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0143 TROUT BROOK ROAD - Health
143 TROUT BROOK.x as cl ! COTUIT `V" r Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form-Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification Property Address: 143 Troutbrook Rd.Cotuit Ma. Owners Name:David&Margaret MacDonald Owners Address:32 Stowe Rd.Sandwich Ma.02563 '�i 99 Date of Inspection: 12/16/2006 Name of Inspector(please print)Sean M.Jones Company Name:S.M.Jones Title V Septic Inspection Mailing Address:74 Beldan Ln. Centerville Ma.02632 Telephone Number.508-778 4597 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: 4 X Passes 1 Conditionally Passes �:. Needs further evaluation by the Local Approving AudWrity Fails ,i u Inspectors Signature Date: ' c-:;�' /4" G The system inspector shall submit a copy of this inspection report to the Approving Authority(Boar of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****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. Page 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cowRquED) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection:12/162006 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: JL 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: Ii.System Conditionally Passes:N/A 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 the 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 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coN mm) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of cesspool or privy is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of 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 conform 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 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A 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: 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 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 CM15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X_ Were any of system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X _Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding SAS,located on site? X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No X _ Existing information.For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance Is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design),_3_ Number of bedrooms(actual): 3_ DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms)330 GPD Number of current residents: 0 Does residence have a garbage grinder(yes or no):_no Is laundry on a separate sewage system(yes or no): no [if yes separate report required] Laundry system inspected(yes or no): n/a Seasonal use:(yes or no)ino Water meter readings,if available(last 2 years usage 6 PD loof,= t to 6 PA Sump pump(yes or no): no Last date of occupancy/use: 9/2006 COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): 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: Was system pumped as part of the inspection(yes or no):—no— If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be Obtained from the 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: 1990 as-built Were sewerage odors detected when arriving at the site(yes or no): No OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner.David dt Margaret MacDonald Date of Inspection: 12/16/2006 BUILDING SEWER(locate on site plan) Depth below grade: 33"below tof Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Joints were in rood condition,no sien of leakagg SEPTIC TANK: X (locate on site plan) Depth below grade_30" Material of construction:_X 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: 8`6"XS`6"X4`10"= 1000 Gallons Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle: 2` Scum thickness: 3" Distance from top of scum to top of outlet tee or ba$le:_4"____ Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined-Opened covers and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): Baffles intact and in good condition Tank was structurally sound and not leaking.Septic tank is due to be cleaned. 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 TIGHT or HOLDING TANK: N/A (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_X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_,0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Leakage into or out of box,etc.): D-box was level and in good condition No solids carryover or signs of ever being hydraulically overloaded. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 SOIL ABSORPTION SYSTEM(SAS)_X (locate on site plan,excavation not required) If SAS not located explain why: Type X Leaching pits.Number:_1_ Leaching chambers,number: Leaching galleries,number. Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Soil was dry At time of inspection leach nit had 0 inches of standing water with no noticeable stain lines. Cover to leach pit is 4 feet below grade CESSPOOLS: N/A (cesspools 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: 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.): i .OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 SITE EXAM Slope XX Surface water XX Check cellar XX Shallow wells Estimated depth to ground water 15+ feet Please indicate(check)methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: 7/11/1990 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 most describe how you established the high ground water elevation: (1)Design plan on file at the Town of Barnstable Board of Health stated the no water was encountered at 16 feet. (2)Across the street there is a small stream approx.20-25 feet below the road surface. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Troutbrook Rd.Cotuit Ma Owner:David&Margaret MacDonald Date of Inspection: 12/16/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building FRONT OF HOUSE A B O 1 TANK A-1=15'6" B-1=27' O 2 A-2=20' B-2=30'6" D-BOX 3 A-3=23' B-3=32'6" C LEACH PIT A-4=27' 4 B-4=52' LOC&TIOPJ : 5EWO,4E PERMIT UO. VILLAGE �II�IST�LLER 5 U&NAE ADDRESS v� � ��X� -.b-c-m �I&L - C1 BUILDER'S 1J&MF- A DARE 5S DATE PERMIT 15SUED 0 ATE CONIPLI L1.MCE ISSUED : _ _ - oat �,� C,� e.o � '� y ,. I, � � :�` � - .. G* +, �, TOWN Of dA'RNSTABLE LOCATION - SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO., SEPTIC TANK CAPACITY LEACHING FACILITYAtype) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Fps............._.�./....� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH GJ .................OF....(�P�►i.�/ a .T�iQ�-� ............_...: Appliration for Mipvii al Works goustrurtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: )Q ... lC o 1� C'.................... Try/�--- -------------------. .....7".... ... -�- ---•-------------------•--•------------------- o. ��'� L ..n- ddrr�s�f ����� �N.... Owner Address Installer Address UType of Building Size Lot...2.-....l�_�/.-- --Sq. feet .. Dwelling—No. of Bedrooms.........%.3...........................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—T e of Building No. of persons........................... Showers — Cafeteria a' Other fixtures ................................. W Design Flow........c' C2....................gallons per person per day. Total daily flow---------44-5C ................gallons. WSeptic Tank—Liquid capacity/ llons 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 Resuys Performed .............................. Date....-........: _... aTest Pit No. 1/..:-.Z...minutes per inch Depth of Test Pit----- z......... Depth to ground 44 Test Pit No. 2................minutes per inch Depth of Test Pit.............._..... Depth to ground water........................ 04 --•--------•--------...-•----------•----•••-•-•---•••-••---•-•-----•.............•-•....-••--................................................................ DDescription of Soil......... .. ----•--•----•------•--•--------------------------------------------•----....------------...-----------•--•--•---•--. x 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 1_T is p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Wn issued by the board of h 1 . icy., 70 _ Si ned- hy.g D e Application Approved By-------...... ----•- -•..... Date Application Disapproved for the following reasons:.. 91 -------------------------•----------------------------------------......... -----------------------------•-----------•-----------------...---•--------------...------------......-----•---•--•----••-••-••---•---------................................. .......................... Date Permit No. -------------•- ................. Issued-....................................................... 9Q Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /D.. .F�l.............OF....C V`y 'T�! � ........................... Qrrtifirat a of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( } Inst at....... .s?T�� �r .es�z.s .�-- ®/CC' ,�1 = -------------•----------------------....---------------- has been installed in accordance with the provisions of iii'T 5 of The State Sanitary Code as described ig the application for Disposal Works Constriction Permit No----- "_.. _._._ datedc_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO� TRt! ® AS ARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. --1z_ DATE Inspector.....�... --•-------• - THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Oq. / .................OF..c„ ...� -a.. .A ........................ Appliratinn for Disposal Works ontrur#ion riermit Application is hereby made for a Permit to Construct or Repair ( } an Individual Sewage Disposal System at: .e�nw a Location Add ess or Lot No. Owner Address .4 ... Owner la...`•5......•--•--•--------- -•-•----.......- . .!��'�':---------,a Installer Address Q Type of Building Size Lot ?'7.26P....Sq. feet V Dwelling No. of Bedrooms........ .Expansion Attic Garbage Grinder p I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures ---------------- ----------------- - ---- W Design Flow......•s.. C?.....................gallons per person per day. Total daily flow........G -2......_.._........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. alr , ,eC� ................................ Date._ d'=.�"' ..:.._.._..._._.. Test Pit No. 1.1___`_�..minutes per inch Depth of Test Pit......1Z/----- Depth to ground water_,Yo_j* �� s✓+� Gi., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P -------------------------------------------•---------------•--......------------•-----....................................................................... 0 Description of Soil.............&76e�)....&.nLd:>........................................................................................................................ x U ----•-•------------- -----•---••--•-----------•--•--------••--•--••---•-•---•----------.......----------.....--------------------------------------•-•----------•---------•---------.........-------•-- W U ;" Nature of Repairs or Alterations—Answer when applicable.-..................................................................................•........... t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in accordance with the provisions of TIT LEE ;of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has j4en issued by�the board of 11941th. `LA it��J Signed - ' ate Application Approved By.._---..... ¢ .............................. ....`. .... ._ Date Application Disapproved for the following reasons-----------------------------••---•--•---•-----............................................................... ---------------------•----------------•-----------------------------------------......---------.......----------•...........----....-----••-••---••••---••--•••------•-••-------•-•••-••----•--••-•----- Permit No � ............... Issued.....Z-'- . / . 4.Date........ .........� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .e!0'0.4?...1e.............OF...e;., ,r�tr�' 1�5'.�° s '>�5�-.-............................ Trrtifiratr of Toutpliunre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed J or Repaired ( } by-----..... ?I 4'Z'• 9--------------------------------------------------------------------------------•----------------------------------- Inst ler at...... 'f a �" .....��x.12.r...1HA_S.Ls_A_e---- . ,Q--•------ 4........0----- --•-•---------•-----------------------•-•------------- has been installed in accordance with the provisions of TI"'TT j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Nr ` �.,. f ..., Ai0 e...............OF....{.. + '�, �` e�". ..................... rE > c Disposal Words %'Donstrurtion rymit Permission is hereby granted' �9! �/isposal .............�� e Ofv.................... to Construct ((/') or Repair ( ) an Individual Sewage System at No.---- .7 •-- street as shown on the application for Disposal Works Construction Permit N� "� .. Dated -/-'"., •---.....•---------•................ .......................... DATE.._ .--••.......................................... Board of alth ' FORM 1255 !J/ & WARREN. INC.. 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