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HomeMy WebLinkAbout0050 VINEYARD ROAD - Health 50 VINEYARD F-W COTUIT A=016-016 t TOWN OF BA.RNSTABLE j L0 TION ., p iJ�4��_ SEWAGE # r .J'U, V�i,.LIAGE ASSESSOR'S & LOT �� INSTALLER'S NAME&PHONE NO. ✓'G �j C AJ SEPTIC TANK CAPACITY t> � P R� 4 LEACHING FACILITY: (type) 5 �9 I /�.+�� C (size) A1 d NO. OF BEDROOMS BUILDER OR OWNER r f . PERMITDATE: 6kzdot 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 90 i No. �V rr36 7- �.. Feel THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for 0topozat opotem Conotructton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S® V, A/N q Owner's T=- and Tel.,No. y Co�-u, Assessor's Map/Parcel Q /G `V/j AM and Ted,1$0. �� c Designer's Name,Address and Tel.No. ��M�4 AJ S to C 40 °v N ok- Type of Building: 7 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil _ r c Nature of Repairs or Alterations(Answer when plicable N C' C r^� c 4 rDate last inspected: Agreement: The undersigned agrees to e e constugANtion and mai t ance of the afore described on-site sewage disposal system in accordance with the pro ' ions of Title 5 nvironmen ode and not to lace stern in operation until Ce cate of Compliance has een issued by d f H Sign Date �o Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued MCI ';y, s's, (. + ;..x i a , y,ti'�,^e ,z.. e !i"��%0.it+,}`..; t .Cl: T�a�• -3cs� ry- ; > h r TOWN OF'BARNSTABLE E LOCATION SEWAGE#- l: VILLAGE��s ;�t ASSESSOR'S & LOTF�/ " INSTALLER'S NAME AME&PHONE NO, SEPTIC TANK CAPACITY C3 j LEACHING FACILITY: (type) SJcrJ rp I N f—�ty (size) NO. OF.BEDROONiS Cr<„ '�i�r? BUILDER OR OWNER h e Y PERMITDATE- / COMPLIANCE'-DATE Separation Distance Between'the Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private'Water Su _l Well and Leachin Facili PP Y g ty (If any wells exist qn site or within..200:feet of leaching facility) Fee[ Edge of Wetland and Leaching.Facili.ty (If any wetlands exist .. I within 300 feet of leaching facility)' Feet f Fi:rrush 'd.by i4'- K 14 No. low (� � .»_,. Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pprication for Migo5ar *pgtem Con!5truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon(f ) ❑Complete System ❑Individual Components Location Address or Lot No. ,S'0 V,.N e YA r Owner's Name,Address and T,ell..}go. Assessor's Map/Parcel C7/ Nam�e+,Addres ,and Tq No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building (/ No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' i Design Flow ( gallons per day. Calculated daily flow gallons. Plan Date f'+ Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil; .e Nature of airs or Alterations(Answer when plicable L ti &'&J C r N ► c J l( - 00 � l be s -, q Date last inspected: Agreement: The undersigned agrees to ensl)r . e constr tion and mai t ance of the afore described on-site sewage disposal system in accordance with the pro ' ions of Title 5 e nvironment ode�and not to lace the system in operation until 7r,,cate of Compliance has een issued by d f H a h Sign • Date �•� _ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 1 —————————————————— ---- THE COMMONWEALTH OF MASSACHUSETTS -- r "w BARNSTABLE, MASSACHUSETTS (certificate of Compliance v THIS IS TO CE t�erl On-s_it�Sewage Disposal Syst.Constructed( )Repaired(/� )Upgraded( ) N Abandoned( ) by uc o nJ .r/U C at A 4,j -;E u r has been constructed in accordance with the rode s Tifl and tl}e for Di�pg y C rsal System Construction Permit No. ZOO `3� dated Installer a 5 v a ry Designer The issuance of this ermit shall not be construed as a guarantee that the systedigill fu i. s-de i VA Date /fit o� Inspector // ^�—------------------- J � ------------ No. ���r 6 7— Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migozar *pztem Conotruction Permit Permission is hereby granted to Construct( )Repat 1` Ugrade( )Ab ndgn( ) System located at 5-0 a—, I-Pe L/!4✓' �'aur't' and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this it. Date: G P ( � �P Approved by / r F 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated Lk , concerning the property located at r e- �* meets all of the following criteria: - - V This failed system is connected to a residential dwelling only: There are no commercial or business uses associated with the dwelling. C/4---`The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present.. f/ • There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen {14) feet above the maximum adjusted groundwater table elevation. [Adjust the:. . groundwater table using the Frimptor method when applicable] Please complete the following: :. A) Top of Ground Surface Elevation (using GIS information) 'l B) G.W. Elevation +,adjustment for high G.W. r DIFFERENCE BET EN A and P S PKA DATE: NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:he2.lth folder:percexmp - r rd D i I r r r r� Jj V , ASSESSORS MAP NO /z1 7.35 �AA PARCEL NO; L No.-Y__U__` ' Fee-------- ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVell Con5tructionj3ermit V Application is hereby made for a permit to Construct (VT, Alter ( ), or Repair ( )an individual Well at: Location — Address • Assessors Map and Parcel --M to le ear Owner Address -&A ^4' oac f/9 Installer — Driller / Address Type of Building Dwelling---------------------------------------------------------- Other - Type of Building-------------------------- No. of Persons------------------------------_-____ � Type of Well-y'----p� C---------------------------------- Capacity------------------------------------------ Purpose of Well-----rlr ------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been.issued by the Board of Health. Signed - -- -- --- ------ - -- -------- date Application Approved date Application Disapproved for the following reasons: --------------------------------------_—_—____—_ --— /'r date Permit No. -2042-��' ---- Issued --- ------- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate Of Compliance THIS IS TO C RT FY, That the Individual Well Constructed ('I Altered ( ), or Repaired ( ) by— — —� ---------- --------------------- ------------------------------ Installer — has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Perl����t--W-Dated�' '� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - - Inspector------------_—_ —_— __ No, Fee r BOARD OF HEALTH h v `� TOWN OF BARNS ABLE ZjpoCication, orr�ell on�truction er - mit -- y - - 1. Application is hereby made;.for a permit to,Construct (✓S Alter ( ); or Repair ( )an individual,V1111 at: -O l G v/(fl Fd' , L'ocat�on Ss Address" -- w }'r,Assessors.Map and Parcel ; , y tA. /vt M Owner ' / p �j f Addrress -�/� �I / !� tC`c�X " (oo-- MoS4 C�4- /uu OJC // [ Installer Driller Address Type of Building Dwelling Other Type of Building -- ,----_ No. of Persons----, - -- -------- —----- J , lvl` " Type of We11-�--n-� - --- - - Capacity--= - -- —- — Purpose of Well 1 i i��u�'w - — - — — - Agreement. . The undersigned agrees to install the.aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health.Private.Well Protection Regulation The undersigned her agrees-not o place the well in operation«until a Certificate .of Compliance has been issued by the Board of Health. r Signed --- -— --- -- _ J t/aU-------- fig � date Application.Apw — -- -- - —— - _-_ -, date 4 Application Disapproved for.the following reasons: =--------------- — — — date L/��( _ �a . Permit No.= '�= � Issued -f� --: _�__---�- -------------- date 0 ea:..redcea�.osatae.h4e�:er:ems.-Qs�+:w:.a_�s:�aVeoagesexaeaesc�..oi_rtaos�4+es+6eserscoae®o4smsaer��easwa�passatas4e.aae.;esewppQaa.'a.gcsxakea.:.:evse�sxraeasae�e'-aie:sepaaxeae. BOARD OF HEALTH ' TOWN OF BARNSTABLE = �Lertificate'�f° �CompYiante , THIS,IS TO C RTIFY, ,That:the;Individual ,Well Constructed ( Altered (.,: ), or Repaired ( ) by-=- -- - -- ---- — -- - -- - - Installer — b.as been installed in accordance with the provisions of the Town of Barnstable Board of Health.Private Well Protection Regulation as described iri the application for'Well Construction Pen = -Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL, SYSTEM WILLTUNCTION SATISFACTORY: DATE— --- Inspector --- - --- —--- �_ 14_4 . ..: ,.a 'r:'r'-. :. •<. d« .. ' . i F w r _ . :t^, r '.• tv."� y. '•' - 'ti. «?irea(M'r•{s?aSi 3>fie60GV4RialliWOAi?O?6'Si!If6 ae'reeeaaaaaeyT.+agaex rew4a'l4eaPil/hAB4LeiA$ei°a�6'7,i� a a�?b $40 11���?w sa'.i a�icai la�.s to aeaera96^4'Saei(. f BOARD OF HEALTH . TOWN OF BARNSTABL£ II� C11L,Cou5truct ion j3ertnit No: � � �` !�•' : Fee ..Permission is.hereby.grantedto Construct Alter( ), or Repair ( ) an.Individual Well at: Street: as shown on the application,for a•Well Construction Permit No. Dated �--------------------- Board of Health `i,y DATE &Jk l a � �D i 1 �/ DATE _11/9/99 -- PROPERTY ADDRESS: 50 .Vine and RoaD 1� -------y----- aD -- Cotuit --------L--------------- 1 -- 02635 __ ----- �� ro 0 o� �9 �J �FS�� �yC� l On the above date, I Inspected the septic system at the bo�ve address. This system consists of the following: ' i 1 . 1-1000 gallon septic tank . 4 . 3—infiltrators packed in stone . 2 . 1—Distribution box. 3 . 1-6 ' x6 ' block cesspool . Based on my Inspection, I certify the following conditions: 5 . This is a title five septic system. ( 78 Code ) O 13 6 . The septic system is in proper working order 7 at the present time . 7 . The cesspool and infiltrator area are dry at this time . 8 . Would Rec : that the system be made larger. Present design is f6r three bedroom home , not a five bedroom home . SIGNATURE:- N a m e:_,1,�` .�4m����L �------ Company; Jose,ph_P_ Macomber_& Son , .Inc . Address:- Box 66 ------------------- CentervilleL Ma__02632-0066 Phone:---—508-775-3338 ------------ THIS .CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY �JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools•Leachf fields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 I • r (� y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:5 0 Vineyard Road Name of owner D a v i d G. M u g a r C o t u i t ,Mass . 02635 Address of Owner: Data of Inspection: 1 1/9/9 g Name of Inspector:(Please Print)i o s e p h P.Macomber Jr . i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) company Name: J. P.Macomber & Son Inc . ManTirvAddress: Box 66 CentPryJ 11 P ,MaaG _ 02632 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: 2, passes , Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: 444 Date: V The System Inspector all su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner "shall submit the report to the appropriate regional office of the Department aKnvironmental Protection. The original should,be sent 1o,1V system owner and copies sent to the buyer,If applicable, and the approving authority. . NOTES AND COMMENTS 1 . Rec ; That the leaching area be made larger to handle a five bedroom home .: : * - ,2 . The present system is designed for a three bedroom,, home under the 1978 code. � II revised 9/2/98 Pagel of11 V, Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Pr.WtyAd&.: 50 Vineyard Road Cotuit ,Mass . Owner: David G. Mugar Date of Insaecti«+:11/9/9 9 INSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 1.5.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: Rec • That the 1 Parh; n$ a�Pn_he ehlarged tEW hapole q five bedroom hQme .T�e present sytsem js designed to fidi e a three bedroom home . ( 78 _Code ) B. SYSTEM CONDITIONALLY PASSES: _,()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. Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipels) 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 The system required pumping-more than fourtfines a yeardue to broken or obstructed pipe(s). The vystam mt-Imn— inspection if(with approval of the Board of Health): - broken pipe(s) are replaced obstruction is removed 7 revised 9/2/98 Page 2orli SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Vineyard Road Cotuit ,Mass . Ownw: David G. Mugar Date Of Inspection: 11/9/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: to 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) SYS REM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WiTH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING W A MANNER WHICH..WlLL.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND.THE EN1 MORMENT 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. AbThe 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. v 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 prejence of-ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance AW f (approximation not valid).- 3) OTHER revised 9/2/98 Page 3of 11 I' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' f' PART A y CERTIFICATION (contkwed) PropertyAddtess: 50 Vineyard Road Cotuit ,Mass . Owner: David G. Mugar Date of Inspection: 1 1/9/9 9 D. SYSTEM FAILS: You must Indicate either'Yes" or "No" to each of the following: — L(- I have determined that one or more of the following failure conditions exist as described In 310 CMR 16.303. The basis for this determinatlon Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No/ Backup of-sewage irrtofeclNtyror-eYetem con'iPonertt'due qo an overloaded orcbggod•SAS-or"aspod. -,--'• ` ' 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 tiet Iywert due to an overloaded or clogged SAS or cesspool. -f-,AJ J JTrAT&-j 1B "y Liquid depth In cesspool Is less than 6" below Invert or available volume Is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. {// Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy Is-within a Zone I of a public well. Any portion of a cesspool or privy Is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria,volatile organio-compounds, ammonia nitrogen•and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: -41 The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system Is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system Is within 400 feet of a surface drinking water supply the system•lss-wiWn 200 Poet of•*-4#4KAa(y4o-a suvfaoa dFkJdA9-WAto+--4upPly _ --- - _ f the system Is located In a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforpation. revised 9/2/98 Page 4of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertvAddress: 50 Vineyard Road• Cotuit ,Mass . Owner: David G. Mugar Dace of Inspection: 11/9/9 9 Check is the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. -None of the system compooents.laave:baan puPMwdsf= Jeast. o•%veaka aa�tbe system hasbaaoQsceiaiagwasraal flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or Industrial waste flow. -7 _ The site was Inspected for signs of breakout. _ All system component3,�4luding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance Is unacceptable) (15.302(3)(b)] The facility owner.(and.==paaU Jf diffareW Informat oaon thA prnpag mai0j4naa•&^f SubSurface Disposal Systems. 7 i t 1 I revised 9/2/98 Page 5of11 I • 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Vineyard Road Cotuit ,Mass . owner: David G . Mugar Date of Inspection: 1 1/9/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: //d g.p.d./bedroom. Number of bedrooms(des' Number of bedrooms(actual) Total DESIGN flow �j Number of current residents: S�.✓tB ` Garbage grinder(yes or no): Laundry (separate system) ( as or r�:_ If yes, separa2eJnspection•required --. Laundry system inspecte ye or no) Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): Sump Pump oyes or no): Last date of occupancy: {I f well has not been tested in the LAST 12 MONTHS . It should be done COMMERCIAL/INDUSTRIAL: �A at this time . See pages 6 A & 6 B Type of establishment: Design flow: /!/ 9ad ( Based on 15.203) Basis of design flow AAA Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)4✓14 ,4 Non-sanitary waste discharged to the Tixle 5 system: (yes or no) v Water meter readings,if available: 41/i - Last date of occupancy: 44 OTHER:!Describe) /✓A Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)-ev— If yes, volume pumped: gallons Reason for pumping: 10 TYPE 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) 1/A Technology etc. Attach copy of up to date{iperation and maintenance contract Q Tight Tank AM Copy of DEP Approval Other APPROXIMATE AGE of�a�11 co��„,ponents, date nstaHed{if known)•end source of•information: y2 4 s d L49147"�9 rap! V � ;:4 � ee� Sewage odor detected when arriving at the site: (yes or no)�V e 6 of 11 Pa revised 9/2/98 g f 1 1 I ` ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Prop"Addre": 50 Vineyard Road Cotuit ,Mass . owner: David G. Mugar Data of tnspection:11/9/9 9 BUILDING SEWER: (Locate on site plan) I Depth below grade: Material of construction:4/4 cast iron/40 PVC,ld other(explain) AJA Distance from yrivate water supply Or suction line kk Diameter 1�1 _ Comments: ;condition of joints, venting,evidence of leakage,-etc.) - ints appear System is vented thr SEPTIC TANK:_ (locate on site plan) J ,r Depth below grade: Material of construction:/oncreteA/�metal Fiberglass t�Polyethylengwother(explain) AW If tank is(natal,list age jig 13.age.confwmed by Certificate of CompllancaA& (Yes/No) Dimensions: r 1 r #alb,, &),A .5,71l Sludge depth: _. Distance from top of sludge to bottom of outlet tee ortaffle: p Scum thickness:�� Distance from top of scum to top of outlet tee or baffie:x— Distance from bottom of scum to bo m of ou at tee or baffle:7441-- j How dimensions were determined: Comments: (recommendstion 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.) Pump sept--ir tank tank Pvary ? ypnrc TnIet & and sriows GREASE TRAP: no evi ence ot ieakage . (locate on site plan) Depth below grade:&/- Material of construction concreta4rti9metaIV.VFiberglassA-&PolyethyleneflAother(explain) AM Dimensions: Scum thickness:--A'—',>Z Distance from top of scum to top of outlet tee or baffler Distance from bottom of sc m to bottom of outlet tee or baffle:AAf Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not prPGPnt - I revised 9/2/98 Page 7of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Vineyard Road Cotuit ,Mass. Owner: David G. Mugar Date of Inspection: 11/9/9 9 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on s:te plan) Depth below grade:44 Material of construction:do0concreteN�metalNAFiberglassiVV Polyethylene�other(explain) NA Dimensions: Capacity: gallons Design flow gallons/day Alarm present Alarm level: Alarm in working order:Yes"NoAO Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) light or o inQ tan s are not present . DISTRIBUTION BOX:_j/ (locate on site plan) Depth of liquid level above outlet invert: AIQ Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) --Distribution box hag two laterals res-spool is in reserve Nn elti danoo of _sQ_ 1 d-8 6ar'1T ever- NA e-yi4enee—eg lealtag-r--inta, 6 -out of the box . PUMP CHAMBER: 4)0,e. (locate on site plan) Pumps in working order:(Yes or No) w Alarms in working order(Yes or No Comments: (note condition of pump chamber,condition of pumps and a%purtenances,etc.) Pump chamber is not present . revised 9/2/�B Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropettyAddress:50 Vineyard Road Cotuit ,Mass . Owner: David G. Mugar Date of kupectkm: 11/9/9 9 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: leaching chambers, number: l '�" leaching galleries,number: leaching trenches,number, length: leaching fields, number, dimen ions: overflow cesspool,number: Alternative system: Name of Technology: i .�7 �e Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to sand .No signs of hydraulic failure or pondinp, goilg era drg _ Vagatatinn is normgl CESSPOO (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 (cesspool must be pumped as part of inspection) ' 4 Uesspool is ary . No signs ot water' intrusion., Comments: (note condition of soil, signs of hydraulic failure,.level of-pending,condition of.vegetation, etc.) Same as above . PRIVY: (locate on site plan) Materials of construction: ��A Dimensions: X/lQ Depth of solids: 4119 Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy ig not Iragant _ revised 9/2/98 Page 9orn L F f SUS-SURFACE SEWAGE DtSPO$AL SYSTEM WSPECTION F09M PART C r it SYSTEM WFOAAAnON(aon*94W) NoponyAd&—: 50 Vineyard Road Cotuit ,Mass . oW"'" David G. Mu ar 11/9/99 SX TCH OF SEWAGE DISPOSAL SYSTEM: . Includs des to at least two p$tmansnt ratarencs landmarks or benchmarks locste all we11s within 100'(locste wham publIc water supply comas Into house) i a 1 1 .. 1 ) �\ ' IC i Gar. Z}.J �1X ' • i revised 9/2/98 ' Pop 109f II q pausTuin3 e3 BUT tloeal301aa3 WE unp!M 1aa3 1•cn3 spUepaM,(ue jj)f4tlt3e3 SUlyaeaZ pue pu¢P2M.3o 08p3 (14moe3 SUttlaeal 30 1023 00t Unp!m Jo ails Uo 1aa3 ae S oe tm a ,C ddn Ja110 a1E�, lsna sham Attu,l1) 14lil 3 Uitl a•I P it M 1 S M ud iaa r iCtt[?ae3 8tmloenjo monog ptm olge.L JaleMpanwo palsnfpy trmurr W ' 1 t r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Vineyard Road Cotuit ,Mass . Owner: David G. Mugar Date of Inspection: 11/9/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater ,Feet Please indicate all the methods used to determine High Groundwater Elevation: �btained from Design Plans on record �Observed.Site erty, bservation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _4,/Checked pumping records —z'Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11 of 11 TOWN OF B,,AARNSTABLE f `J LOCATION L� I�.r.�'���� — SEWAGE # VILLAGE �T� ��.9 0 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ' (size) NO. OF BEDROOMS BUILDER OR OWNER I PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exPAc within 300 feet of leaching fa ty Feet Furnished b Cc A. X :a •jam �< G V >•nrnr+r.-nrn-.-rr- rrr.-mr•nsnrrnn nnre*�i:•s-►z+R►r�+�+�+•n+n nerns.i+ie�rtat� TOWN OF Barnstable BOARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEII'PJ FJCATION ^•rn-r••.-:: -r.,r.-...:rrtr r.+n•rr.•rrrnnres+ran-nrr.�.titi�vrn�trRhT�n�+ws�n�s t�nn v.+ra-r•rr--r�r.� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 50 Vineyard Road Cotuit ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME David G . Md4ar �s PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . , COMPANY NAME J.P.Macomber & Sldfi ' Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town, or City State LIP COMPANY TELEPHONE ( 508) 775 - 3338 FAX ( 508 1 790 - 1578 At CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and omplete as of the time of -inspection , The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: ' System PASSED : The inspection «hick I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 - 30.3 , Any failure criteria no v t evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con cted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted. on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date "'A 5z 3wh'76 copy of this rtification must be provided to the OWNER, the BUYER re applicable ) and the I30ARD OF HEALTH, * If the inspection FAILED, the owner or,ho^operator shall u P pgrede ' the system. within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd .doc s� DATE:8/8/98. PROPERTY ADDRESS: •50 Vineyard•Road - Cotuit,Mass. 02635 On the above date, 1 Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1 -1000 gallon septic tank. 2 . 1 -Distribution box. 3 . 3-infiltrators. 3A. 1 -6 'x6 ' block cesspool. eased bn my Inac actlon, I certify the following conditions: 4 . This is a title five septic 'system'.­(s= 78 * Code ) 5 . The septic system. is• in proper' working order at the present time. SIGNATURFF: Name : J . P . M'acomber Jr., i : . . ------ ,--------------- Company _J_, P_Macoruber & Son`Inc , Address:_-Bex-6b------a---,-- Centerville , Mass__02.632 ' Phone:___548�Z7S-.3338------- - 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY' OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tank&-Ceupool&-Leachflelds 1 . Pump*d & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632.0066 775-3338 775-6412 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) Vf�� C DATA V �.\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON. MA 02108 617.292.5500 TRUDY CO: WILLIAM F.WELD �` ��(� Sccrct: Govcmor � tllmmlsslol B.STRU. ' ARGEO PAUL CELLUCCI Lt.Govcmor UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION O;RM qG �*, �t Z PART A CERTIFICATION '�• O Property Address: 50 Vineyard Road cotuit,Mass. Address of Owner. i 91y992 f9 Date of Inspection: 8/8/9 8 (If different) Name of inspector: y11].SBpIL�.Ma -QMber JR. ®� l am a DEP approv, cyst inspector pursuant to Section 15.340 of Title 5 (310 CMR 1 .0t1,0) Company Name: J.P.Macomber & Son Inc. Mailing Address-. Box 66..._enterville,Mass, 02632 _ Telephone Number: r;n8—.77-5—333A CERTIFICATION STATEMEN I certify that I have personal]% spe ,' the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time ( nsp .,n. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewaF . .`isp systems. The system: Pasva Com nal asses _ Nee( unl. :valuation By the Local Approving Authority _ Fails Inspector's Signature: 1� C r Dater P 8 The System Inspector s all st. it a !y of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a rec : .tem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate on, :ice of the Department of Environmental Protection. The original should be sent to the system owne and copies sent to the buyer• pp' le, and the approving authority. INSPECTION SUMMARY: ec',. B, C, or D: AJ SYSTEM PASSES: �I have not founcla�' for: �n which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria _v o :d are indicated below. COMMENTS: BI SYSTEM CONDITIONAL! 'AS 1106_ One or more systen :nr­ ::s as described in the `Conditional Pass" section need to be replaced or repaired. The system, upa completion of the n -c­ . or repair, as approved by the Board of Health, will pass. Indicate yes, ao, or not deter; _d or ND). Describe basis of determination in all instances. If`not determined', explain why not. .OAO The septic is :al, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliant ) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;,o the septic .er or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is ii :)L:: fie system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approvL ;ard of Health. (revised 04/25/97) Pray• 1 of 10 DEP on the World Wide Web: http:llwww.magnet.state.ma.u side p Printed on Recycled Paper . U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Vineyard Road Cotuit,Mass. Owner: Sondra P. Zimble Date of Inspection: 8/8/9 8 6) SYSTEM CONDITIONALLY PASSES (continued) dLO 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A/D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: .b Cesspool or privy is within 50 feet of a surface water 424) Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 20 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has aseptic 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 S ppm. Method used to determine distance .U,� (approximation not valid). 3) OTHER A/H (r.vs..a 04/25/117) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Vineyard Road Cotuit,Mass. Owner: Sondra P. Zimble Date of Inspection: 8/8/9 8 D) SYSTEM FAILS: You must indicate ei-..er "Yes" or "No" as to each of the following: A1'A 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. zt e%00Z ,- "VAtrrA,,4S Liquid depth in eesspac+is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. !/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply AO the system is within 200 feet of a tributary to a surface drinking water supply jthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Department for further information. (revised 04/15/17) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Vineyard Road Cotuit,Mass. Owner: Sondra P. Zimble Date of Inspection:8/8/9 8 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No i Pumping information was provided by the owner, occupant, or Board of Health. 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. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,eluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ZExisting information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) (revia•d 04/25/97) Pag: 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address:50 Vineyard Road Cotuit,Mass. 0-net: Sondra P. Zimble Date of Inspection: 8/8/9 8 FLOW CONDITIONS RESIDENTIAL: Design flo-. jA0 g.p.dJbed(oom (or S.A.S. Number of bedrooms: 0 Nvmbtr of cvrrenl residentsWl� Caroage gander ryes or no) .G1Cr Laundry Connected to system lyes or no). Seasonal use (yes or not Nab Water meter readings• if available (last two (2) year usage �(�pdt: m mno): �J ® Sup Pup eyes or � �l ..C9 ;,.,'/ oN� ,fie Clove? ,7` >11s X'� :ast Dale of occupancy See p4ga s-o �-�d COtitMERCIAVINDVSTRIAL Type of establishment:_ &.4 Des.gn flow AM Rallons/day Crease Irap present: (yes or no)AO indvstrial Waste Molding Tank present: (yes or no)_&i Non•sanaar� -isle discharged to the Title 5 system: (yes or not Waur meter readings, if available._ AIA .U/IZ Last date of occvpancy: OTHER: :Describer Last ogre of occupancy' GENERAL INFORMATION PUMPINC RECORDS and source of information. System pumped as pan of inspection: (yes or no), If yes• volvme pumped: d gall ns Reason for pimping ! AJOT f�,41p0 TYPE Of $,YSTEM _J--�SepuC lank/dislribvlion bore/soil absorption system M Single cesspool 4)Zi overflow cesspool`- Privy UP Shared system (yes or no) (if yes, anach previous inspection records, it any) ,VJ VA Technology tic. Copy of up to date contras( Other APPRg X,IMAT,E AGE of all components, date installed ( _f nown) and source of information: 4� w / S,?-JSc odors detected when arriving at the site: (yes or no) I tr..s,.a Os/Js/771 Y�O. $ of 10 a V BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT P.O. BOX 427 °i B^R'ysa� SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 �y„Ss PHONE: 362-2511 EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not till bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM.are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS. THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED. '` PLEASE COMPLETE REVERSE SIDE OF FORM PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT 362-2511 X 337 DRINKIlVG WATER ANALYSIS LABORATORY SHEET Name Sampling Date: Time: Mailing Address: Sample Location: (Street or Box) (Street) (Town or City) (State) (Zip) (Town) Telephone: Year House was Built: Bottle Identification Number: Well Depth Feet (Taken from Bottle) Reason for testing (Check one): ❑ suspect a problem ❑ required by DEQE ❑ for information only ❑ new well real estate transaction' -a_other: _ Note*: Some banks.and mortgage companies may require additional nal testing which costs more and requires more water. Check with Lab before bringing in the sample. Distance of supply from possible contamination sources (check all that apply): septic tank / cesspool feet ❑ farm feet ❑ salted highway feet ❑ buried fuel tank feet ❑ landfill feet ❑ other feet Treatment used: ❑ none ❑ water softener ❑ filter SIGNATURE OF SAMPLE COLLECTOR: ❑ Well Driller ❑ Owner ❑ Realtor ❑ Tenant ❑ Other - FOR LAB USE ONLY - i -Total 961iform / 100 ml pH Conductivity (micromhos / cm) Iron (ppm) Nitrate- Nitrogen (ppm) 'J Sodium (ppm) ( " Copper (ppm) I , '^I SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SO Vineyard Road Cotuit,Mass. Owner: Sondra P. Zimble Date of Inspection:8/8/9 8 BUILDING SEWER: (locate on site plan) Depth below grade:d / Material of construction: 1� cast iron 6/40 PVC_other (explain) Distance from private water supply well or suction line P't' Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear SEPTIC TANK: Z�W (locate on site plan) Depth below grade: Material of construction: Y concrete _metal _,Fiberglass _Polyethylene _other(explain) If tank is metal, list age 4LJL Is age confirmed by Certificate of Compliance. (Yes/No) Dimensions: 71 rri+D4 3Grld~ll� a� 6�7�r Sludge depth�ofsludge Distance froo bottom of outlet tee or baffle: Scum thickness: 31 1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet t e or baffle: /B How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural Inlet & outlet �tegrity, evidence.of leakage, etc.) Pum _ ees are in place; Liquia depthat t e outlet invert i " The septic tank is structurall o signs of leakaae- GREASE TRAP:A2AW (locate-on site plan) Depth below,grade:-&9 Material of construction 414 concrete A✓WmetalW/i?Fiberglass t/A-PolyethyleneA(&4other(explain) AVA Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: A40Q Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) Grease traip is not pre-;Pnt- - (revised 01115/17) Pay• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Vineyard Road Cotuit,Mass . Owner: Sondra P.Zimble Date of Inspection: 8/8/98 TIGHT OR HOLDING TANK:V40C Crank must be pumped prior to, or at time, of inspection) (lo(:ate on site plan) Depth below grade: A),* Material of construct ion:,0 concrete Cmetal VAFibergIass�t±PoIyethylene.elother(explain) Dimensions: Capaciry: gallons Design flow: Al gallons/day Alarm level:__Alarm in working order.VR Yes;4a No Date of previous pumping: „'Q-4 Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holdinq tanks are not present. DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.) Distribution box has two laterals;No evidence of solids rarrT_nvcr-Nn avi rlani'0 of l eakagiz into or 01-i't--of i-he d--6*-:-'--1;ut--6f3 -h93f PUMP CHAMBER:Akm (loca(e on site plan) Pumps in working order: (Ye,s or No) i Alarms in working order (Yes or No)—AA Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) Pump chamber is not present. Gravity fed system. (revlaod 01/15/17) Y.y. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddress50 Vineyard Road Cotuit,Mass. Owner: Sondra P. Zimble Date of Inspection: 8/8/g g SOIL ABSORPTION SYSTEM (SAS):_Z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 1 leaching chambers, number: d leaching galleries, number: W leaching trenches, number,length: d leaching fields, number, dimensions:__ overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to fine coarse sand;No signs of hydraulic faill,re or pondinq;All vegetation is normal CESSPOOL/: (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: ,,rj inflow (cesspool must be pumped as part of inspection) pi r3 nr)fi plimp r PgSPnn i t i s nni- a i pf 1_QW Gg sspQQj Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to fine coarse sand;No signs of hydraulic failure or ponding; `All vegetation is normal. PRIVY:/�je_ (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.) Privy is not present. (revised 04/25/97) Pag• 0 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propeny Address: 50 Vineyard Road Cotuit,Mass . O»net: Sondra P. Zimbl.e Date of Inspection: 8/8/98 SKE-TCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) U 1 n OS _ i b� �C 7Gw i Os� \ 0 A r4g. .i of 10 lr•ri•.d 0�/11/17) SUBSURFACE SEWAGE DISP(.::S;;L SYSTEM INSPECTION FORM C SYSTEM INFOR,.', ,rlON (continued) Property Address: 50 Vineyard Road Cotuit,Mass. Owner: Sondra P. Zimble Date of Inspection: 8/8/9 8 1 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: /Obtained from Design Plans on record y Observation o ae un ng prope bservation hole, basemt.rk sump etc.) �etermine it from local conditions Check with local Board of health � Check FEMA Maps 41 ' Check pumping records heck local excavators, installers Use USGS Data Describe in your own words how you established the High Grourw4wrer'Elevation. (Muji be completed) Used water contours map. Gahrety & Miller 12/16/94 (revised 04/25/97) Pag, ''QOt 10 a•rn.n r,r T-niT�r—.r+r'\rn:mr•n\+n.s�.n+TrrlrrarnT+•'w•nr�nr*ennn nsr.ti ns�r�viwr. **Tar*s+r*e+rra.rn•r-rr.t+-m—:..t..r TOWN OF Barnstable LlOARD OF HEALTH 11 SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION 11^•TI7^7'%•::\�T.IIR^•T.TTJ'1•.wIT.1lIT1PRRIITATT[T�.t1T'1 VIw1'�RR11-T��R�1.tRrIRS IT.AN•Rr'TITTiT!'\TTTrnr.•.rI••T'Tr1 � —TYPE OR PAINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 50 Vineyard Road Cotuit,Maass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Sondra P. Ztmble PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Irre.' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City state LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( ) 508 790 - 1 578 - i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a this address and that the information reported is true , accurate , and complete as of the time of ,inspection . The inspection was performed and. any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on. site sewage disposal systems . Check one : Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public -health or -the environment as defined in 310 CMR 16 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con cted has found that the system fails to protect the public health and the environment in accordance with Title 6 , 310 CMR 16 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature -" Date _ .�� _ One copy of this certification must be provided to the OWNER, the BUYER ( Where appIioable ) and the BOARD OF I11CAL1'li. * If the inspection FAILED, the owner or"`oparator shall u d within o'ne year of the date of the inspection, unless allowed ort required he m otherwise as providdd in 3.10 CMR 16 . 306 . partd .doc W yJb. C` S S byV THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. - Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. lunc x iw ncimy Dirccto r u[ thc. t)' i wn ul WatCi Pulluliun C���ttri�l -1 TOWN OF BARNSTABLE •a �S T LOCATION d O t//NEB �Zh SEWAGE # VILLAGE C 0-ru 6 ASSESSOR'S MAP & LOT /(g, o/6 INSTALLER'S NAME 6z PHONE NO. -_T� P A ,9c o /Vt 3ee+S©A1 SEPTIC-TANK CAPACITY LEACHING FACILITYAtype) %r/SIG Jr 7-0-9, (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT.ISSUED: — DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� IN a TOWN OF BARNSTABLE L66ATION V SEWAGE # VILLAGE COl V ll ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY - ' � C��► (�- LEACHING FACILITY:(type) 1� (Size) 10 J NO. OF BEDROOMS 12, PRIVATE WELL OR PUBLIC WATER PU QLX, BUILDER OR OWNER 4,YagJ, DATE PERMIT ISSUED: DATE .COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No AT Q Pao 5� TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE a��s�• ����� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /lV LEACHING FACILITY: (type)�de; (size) ld�C3 NO.OF BEDROOMS - - BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: f �r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ,X fT Edge of Wetland'and Leaching Facility(If any wetlands exi;1 j N within 300 feet of leaching.fa ' :ty,% a Feet b Furnished �� _ .•- _ i �I _ �'! '� .:� �� �`�\. .. � °�S a 6% i ;,.;,�t,t,,,rf re �e y', _ .� a° - w THE COMMONWEALTH OF MASSACHUSETTS AFMCM BOARD OF HEALTH OWN OF BARNSTABLE �r lirtttr for Diripuial Worlig Tomitrurtion Prrnti# Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 50 Vineyard Road Cotuit .... --•----•-•-•--------------•.--.......-..---•----- -••---•-------------•------------••--••-....---••••--•-•---....--...-.......-..-..---....------•-- Location-Address or Lot No. ........... ...................................------ --------------------...-..-.....-..-..----•-•------•--....•-........-----.....--•----••-- o"ner Address WtT-_P-_.-Ma-CQMbe.----.sr-.------------------------------------------- Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) WDesign Flow-�ther fixtures ---..-:----'____gallons per person per day. Total daily flow------------------•--_.-----•.-.----•---..gallons. WSeptic Tank—Liquid capacity-•.....•---gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------._--------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. L...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ------------------------------------------------------------------•.•••••••-•-•..-...........-...-........---•--.-..-•.-•--•.•-.-.....•-•••-.......-...•--•-- 0 Description of Soil...............................................---...................................................................................................................... U ........................................................Saxt-d.................................................. ---•--------------------•-••-------•----•------....-.-......--••-•----...-----••--- W UNature of Repairs or Alterations—Answer when applicable----1.-Leaching.-.pi.t.................................................... •---..-•.....-•--------•...........................•----••-•--------.....------------------------...•--•--------..-.-.-----------------------------•-------------...•----------------------...........-. Agreement: Theundersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia `ce hasZej u d y the bo o alth. ry Si ne ' ........ ..........$/..1.1:/..9 3....- g - -... .. . ...................... ... ............ Dace Application Approved By ..-------.� ... a�.�, .�............................ 6....-rr.-.�'-.�.. --...................—...----`----- .......`! Dace Application Disapproved for the following reasons: .............................. ... .............................................................. .............................. ......................... ..... ...... .... - .............-..............-.......-............-....... ... . ................................ Permit No. ......../....3..-..y a,�� Issued ............�...^ �..�...'... Da e...... Dare �.�;.-e•.r�.b'"'.•.xt-a-is .iilliirl�..::'i r ,v., - ',�+, , �� ,-....�+-.-toyVs.�...�.::s+ .�'�=* y,.�y,,��..�, No...�..... .2 Fps.....$....3 0..00 > THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AVV trafla t for Diripatial iVor1w Tolttitrnrtitun jkrmit Application is hereby made for a Permit to C'otlstruct ( ) or Repair (KX) an Individual Sewage Disposal System at 5.0 V i n e y a r d Road C o t u i t -------------•----•---------•----------._.............---•--•------•-- Location-Address or Lot No. Murry Owner Address a ............ U n�a r• r,tn r r-- ---•-- l� Installer t Address Type of Building _ Size Lot............................Sq. feet r Dwelling— No. of Bedrooms.-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Tye of Building ---------------------------- No. of persons ................ Showers — a Type g p ( ) Cafeteria ( ) dOther fixtures ---------------------------------------------------------------------------------------.-------------------•- ---------- W Design Flow............................................gallons per person per day. Total daily flow;'........_.__----*...-_.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width--------.._._._ Diameter........... Depth................ x Disposal Trench--No. ­, Width-------------------- -Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............................. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-t Percolation Test Results Performed by..................... .................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water.--..................... �Zt Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r -----------------------------•-----•--......-------•---....----------.....----------•--••---....--••......................................................... 0 Description of Soil........................................................................................................................................................................ U ---------- ---•-----•-- ......----••--••------•-------.Sand-•----------------•.....---•----••••-•---•-•--- W -------------------------------------------------------------------------------------------------•-----.......--------....-----...---••----------------•---•-•---•--...----------------.......---•--•-- U Nature of Repairs or Alterations—Answer when applicable..---1_-Leaching...x� t_____________________________________•.•.••-••••,__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complies ice has begin issued by the board/oftealth. Signed,,�----------- ---------------�jt h 8/11/9 3 I Date Application Approved By --------- ' _................................- �� _ v V Date Application Disapproved for the following rea.fons: ................................................................................................................................. . .......................................................... .... ................................. Permit No. ......../... ..- V0- ------------------------_ Issued ............ ._-1...I...'_ �� .... ......Date...... ­ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Clertifirate of C11omplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by J..P.Macom ............................................ _. - -------.................................. - ...._......................................... i�a�ii« at --------50 Vineyard Road C- otuit -- _- --__-----------------....--------------......---...-------.----------------------------.-................---------..-....------------------........ .. has been installed in accordance with the provisions of TITLE 5��ooyf The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...-....l., ...-.... , -, dated .............- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL iFUNCTION SATISFACTORY. p � � DATE.. ...._------- (} -' .. --_._--------------------------- Inspector ..._......... - - .................... Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.. �---�.. FEE..$...3 0..0 0.. Disposal Workii Tomitrurtion fernfit Permission is hereby granted.................J. D.,_MacomberKe.- -- ------ to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at No.......50 Vineyard _road cotuit •. Street q as shown on the application for Disposal Works Construction Permit No..l.�^.��_�. Dated------------------------------------------ •••...............••-•-• ;1 -------------------------------------------•--------------- / C� Board of Health DATE............... ).... ! ...........-......... .......... FORM 3830E HOBBS 6 WARREN.INC..PUBLISHERS