
Descriptionof Soil------------------------------------- ------•-•-•-------------•---•-•--------------------------------•--------•--..-..--••-----------••---------•---••---------------
x
W
UNature 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 Article XI of the State Sa ' y Code—The undersigned further agrees not t pace the system in
operation until a Certificate of Compliance has n i sued by the board of health.
Si e ...- -- ---- ' -- r ....... ••... c
L, , Llit/1 ,3 —D t 7,S
Application Approved By............................................................... ----------------------------•- ••--•-..............
..............
Date
Application Disapproved for the following reasons:-----•---------------------•--•-•-••-•--•------......-------------------.-..-•------•-------•-----------•-------
----•--•-----•---••--------------•--......------...-•---------------------------------••------•------......
Date
PermitNo......................................................... I Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/,OF HEALT
................... ..........O F.....................................................................................
01rrtifir tr of Tompliana
�TH� ,, R IFY, 1 t t In v Sewage Disposal ystem onstructed ( ) or Repaired ( )
by---------- ---•- -----^-------••------•'-- ------ . ---•••---------. ----� . • .............................................................
d� `_Installe.....
Q
at........................................... '-----------•------•----•--•----•----------•••....--•----------------•-•--•--••-.
has been installed in accordance with the provisions of . X T e State Sanitary de as�c de ' e -itrthe
application for Disposal Works Construction Permit No.. .................................... dated.. ...3-_-�_�-.--....._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.................................................................----------------•-
N
7 THE COMMONWEALTH OF MASSACHUSETTS
BOARD ALTH
....... OF..........................................
...................... 1a
No......................... FEE........................
o orkii LIT, o rrmit
Permipsiol4fs hereby granted......... .................................. ---- -------/------------
to Cons u )•for J,epair a 3vi u 1 e Dlspo
at Noce;'V .
et
--�-• ---•
as shown on the application for Disposal Works Construction er it No.-- _---_- red........... .............. .........
(
�--- � r „� � �.✓ Board of Health -------•-•-••••-----•---�
7
DATE.... ------------------------------------------------------------------ _ _
n�7 / f \ ^ /
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS / v U / /Y/\ `L `.,JI/ S
r
ALAN W JONES & ASSOCIATES
CONSULTING ENGINEERS'
Carleton Drive
East Sandwich, Mass. 02537
Telephone 888-3154
TEST PIT AND PERCOLATION TEST
30 April 1975
To: Sea-Lake Corporation Personnel Present: Paul Murray
Route 6A & Tupper Road Norman Ayotte
Sandwich, Mass. 02563 Alan W. Jones
Re : Lot #29, Trout Brook .Lane Test Location: 95' into lot -from
Hillcrest Trout Brook Lane_
Cotuit,. Mass. layout
010". Ground surface
,l
110" To soil
Sub-soil
'0"
Coarse, medium, yellow
-- -- -- - sand; trace gravel
''4a
OF
A510
fd •�::<�
qs
ST
12'0"
ssro;va�E•. ' No water encountered
Assumed Percolation Rate:
1" drop in less than 2 mina
Water levels indicated, if any, are those observed when test pit was '
excavated and do ,not necessarily represent permanent ground water levels®r
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PERMIT UO---
-- v-►L ao--cam - ----- --
1NSTQLLER�S--1J-�►PJ�E =�-ADDRESS
---BUILDER 5-1\.I-I�,IJIE-�-AD-DRE-SS
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---- -AT_E- -COMPLI.W-ACE__ISSUED-:_
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