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Home My WebLink About0014 WALNUT STREET (COTUIT) - Health 14-WALNUT STREET, COTUIT A=,018.044 i Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9- 01 . 14 Walnut:$treet1. ._._.:. . ... Property Address Linda Sullivan Owner . Owner's Name information is Cotuit MA . :: 02635 . 3-12-13 _ required for every - -- page. City/Town State Zip Code Date of Inspection Inspection'resutts must be submitted on this form. lnspectllon forms may not be altered in any way. Please see completeness checklist at the end of the form. '"'ng out`rms A. General information filling out forms `p�i�uUglllrUir� on the computer, `\`SINS j� k OF fygS,So�� .��. q �% use only the tab 1. Inspector' �s, key to move your z .G cursor-do not = o:. JAMES •: ,lames D. Sears _ use the return Name of Inspector t key. o_ CapewideEnteh rises, LLC .•�_ o: � Company Name. W Sp�G'�h\```�� 153 Commercial St. ' �riiyk+,Hi+++►a"` Company Address MW Mashpee MA 02649 , CityrroWn State Zip Code 508-47'1-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails EJ Needs Further Evaluation by the Local Approving Authority _f W wet s d� 3-12-13 �InspectoesSignature'— Date »_ _rl Co o The system inspector shall submit a copy of this inspection report to the Approving Authority(13c ""rd of Health or DEP)within 30 days of completing this inspection. If the system is shared system'ST has a design flow of 10,000 gpd or greater,the inspector and the system owner j'shall subrgit theme report to the appropriate regional office of the DEP_ The original should be sentto the system orv►ffter and copies tagnf to the buyer, if applicable, and the approving authority. t..wa u.d, ****This repot i O�is descrilb 4 conditions at the.ttme of inspection and under the conditions of use at that time: inspec(,jgp does not adt .�tlr W the system will perform in the future under the same a[XIEtf Qrent cpnoll(ions of use. t5ins-11/10 Title S Official Inspection Form:Subsurface seurdge Disposal System•Page 1 of 11 A I/UU Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is 02635 3-12-13 Cotuit MA required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13 System Conditionally y Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for`yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): (Sins•11110 Tine 5 official m specrion Form:SLbsrrfaoe Sewage Disposal System•Page 2 of 17 Z•d dt,l:Lo`i, Z6Jen Commonwealth of Massachusetts Title 5 Official Inspection Form =l a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yt 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 3-12-13 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont,): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland oral salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 E-d d-V6:L0£L Z I aen Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other; D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in I is less than 6"below invert or available volume is less than'/day flow 00/7 - (Sins-11 r10 Title 5 Official Onspection Fam.Subsurface Sewage Disposal System-Page 4 or 17 d d91,10`✓I• ZI•jen Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02835 3-12-13 page. City/Town State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well, ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana(ysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no'to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes° in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•11110 Tice 5 OWal lnspechm Forrtc Subsurface Sewage Disposal System•Page 5 of 17 9-d d9 6:L0 C 1, Z I,aaN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -, 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is COtUtt required for eve MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on. ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•1 /1U Tille 5 Official Inspeclion Form:Subsurface Sewage Disposal System•page 6 of 17 9'd d5l L0C1, Z1,JUN I Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L ' 14 Walnut Street Property Address Linda Sullivan Owner Owners Name required is Cotuit MA 02635 3-12-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal tank D Box and Pit Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® .No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2011-55,000Gais 9 ( y g (gpd))' 201241,000Gal's Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: -- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes [] No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-11110 Title.5 Official Inspection Form:Subsurface Sewage Disposal System-Pege 7 of 17 L-d d9I,:Z0Ct Z6ae" i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 3-12-13 page. City/Tom State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 0-4/0-6 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: ---- Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-1 U10 Tine 5 official ins pection Form:Subsurraoe Sebrdge Disposal System•page 8 of 17 9-d d91:L0 Cl• ZI•aeN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Walnut Street Property Address Linda Sullivan Owner Owners Name infonnationis required for every Cotuit _MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1983 Permit#83-688 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): .Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank (locate on site plan): Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal Precast Sludge depth: t5ins-11110 Title 5 Official Inspection Fonn:Subsurface Sewage OispOsal System Page 9 of 17 6'd d96:L0 E 1• Z I•aen Commonwealth of Massachusetts Title 5 Official Inspection Form l: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y .14 Walnut Street _ Property Address Linda Sullivan Owner Owners Name information is required for every Cotuit MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 9 2" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc_): Tank and covers at 15" below grade wtiniet Tee,outiet baffle. Tank at working level. No sign of leakage or over loading_ Note: Tank and covers under brick walk way. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•11110 Title 5 Official tnspedon Forth:Subsurface Sewage Dispasal System-Page 10 of 17 06'd dLl L0�6 Z6 aaW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name . information is required for every Cotuit MA 02635 3-12-13 ---- page. Cityfrown State Zip Code Date of Inspection D. System Information (cons) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc_): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction:. El other(explain): metal fiberglass ❑ polyethylene ❑ concrete ❑ ❑ g Dimensions: ------ Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Tide 5 Mcial Inspection Form:Subsurface Sewage Disposal system•Page 11 or17 I•l'd dL1,1001, Z6aen Commonwealth of Massachusetts a Title_ 5 Official Inspection Form i� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Walnut Street Property Address - -•.-•-••-__-�__. Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 under brick walk way. Camera out from tank and pit. D Box looks to be solid wlno sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): if SAS not located, explain why: ISins•11/1C Tille 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 ,d d ar; Zl Ll�LO�IZI. W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walnut Street Property Address '- Linda Sullivan Owner Owner's Name information is required for every COtuit MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Typelname of technology: Comments(note condition of soil, signs of hydraulic failure. level of o 9 y p ndtng, damp soil, condition of vegetation; etc.): Leaching is one 4'600 Gal Precast pit w/2' stone. Pit at 40" below grade w/cover at 2'. Level in pit at 30" below top of pit w/no high stain line. No si n of over loading or solid carry over. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer _ Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins-1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 E� d d8l,:L0 E6 Z6 ae" Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 14 Walnut Street _ Property Address Linda Sullivan Owner Owner's Name information required for every Cotuit MA 02635. 3-12-13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurrace Sewage Disposes System-Page 14 o117 b6'd d8L�L086 Zl•aeW Commonwealth of Massachusetts Title 5 Official Inspection Form '�" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 3-12-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks_ Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 03 a ; 3 t5ins-11110 Tine 5 official Inspection Form:Subsurface Sewage oisposal system-page is or 17 96'd d91,10£l Z6 aaW I Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is required for every Cotuit MA 02635 3-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 3-22-83 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain.- El Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: T_H_ on design plan 3-22-83, No G.W. at 12'. Bottom of pit at T-4". Bottom of pit 4'-8"Above T.H. Depth. Before filling this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Otridel Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 9l,'d d9I,:Z0 Cl• Zl aeA Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Walnut Street Property Address Linda Sullivan Owner Owner's Name information is Cotuit MA 02635 3-12-13 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,,D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tNns•1 ir10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 or 17 L 6'd d61,10 0L Zl aeW DATE:_s124.49-s -- PROPERTY ADDRESS:__L4_-K&]ni-.s±xaat-______ J Cotuit,Mass . ------------------------ MAY 02635 2 6 1995 j ----------------------- itMTH DE OM CF ewst= . On the above date, I Inspected the septic system at the above address. This system consists of the following: A. 1 -1000-4allon septic tank. B. 1 -DiELtr:Lbution box. C. 1 -600 gallon leaching pit. i Based on my inspection, I certify the following conditions: A.• This is a title five septic system ( 78 Code ) B. The septic system is in proper working order at the present time. j NATURE: SIG Name:_J_P_Macomber_Jr Company: J_P.Macomber & gSon Inc. Address: Pox 66 Centerville,Mass . 02632 -------------------- Phone: 5o$=ZZ _33.38_------ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY I JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 . t RONALD J. CADILLAC, PLS, RS Land Surveyor & Sanitarian Page Box 258, W. Yarmouth, MA 02673 (508) 775-9700 SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FOMI St , Address of property �1-�- W /N�� Cam Owner's name (and/or resident) 1{6,I oCjjh? Date of Inspection �� r PART A CHECKLIST Check if the following have been done: ✓ Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least days 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. Z As built plans have been obtained. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. I/ tic The septic tank manholes were uncovered, opened, and the interior of the se _ P 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The.facility owner (and occupants, if different from owner) were provided with information on the proper maintrnanee of SSDS. page 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `. PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms (� number of current residents �o garbage grinder, yes or no laundry connected to system, yes or no /l1p seasonal use, yes or no ? If nonresidential, calculated flow:' Water meter readings, if available: Last date of occupancy GENERAL INFORMATION : -,nping records and source of i ormation: AM .l0 System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: T)Ipts of system _✓ Septic tank/distribution box/soil absorption system Single cesspool _ Overflow cesspool Privy U Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of infonnation: �q 6� Sewage odors detected when arriving at the site, yes or no Page 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: V/concrete _metal _FRP _other(explain) dimensions: ('41 sludge depth Z /Q'distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle Ga, distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc,.) z ' v {' w Ar T/,n?,.).(--- y»zt h0t,7 1 P b�,u > i_ o l✓� �Cr leer .rP -, i K DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert / '� �eldc.cJ d U Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) C4-9- tl o(Jpy- — C6u PY CK4 CJ�e� /)n 1— _ page 4 PUMP CHAMBER: Ma ate on site plan) pumps in wor ng order, yes or no Comments: (note condition of pi mp chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number ( ('/1 /lvy / 211/ leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) a.L/ /�,/ T fjv t �a f ✓.v y�SE' — �-v�-' Page 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued CESSPOOLS: h61Lj� (locate on site plan) number and configurat on depth-top of liquid to i et invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwate inflow (cesspool must b pumped'as part of inspection) Comments: (note condition of soil, signs cf hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of ydraulic failure, level of ponding, condition of vegetation, recommendations - maintenance or repairs,etc.) page 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR. I PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 2 ST� w0a (> D 00 bo ttvm power, 8 1 Ib P C h I VI,KJ L1 COQer Z �D� r'fi GU DEPTH TO GROUNDWATER l [ - 8 GIY9JN�1 i raja �C� ' /}yG� -36' Ce depth to groundwater 6 e)o w 6 011� ` 2,c `tee 12 , method of determination or approximation: _ � ' SST Gr�v��w � C1, rye K- T . page 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM 1116PECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or NTD). Describe basis of determination in all instances. If "not determined", explain why not) N0 Backup of sewage into facility? ft Discharge or ondin of effluent to the surface of 9 — g P g the ground or surface waters. Vo Static liquid level in the distribution box above outlet invert? (2r% No Liquid depth in c ool <6"i below invert or available volume< 1/2 day flow? VVv Pumped 4 times or more in the last year? number of times pumped _ /VD Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy; ,Vo below the high groundwater elevation? lbb within 50 feet of a surface water? Nb within 100 feet of a surface water supply or tributary to a surface water supply? IVo within a Zone I of a public well? & within 50 feet of a bordering vegetated wetland or salt marsh? within 50 feet of a private water supply well? less Own 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 eoliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. page 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Ronald J. Cadillac Inspector Number Registered Sanitarian No. 1060 Company Name Ronald J. Cadillac, PLS, Rs Company Address Box 258, W. Yarmouth, MA 02673 (508) 775-9700 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 complete as of the time of inspection. Check one: I have not found an), information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAII,URE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310_CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date 5-1Z_31q-5- Original to system owner Copies to: Buyer (if applicable) proving authority L 0 C T'ION SEWAGE PERMIT NO. WA VI L L AGE INSTA LLER'S NAME 3 ADDRESS T se Ph B U I L D E R OR OWNER M o te o c. ko r. r tw GN DATE PERMIT ISSUED _3a� DATE COMPLIANCE ISSUED � r ��f3 i FOJiv�y�Ip� � , A Otek yo 1prik i s PT z4tp,,rT6WN:OF BARNSTABLE c14 '" t LOCATION r, �,, ,� AL�L v t S'j' SEWAGE # VILLAGE �"�_ 'ASSESSOR'S MAP & LOT 01 7- Day INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE ..COMPLIANCE ISSUED: VARIANCE G��fNTED: Yes No c ��KCYo�2L%�� d -,7 r r oil_. �`j/•�l �� No.... .L�. Fx$............................_ THE COMMONWEALTH OF MASSACASETTV BOARD OF HEALTH low .............oF...-.......��`}ie -Tfi t- ................. Appliration for Disposal Works Tonstrurtion rumi# f Application is hereby made for a Permit to Construct (� or Repair an Individual Sewage Dis posal System at: '1 "� 8 NO M Liuo.T.............. ..� .Y....G' .T..v!..[.... ... ----...-x ---------....,... ....................................�-•----•--•-•-- Locatign-Are s✓ or Lot No. ...�.7. Y :.1_.d...t..t C..g3,?�...................... ....�a s�l-�.�. Q 1'...------.1f4�-c•s . -d �............... ._ '�Y 6, i, / Owner Address a ..............•... W. ..:.........-.-.-.-----•-----•-•----•-----•-- ............................... .............-•----............................ Installer Address Type of Building Size Lot....l._ �__Q.aG?....Sq. feet Dwelling—No. of Bedrooms................. ......_.......__...__._..Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of persons............................ Showers Lti, YP g ------•--•------•----------- P Cafeteria ( ) Pa Other fixtures ..................•••-••---•.... W Design Flow.............. ..........................gallons per person per day. Total daily flow......._.3_3.0..____.._.._..._____.gallons. WSeptic Tank—Liquid capacity lOOOgallons Length..8_........ Width... .'...__. Diameter................ Depth...'....... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area............._.._...sq. ft. Seepage Pit No....... ............ Diameter.._10.!.5._.... Depth below inlet..... ..:....... Total leaching area.41(.,.4.-9"-t.<;. P, D Z Other Distribution box ()C) Dosing tank ( ) Percolation Test Results Performed by....4AXT AR.....,f .___AJV E................. Date..s-_—.zZ .___._.. W •..._ . • ri a Test Pit No. 1.7_.........minutes per inch Depth of Test Pit---- Depth to ground water.N.o.T..6_ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate ....................... 9 .........-•---••-••----•• ...................................................................••------..................---••••---•...... ODescription of Soil................�a 6....... L ! .........................------------...........-..........................•.................................... ............. .......------------------ •-•------------------------------------- ----------- •----------------------------------------------------------------------------- •----------- ...._...------------- W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------------------------•--.....•...........----------....--••----.....-------•------------------•---.....---.....-------•---------........------..........---•--.....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:I'= 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bc&V of 1 ealt . Signed..Vr/ ....... .. ... .......... ..................... Date ApplicationApproved By........ ------- ----------• •----------------•--•----------•---------------.. Date Application Disapproved for the following reasons---------------•------------•-----------------------•---•----------------------....----•-•-•-•-...........------ -----•-----•.....-•••--------•---•-•---•....•-••-------•--•----•--•••••••-----•---•---......-••--•--.......................•••---•---••-••-•---•...----•----•••-••••••••••--•••----••-•-•--••-•...--•••- Date PermitNo..................................................._._.. Issued....................................................... Date ............... NA THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF............46,0e.l.,.)�^�'..774 '"t_.... Appliration for Distimal0orkii Tvmtrurffint Frruat Application is hereby made for a Permit-to Construct or Repair an Individual Sewage Disposal System at: .1 07 .......AW.A 4 (r.*1? ...........c5..Eftj • .. ...... ...............4.............. ..................................................... Location-Address or Lot No. .........C0�-------------........ ..... 0-y0ft----------4O&JSA.—J.17-4�................. e Address Installer Address PQ Type of Building Size Lot...../Z Dwelling—No. of Bedrooms.............. ...Sq. feet ........................7-----Expansion Attic Garbage_Grinder a .. Other—Type of Building .............. ........... .No. of persons............................. Shower's Cafeteria Other Dxtures ...... -------------------------..................*--------------------------------------------------------....................................... Design Flow...........;.�;5.........................gallons per person per day. Total daily flow......... ___......__._........gallons. 4 CD------------------ 9 Septic Tank—Liquid capacity.Z.Vlegallons - Length...je�_. Width..... Diameter---------------- Depth-.42"...... Disposal Trench—No. .._.._.. .-._....... Width_.._ ....._.... Total Length.................... Total leachingarea...................Sq...ft. Seepage Pit No... ......... Diameter...Iq__15.'...' Depth below infet.......4......... Total leaching area._4&.4.Sq-.4.4, P,.D, Z Other Distribution box Dosing tank Percolation Test Results Performed 4.....Alvr:......................... . ... ................................ Test Pit No. I__!!<9...minutes per inch Depth of Test Pit-___ Depth to ground water _'i Test Pit No. 2................minutes per inch Depth of Test Pit..._................ Depth to ground water ........... ......................................................................................................................................................... 0 Description of SoiL..'............ A). .................................................................................................................... ------------- - -- ------------------------------------------------------------------------------**---------------------------- ------------------------------------------------------------------------------n-7,:----------......................I------------------------- .......................................................... U Nature of Repairs or Alterations—Answer when applicable._....._._.`...........................................I......................................... ....................................................................................................................................................... ................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal -System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned furtl.er agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed------..r........................I..................................................... ................................ Date Application Approved By........ ............................................ ........................................ $;_ ;� Date Application Disapproved for the following reas:s:......I.......................................................................................................... ............................................................................................................................................................................... ...................... Date Permit No........................... ............................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF Tntifiratr jaf ToutplizUtIrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at- .................. . ..... ..................................................................................................... -------------0� ------- has been installed in accordance with the provisions of TITLTE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No . ................... daied......... ...................................... e3r, "Arlr THE ISSUANCE: F. THIS CERTIFICATE SHALL WMECONST D AS A GUARANTEE THAT THE 4 WI U CT SYSTEM Wl�= TION SATISFACTORY.. r .... ......................... to . ................ DATE..A........ ............. .............. Inspector .. ............................................................................. THE COMMONWEALTH OF MASSACHUSETTS .BOARD OF HEALTH ...OF....... FEE............ Permissionis hereby granted......................................................................t... ...................................................................... to Construct or Repair an Individual Sewage Disposal System at I*........4 P....... .. .......... ........ ....................................................................... ------ ----- Street as shown on the pli >on for Disposal Works Construction Permit No..................... Dated.__....................................... ....... .......................................................... ---- -- ------ Board of Health DATE.............. ...................................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS' _ - 4 x _ h •.. .:..._.. .mow......-_w...._.... ' - .+ .-r w-_ ...__. .. _.__-_•._. - . _ w 7 oi aox - / Q • �ry . , s F d n _ Z S. G .DO / 00 AJOTE EICTEeIJD ALL A oO[-lCf� 8L E f40 Q/Z. S C/9 L E / � � /O� S � C..� T- � Q l V E �2 T' S C fi L Er / = i 0 /"l A ti H O L E COVERS 7-0 w1 T /N ro oscd round r-of! le i� /2" OF FlA -SHED G 2ADE ' fl' SCHED. 40 P- V C. OAR F / ti / EQUi9L - m �°EPT/C Cm/n/rnurn AV Per �'oo-f-) 2 of �8 '� /�2^ wcts/�sd sfonG it 4 � -lilt a vj G 13 T D/S T BOX e t 'dia. ' su,rnp h'\ [ o p • 0 , e • / w /oop GAL. SEPT/C Tf�,yK ° c A e o ' V,4 / / SCALE: � _ Ef� CH P! T P '' ✓� Vi L i tA'or- 3 0 \\ �� co / f3 �D�2 O O M HOUSE D f3 T 4!-r:- 53 TES " AS _► �E --- - 0 Cno a'tsPose'r� _ / 7-1 _ T- ei=jAA15rAac_C 1 _ _ Ic- [_- C7 Cn/ ,mac'f 7 T E > 3 G _ C=�9 c_S./D A> DATUM s r / \\'t \ SE PT/C T/9AJK x /. 5e `�5 TEST HDLE #/ 7-Er HOLE_- fir? 2 �v S USA: /ocJ- GAL. TAA./K J g 000� 2 /� 2� �/. ?.c9. � Ci GEr9G'f-1 P/ T: LciHr� 0 Difa. \ EFF• D E P r/-,r D C- L L = % /. 9 S. F. _' `` ?2 a, G. P. D.- 0 1 \ f Z EF9c%4 F'/ 7' i !! 10 '7 - � , ,� / %' P/2oPo5ED oti1 THE G�2oun/D r95 S / T� - v�/ C'� L /v U r ` H O !�/A J O A./ T14/S P L AJ DOES - .: O/� f / .�.,E 1� - l�L . ! -. ^J.. A �o� . LOTS /? �� _ - f 4 GONF0�2M TO T/-/E B(J/G.D//l/G -15&7-- ( c 7 r �2E MEiIJTS OF THE 7-O/.v nJ O F T %, PEE P/92 E D FOB. i ,9S S N O!n/�/ IDf4 7-C- H Al s• / ` Y v MiNCKL E� rn O/ST S c /9 L E / _ ,ono 13214. /)/ f Np - v�ytl f � � 0tJ e LAJE- LLE- )�2 , / CSC 0 0 0 = x /S-tt n q e /e vatr o n BL D G• SET o. O O Proposed e !e va-t/on �2E QU/QEEME AJ7-5 - - - -- ---- - - ex /Sf/ nq contains B0f)A20 O/= HEALTH _. N7/9 S S —