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Home My WebLink About0329 WAQUOIT ROAD - Health 329 WAQ,VPIT FfW COTUIT UPC 10334 o.2-153 kW �e �ga 0tc- ^ sks-S J.'z Jti►, ems ,rw 1 I I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 Waquoit Rd. e,h Property Address g McDonnell ; Owner Owners Name information is required for every COtuit ✓ MA 02635 5/10/19 w, page. Cityrrown State Zip Code Date of Inspection cr Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Is Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/10/19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner s Name information is required for every COtuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): y ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owners Name information is required for every Cotuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �n 1p Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owners Name information is required for every Cotuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for aH inspections: 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)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. Cityr'rown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? E Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes- ® No Seasonal Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,ig Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every COtuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/user Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons .How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �o ,p Title 5 Official Inspection Form If Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1988 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: - ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �o 329 Waquoit Rd. Property Address McDonnell Owner Owners Name information is required for every Cotuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 11 feet 8 Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) H-10 tank appears to be structurally sound, outlet cover raised to 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 3„ 11 Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" - How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts - p Title 5 Official Inspection Form 1'o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owners Name information is required for every Cotuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): H-10 d-box is 3' below grade, no indication of past hydraulic failure t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owners Name information is required for every Cotuit MA 02635 5/10/19 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑: ' leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts {9 Title 5 Official Inspection Form I ,l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit is dry at this time, stain line about halfway up the sidewall, bottom of pit is 12' below grade, cover raised to 12", no indication of past hydraulic failure 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waguoit Rd. Property Address McDonnell Owner Owners Name information is required for every Cotuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner s Name information is required for every Cotuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 a C t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 i Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 329 Waquoit Rd. Property Address McDonnell Owner Owner s Name information is required for every COtU'it MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >16' 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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 1988 compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, site is 24'msl and nearby surface water is at 2'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ja ,,P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waquoit Rd. Property Address McDonnell Owner Owner's Name information is required for every Cotuit MA 02635 5/10/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. _ 329 Waguoit Rd Property Address ! Patty Mcdonnell t Owner Owner's Name information is Cotuit Ma 02635 6/30/17 ' required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information S/. a Ya g on the computer, use only the tab 1 Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Q Company Name 35 Content.Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 S113522 Telephone Number -License Number B. Certification .. .s mot:" f• a - I certify that I have persorially 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 ❑ Needs Further Evaluation by the Local Approving Authority 7/5/17 Jn'spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of.Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e' 329 Waguoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 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: of found any information which indicates tfiaf 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: Sytem contains a 1000 Gallon septic tank. As well as a concrete distribution box and a 600 Gallon leach pit. There were no signs of failure at time of inspection B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspeption Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cwM 329 Waquoit Rd Property_Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational: System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: . ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance.with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins°3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 � Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M .329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 - 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.systemhas.a septic-tank and soil,absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Q ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Q ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/ day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form IN Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 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 analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] EJ ® 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 El El the.system.is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)'or a mapped,Zone II of a public water supply well If you have answered "yes"to any question in Section Ethe 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. t5ins-3l13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fort Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments 329 Waq uoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every. Cotuit Ma 02635 6/30/17 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. ® F-1 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t 1 .Commonwealth of Massachusetts. - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. CityTTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): ^ . 198 Gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date CommercialAndustrial Flow Conditions: Type of Establishment: Design flow-(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System. Form - Not for Voluntary Assessments t 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Annually 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth ofWassachusetts W Title 5 Official Inspection Form _ ® m p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 329 Waguoit Rd Property Address. Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 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.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene C] other(explain) 1000 If tank is metal,:list age. ; years Is age confirmed by a Certificate of Compliance? (attacha copy of certificate) - ❑ Yes ❑ No Dimensions: d Sludge depth: e t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i - - Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is Cotuit Ma 02635 6/30/17 required for every 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 24" Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's were in place at time of inspection Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ' .Date t5ins•3/13 Title 5 Official Inspection F.orm:,Subsurface Sewage Disposal System•Page 10 of 1,7 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page.11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments q ^M 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 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 Level and at normal level with no signs of higher levels 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t � Commonwealth' ealth of Massachusetts R. W Title 5 official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Waquoit Rd Property Address _ Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Type: leaching pits number: 1 El leach,ing_chambers. r .-.,' ,. number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of failure at distribution box Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer, Depth of scum layer' Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 329 Waguoit Rd _ Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. City/Town 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.): l5ins•3113 Title.5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 14 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary,Assessments w 329 Waguoit Rd Property Address Patty Mcdonnell Owner Owner's Name . information is required for every Cotuit Ma 02635 6/30/17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Waquoit Rd M Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: USGS maps indicate no ground water at 10+ ft Before.filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 b � �-� { �... 1 .. ice__._--�-�- � - � � - � � [ ,, � r ��,1 � _ i 1_ u ti K 4 4 E h .. �i ', i _ �. .. ._ � -� C :,�.i tl F �. d F � ' .. I.� f� — i� ... i - i . - - a. � F ' • ' t P - � Commonwealth of Massachusetts gp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M e 329 Waquoit Rd Property Address Patty Mcdonnell Owner Owner's Name information is required for every Cotuit Ma 02635 6/30/17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS IN EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ra B PART A CERTIFICATION PD e� Property Address: 329 WAQUOIT RD. COTUIT MAP 156 PAR 6-79 L 103 B Name of Owner TOM SMITHr 9� o Address of Owner: SAME ° ,," Date of Inspection: 5/11/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Eva ation By the Local Approving Authority performing at the time of the inspection.My inspection does Fails not imply any warranty or guarantee of the Ionggevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/12/99 The System Inspector shall ubmit 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 of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.THE LEACH PIT HAD 8"OF LEACHING LEFT AT THE TIME OF THE INSPECTION. revised 9/2/98 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 156 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:5/11/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n[a One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND .Describe basis of determination in all instances. If"not determined",explain why not. Wa 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. WA Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_ (approximation not valid). 3) OTHER nLa 4 revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply -X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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 15.30412).Please consult the local regional office of the Department for further information. i revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 329 WAQUOIT RD.COTUIT MAP 156 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information, For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. { revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 FLOW CONDITIONS RESIDENTIAL: Design flow:J40 g.p.d./bedroom ! ;� Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 440 r Number of current residents:2 Garbage grinder(yes or no):MQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nLa gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): �LQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:nLa Last date of occupancy: nLa OTHER: (Describe) nLa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa_ gallons Reason for pumping: nLa TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank ' Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: 1988 PERMIT#87-792 Sewage odors detected when arriving at the site:(yes or no): N_Q revised 9/2/98 Page 6 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 BUILDING SEWER: (Locate on site plan) Depth below grade: Z!E Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 2 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ n& Dimensions: L 8'6"H5'7"W 4'10" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 2.0 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: E How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY ONE YEAR. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete metal_ Fiberglass _ Polyethylene_other(explain) Dimensions: n& Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:ja& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n& revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:5/11/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NO Alarm level:j2ta- Alarm in working order:Yes—No—: NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:5/11/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 624'PIT WITH 4'OF STONE leaching chambers,number: .n(a leaching galleries,number: jiLa leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: nLa Alternative system: n& Name of Technology: _3& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY,THE PIT HAD 8"OF LEACHING LEFT AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: DLa Depth-top of liquid to inlet invert: n& Depth of solids layer: n/A Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)D& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:Wa Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& I i revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 166 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a a3 � 3y a revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WAQUOIT RD.COTUIT MAP 156 PAR 6-79 L 103 B Owner: TOM SMITH Date of Inspection:6/11/99 NRCS Report name: nLa Soil Type: nLa Typical depth to groundwater: nLa USGS Date website visited: nLa Observation Wells checked: XG Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2/98 Page 11 of 11 L i TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS:%Z_- i1/^�5,� Ql ,� �J Mail To: g�Gj�,��l Board of Health :BUSINESS LOCATIONS Town of Barnstable MAILING ADDRESS: P.O. Box 534 TELEPHONE NUMBER: Q/ Hyannis, MA 02601 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities tot Iling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your ' mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business OF BARNSTABLE LOCATION p ®)AOWN �jQ'0001 o&( SEWAGE # tjZ-792 - e VILLAGE C&i I % ASSESSOR'S MAP & LOT 161, Z•—� INSTALLER'S NAME & PHONE NO. SvOIZL Q SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) boo NO. OF BEDROOMS PRIVATE WELL OR LIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: "7 - a go VARIANCE GRANTED: Yes Now VC 2 9 Vl/ �� T" 1 C" THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF -HEALTH Appliration for Diopootti Works Toustrudion Frrutit Application is hereby made for a Permit to Construct (Y� or Repair ( ) an Individual Sewage Disposal System at: ISS --...-----••------•----•- .............. .......................................... ------------ Location-Address or Lot No. ......................_.....---.............------.......---------..._......._.._._......._._..._ ..........--._.._._.......--••--..._....•-•-------•-...........•-----^-.......................--- �j Owner Address JU Installer Address Type of Building Size Lot.Z?--)PM..........Sq. feet Dwelling—No. of Bedrooms.........3..................._..........Expansion Attic �Ql Garbage Grinder Other—T e of Building No. of persons____________________________ Showers — Cafeteria dOther fixtures ------------------------------------------------------.....-----------------------------... ........................................................... W Design Flow............ 5........................gallons per person per day. Total daily flow__._._.__�._6s�____________._____._.___gallons. WSeptic Tank—Liquid capacity __gallons LengthgG..... Width4-l _.. Diameter_____ _______ Depth_;5��.__. xDisposal Trench—No...........:......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.._._..__t-.____ ___ Diameter_._.A__......... Depth below inlet__'............. Total leaching area_.I-b......sq. ft. Ig Other Distribution box (1(G$ Dosin tank (4 g ~' Percolation Test Results Performed by. D4T— ._V.11Y _1 . ...................... Date._��'.�®.: ?. _.._.__...__. Test Pit No. l _ minutes per inch Depth of Test Pit Depth to ground wate _ -�9..... .Z..._ ___«___.__.__. r_dT -CViC7At TeEGD fz, Test Pit No. 2....4. ___.minutes per inch Depth of Test Pit----LO........... Depth to ground water________________________ ...................................-----::1.-----••••••--___..... -••••----- ----•-----........................................................... O Des rip ion of Soil_7:4 : �' A..-K- -- b z-1 oees-r�pgvm A ue>w- t C. Z_-4' C-,c>A,OA 5 __ VQ.1V 6 C.• I b--• ..--C --------------------------------------------------- ----------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------•-••-•__-- UI Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---...................----............................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITLij 5 of the State Sanitary Co The unde igned further agrees not to place the system in operation until a Certificate of Compliance has bee is ed by the o rd of healt . Signed_ ....... ..•••-••-••.----- Date_-__-•--__--_-- ------ Application Approved By............ �--'�'-='--�---��--� ---------. ............ .'.--------•---- ........................................ Date Application Disapproved for the following reasons:___•__•_________________________________________________________________________•___.__.._...__......_____.__-__ ---------------------------------------------------------------•-------------------------..._....--••--.. Date a PermitNo...... --------------------- Issued........................................................ Date No.._r .�:... 2 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH you! 1.................OF.... ►-,.IU C,. ,..---------...............----...----- Appliration for Disposal Works Tonst.rnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: _ ---- ..!......-� --------------._csv.!.r-...------•.. ..........................................................................-o..•••.� -�----------------------..._............................... Location-Address or Lot No. ......................—.......................................................................... ................................................................................................. O -C1 .�.....ner ................................Address Installer Address h dType of Building ;�t Size Lot.7-11 --......Sq. feet V Dwelling—No. of Bedrooms.........: ................ ... Expansion Attic (I�� Garbage Grinder Other—T e of Building No. of persons............................ Showers — Cafeteria PaOther fi-Uures ..•-•-------------•-------•---•-..........--------•-•------------------------•-•••-------•---•--..............------------..........-••-••-•....----• W Design Flow..........5-5.........................gallons per person per day. Total daily flow........._5_ 0. .....................gallons. WSeptic Tank—Liquid capacity)P ..gallons Length&. �?..... Width 4-� .. Diameter"-�.. Depth.S__j?.�'._.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NO..........i ........... Diameter....,........... Depth below inlet......-............. Total leaching area.3.0.b------sq. ft. Z Other Distribution box (�q :.I Dosi tank ! Percolation Test Results Performed byl................. .agY� q.�...................... Date...�_'.Q..B.r7........._... 04 Test Pit No. 1...G.Z.....minutes per inch Depth of Test Pit...A 0.......... Depth to ground water.... . Test Pit No. 2....4..g ....minutes per inch Depth of Test Pit___i o......_._.. Depth to ground water........................ ..........................................".'................................... .........................I................................................. O Des ri ion of Soil- �-1 �----�'.....0-7_ .Y0%2 e5r Loi-\Vti�l...A U�soI 1. - ._- �} U .--�. _�Z-!\(G C.-�l-I-- f-- �--�'----� c-------�-- _.�4� - ------------------------------------------------•-- 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 iITLL 5 of the State Sanitary Co The under igned further agrees not to place the system in operation until a Certificate of Compliance has eetr is ed by the o rd of healt Signed. -------------------- --------- Date Application Approved BY.......... --�`"�.�``=`--`'�-�-~'.:`_�------------- --------------- ................... ............ Date Application Disapproved for the following reasons:........... ..................................................................................................... ---------------------------------------------------------------------------------------------------------.....------------------.....---------------------------...--------------------------------.--•-- Date PermitNo.....� -b ? - 7.1- -----------------•-•. Issued.---•-......---------------.....---•---•-- .------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................OF..................................................................................... (Intifiratr of f�lant rli nrr THI S T CER IFY, That the n ividual Sewage Disposal System constructed � ) or Repaired ( ) by....--------� =: i�.....---- • ---------------------------------------------------------........-----...------------------.........................-•---------------- Install at has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... /.— .-? ........ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................(...--•-------..............------------............. Inspector................ -• ,---- .._....----------------------•-•----•----•-••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH GGc-z-i_ OF.......... �-s2�e.p er, / /( N �. -�-- .................. FEE./ Dispoa lRvr Tans ion umit Permission is hereby granted.......... ... ........................................................................................... to ConstructL)oort Repair an Indijdual Sewage ispo�Sal,lSystemc� atNo !! // f�.....---- --------- ---------------------- .-•.........-•-....------•---•-•----•-----........-----....---....--•-••--•-------•----•--.................•...... Street 7' y as shown on the application for Disposal Works Construction Permit No...............1- Dated.......................................... Board of Health ------- DATE................ - i_ram'............--------------•. FORM 1255 .HOBBS & WARREN. NC.. PUBLISHERS .71 s ! I , `. rill fir ._ . i t i i rr(•1� � co : 1170 10 � � � , .:_ Sly -� � : '� ' r , . y8 �� • : Y1 f i-, o i tit Of TER: A Sl1LLfv AI ci+ Ro r A' _. u0"29731, ty ; '8AX"ITER, t , ils- !�a w •- �A Ise ! � d Y _` ".• S`Gcl LE 7 �z ;- , �•,_,. /moo ., : ; : , . E � , I � � Cam- '_ _ZCY ?7 T" ../74 a✓ ,. P T!o�r>(lGW '4i `?�-� G4� T �il� c�M/�i�,� F I . .. . `A � 0. N (N�AI:FlAtdE N4'�h'GUIDE f.tNf. �: '�r,b i . s ® Y I f ; t_ 3 _ II � tl r CL 1, i ... . i Foyer it �! I K ift i . fa t car i i h ' I A6 126 6 CL ��RFld1 146 CL- 7- -ca - ±f i Y: �I CL 40 � S y i j f' t9it :x utlit 40'x 132 utfut i 1-3'F WN ublINty. - � ° i Barnstable,MA 02635 $495,000 4 3.5 1 3,441 Sq.Ft: Price Beds I Baths I $144/Sq.Ft. Redfin Estimate:$470,664 On Redfin:553 days ' Status:Active LLLI L] CA -- — 4 of 27 Go Tour This Home ----.----.-.._..._._.._ MONDAY f TUESDAY WEDNESD https://www.redfin.com/MA/Cotuit/329-Waquoit-Rd-02635/home/111100012?utm_source=google&utm_medium=ppc&utm_campaign=1014251&utm_.. 1/21 JG.J •�NI�NV � \N Barnstable,MA 02635 r $495,000 4 3.5 3,441 Sq.Ft. Price Beds i Baths $144/Sq.Ft. - Redfin Estimate:$470,664 On Redfin:553 days Status:Active D fL rl �. a-W F i E I 7-11 l Go Tour This Home MONDAY TUESDAY WEDNESD e)-7 e https://www.redfin.com/MA/Cotuit/329-Waquoit-Rd-02635/home/111100012?utm_source=google&utm_medium=ppc&utm_campaign=1014251&utm_... 1/21 Barnstable,MA 02635 $495,000 4 j 3.5 3,441 Sq.Ft. Price I Beds Baths $144/Sq.Ft. Redfin Estimate:$470,664 On Redfin:553 days Status:Active utaty s• Y u utaeyy_ i0•a'13' - F UvRy 13'�7 T Yt7i W$9'p t - Go Tour This Home MONDAY ; TUESDAY WEDNESD �7 https://www.redfin.com/MA/Cotuit/329-Waquoit-Rd-02635/home/111100012?utm_source=google&utm_medium=ppc&utm_campaign=1014251&utm_... 1/21 3/25/2019 AsBuilt ro 6 b �-�. OWN OF BARNSTABLE LOCATION k7 SEWAGE # a7 Zq2 VILLAGE Co%U t % ASSESSOR'S MAP & LOT,,6t INSTALLER'S NAME & PHONE NO.?)QU,$)0lZ-L,p c Ol SEPTIC TANK CAPACITY /006 9R� LEACHING FACILITY:(type) iOl Q4 u�5�STd (size) BOO NO. OF BEDROOMS PRIVATE WELL OR LIC WATER-� BUILDER OR OWNER_ / m 119y.,r/Y DATE,PERMIT ISSUED: `.QG1,CrB' DATE COMPLIANCE ISSUED:__ :z -a VARIANCE GRANTED: Yes Now, http://issgl2/intranet/propdata/prebuilt.aspx?mappar=006069&seq=1 1/2 3/25/2019 AsBuilt http://issgl2/intranet/propdata/prebuilt.aspx?mappar=006069&seq=1 2/2 el �— �0 4A l `Je d— C-4^0cr�,k `:•�` z srvv IS 1