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Home My WebLink About0006 WINGS LANE - Health Wings Lane Cotuit f A = 01-9 174 r' I i f a z�. DEEFOBSERV� ' Ol�l DOLE LOG Depth from Soil .Horizon. Sorlextirre Sa11 ' fors: :' Soil —Other :.' Surface(ia) (USDA) N (Ivtunseil) ttling (S�trltctun,$tones,Boulders: z � . . 1.3 2iYL 1 OV4a � '�O�.Lt ryLOt�iA H018# ;,, Depth from Soil Horizon Soil Texture Soil color t Soil Other Surface`.(in.) (USAA) (Munsell) Mottling (Structure,$tones,Boulders.: �'►S t s DE kF Mt VATWTN HOLE:LOG Hole Depth from So►I Horizon Soil-Texture Soil Color: Soil Other' $urfact:(in.) (USDA) (Munsell) Mottling (Sductute,Stones,aoylders. 3� Q AxS ld rts . Z55Y DEEP QBSERVATION ROLE`LOG Hole# —" Depth;,frog Soil.Horizon. Soil Texture Soil,Color Soil Other S.nrface:(iai) (USDA) (Munselq Mottling (Structure.Stoti..I Bouldors, ve L- S tc t`C y z 3y i3Z 77 _. r �lerod 1 ,g�e�Ra_,,.to Man - Ao1�e Sear flood boundary No'_ 'Yes ifi�ttlCto S`Q0 yesrbouadary No Wthtn COO year flood boundary No�� Yes i got Afllaala` Oecurrin>;Pervious Material �.ots�at ltfotir fret of naturally oceurrtng pervlous inatertal.ezisr in ail areas;observed throttgk�qut,the area proposed#or the sotlabsorpton system? If not,what is the dept}t of naturally occurring ptrvious<matoril?, .._ ...,.. Ce>�f I have assed the soil evirluator.exaW atton approved I c �tbat on ( p D arepcflntronmental proteehon and- 7thaE the above analysts was perfgrnied by trte cofis Cwtth f. Y 7-` tired ttinti ,ex erhse>aft d eicp"erence lescnbed th lO CNIIt `.1 . the tq g P 14 Date . Sigttature %SBI�'1+ICIPBRCFORM.DOC To -0. b� Depaienty ofRegulalry:Services . . I<' f; l3 2*Main Street,Hyanals MA 02601 i u� a iOl 7atCctledtited r Time Fee Pd.: lCJ6 cZ . 1 0 Svi Sutacb Assessment i>3r Se a , s : f PEtforriied Byi_ �1-Q aC. � + Witnessed 13y:. _ LOCATION 4AL " LN h �t ou me C,f' Address - 5 5. �V`c l C/ ( / Engineer's Name REPAM Telephone# cT��" �-- .Land Use. 1�-F) ��1��,\�Qt t Slopes(%) Surface Stone$ �— Distances:frnm: Open Water Body 1��U ft 'Possible Wet'Area CS�a ft Drinking Water Well S�Q ft Drainage Way �1� ft Property Line. ( -fl—ft Other` ft S'�TC` (Sttett name,dimensions of lot,aaact•locations.of test'holes&perc tests,locate wetlands i'n:pt+olladty to'hwds)' f I . ( 3 V. d t�� 66 P. Parent material(geologic) ` Depth to Rodrock l .Depth to Groundwater. Standing Water.in Hole: Weeping from Pit:Face,, r ,, s• j Estimated Sea3onal-High Groundwater �7 r I IDETERWNATION FOR SEASONAL HIGH WAT1�R TABLE Method Used: Depth Observed standing in obs,hole: in, Depth ro soil. Depth to weeping from side of obs.hole: in, GroundwatergdJuatment ft. Index.Well:# Reading Date: 0o index Well level, � Adj.lector Aijl'tlrouttdw. E ievgl,,,,. YA t t� -2. -7?0 P.ERCOLA -,�ON TEST r�4te Observation Hole# l P—r �3 Time'at 9" Depth of mac' 'Tillie,at.:6" Start Pre-soak Time® Time(9"W') End Pre-soak Rate Min✓Inpli: �.• ?- �1 I- Site Suitability Assessment Site Passed Site:Failed Additional Testing NeZded(YJN) Original Pybl c Health Uivisibn Observ0ion;Hole Data To`Be Completed on),Back-- •- -- If percolation test is to be conducted within 100' of wetland,you must first notify tho . Barnstable Conservation.Division at least one('1)week prior to beginning, Q:ISEPTr0PERCFC)RM'.D0C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 6 Wings Ln Property Address Heidi+Thomas Owner Owner's Name information is Cotuit MA 02635 7-27-10 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. A. General Information 1. Inspector: Shawn Mcelroy :Name of Inspector rr Upper Cape Septic Services company Name = 29 Atwater Dr Company Address .E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification . I certify that I have personally inspected the sewage disposal system at this address and that the infcrmation 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 2 ❑R�Nee *,Iller, valuation by the Local Approving Authorityco o - a 7-28-140 Coo Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority Xoard • of Health or DEP)within 30 days of completing this inspection. If the system is a shareRyst@rtt 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. I t5insp official document•00/08 Title 5 Official Inspection Form:Subsurface Sewage Di osal System•Pa e 1 of 15 Y f I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 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: ® 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Wings Ln - Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 f J - page. City/Town State Zip Code Date of Inspection F B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced . ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of,Health): ❑ broken pipe(s) are replaced ❑ obstruction,is removed ND Explain: C) Further Evaluation is Required by the Board of Health: e❑ 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 mannerwhich 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 42. 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. F ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 t, r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 - 7-27-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 cesspool is less than 6"below invert or available volume is less than '/ day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M '~ 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ • ® 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 d 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 ;. - ❑' ,�'❑! thersystem 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 El ❑ Area— IWPA)or a mapped Zone II of a public water supply well ` If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. - • II t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 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 CM 15.302(5)] t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit a F MA 4' 02635 7-27-10 - page. City/Town ;,. state Zip Code Date of Inspection 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 Number of current residents: w , . 3 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 years usage (gpd)):. Sump pump? j El Yes ® No, ks H Last date of occupancy. ,, 7-2010 `' D ate 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? Y. ❑ 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: Last date of occupancy/use: Date • Other(describe): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts , T _ Title 5 Official Inspection Form 1 J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit '-' 'MA 02635 7-27-10` page. City/Town State Zip Code Date of.Inspection w D. System Information (cont.) Building Sewer(locate on site plan): ' 12" Depth below grade: _ ,, _. 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.): . - • Good condition: Septic Tank(locate on site.plan): 6" Depth below grade: feet Material of construction: concrete metal _ fiber lasspolyethylene other ex lain ® 9 ❑ ❑ (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 12,. Sludge depth 20„ i-;I, Distance from,top of sludge,to bottom of outlet tee or baffle Scum thickness . 6" Distance_from.top.of scum to top of outlet tee or baffle r� Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape - t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 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.): Tank is in good condition with baffles installed and no sign of leakage. 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.): 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): t5lnsp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntay Assessments' 6 Wings Ln 5 Property Address` Heidi Thomas Owner Owner's Name information is Cotuit ' MA 02635 7-27-10 required for every _ page. City/Town State Zip Code Date of Inspection D. m Inf r System o mation: cont. Tight or Holding Tank (cont.) 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 '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.): Good condition with water at working level and no sign of back-up. a A. ' Pump Chamber(locate on site'plan): w Pumps in working order: t ❑ Yes ❑ No- Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 • I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 1000 gal ® leaching chambers number: 4-infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: r failure, level of ondin dam soil condition of Comments (note condition of soil, signs of hydraulicp g, p , vegetation, etc.): Leach pit in good condition and holding 36" of water with no sign of recent back-up. Infiltrators in good condition and empty with no sign of back-up. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts T. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 6 Wings Ln Property.Address Heidi Thomas Owner Owner's'!Narrie t information is Cotuit MA 02635 7-27-10 required for every page. City/Town ' t. State Zip Code Date of Inspection D. System Information (cont.) 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.): . 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.): u t5insp official document-03/O8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Wings Ln Property Address Heidi Thomas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 page. CitytTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1 o u 0 3 Lo a C� 8'� t5insp official document•03/D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ny 6 Wings Ln Property Address Heidi TI-omas Owner Owner's Name information is required for every Cotuit MA 02635 7-27-10 - 4 - page. City/Town 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: pate �Cs Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: w Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Ycu must describe how you established the high ground water elevation: Original design plans show no groundwater at 10'. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS h M d DEPARTMENT OF ENVIRONMENTAL PROTECTION 0W TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 Wing's Lane Cotuit MA 02635 Owner's Name: Barry Neagle Owner's Address: PO Box 2037 Cotuit MA 02635 g Date of Inspection: January 4,2007 Job#07-01 Name of Inspector: PATRICK M. O'CONNELL r ; Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD ...;� MARSTONS MILLS MA 02648 cfr! 731 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT r"" 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: PP Y P P ( ) y X Passes ; -- —Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: - Date: 1/4/07 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. Notes and Comments: Infiltrators have no standing water and tank is not in need of pumping. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of i l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have net found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed. ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 C. Further Ev€luation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System Will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No —X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool —X— Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 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. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile.organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria . are triggered.A copy of the analysis must be attached to this form.) _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be.necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no. the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to.a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following• Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health — _X_ Were any of the system components pumped out in the previous two weeks _X_ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? . _X_ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out _X_ _ Were all system components,excluding the SAS, located on site _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no) No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 96,000 gal.= 131 gpd. Sump pump(yes or no): No Last.date of occupancy: Vacant for approximately two years. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval 4 _Other(describe): Approximate age of all components,date installed(if known)and source of information: -Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I I a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan). Depth below grade: 3" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide— 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles are intact and clear,liquid level at bottom of outlet invert Tank is no tin need of yumyine at this time. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO RMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 TIGHT or HO LDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments n e( of if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or high stains. Liquid level at bottom of outlet invert PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X leaching pits,number: One 6x6 pit. _X_leaching chambers,number: 4 Infiltrators. _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.): Leaching pit had previously failed however is still connected Infiltrators have no standing water or evidence of surcharge. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) " Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Barry Neagle Date of Inspection: January 4,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Wing's Lane Y 47 Water 56 Service 33 . 13 D riu w j Page 11 of 11 a � OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit , Owner: Barry Neagle Date of Inspection: January 4,2007 . SITE EXAM s Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water; More than 20 feet ; Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:p 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) _X_Accessed USGS database-explain: USGS topo map and town GIS ° You must describe how you established y s ed the high ground water elevation: . Town groundwater contour map shows water below el.5 and topo map shows property above el.30. Y � r COMMONWEALTH OF MASSACHUSETTS d EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A F d DEPARTMENT OF ENVIRONMENTAL PROTECTION ' 'ARC 1 4 - 1_ `E I A . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 Wing's Lane �. Cotuit MA 02635 Owner's Name: Rita Morrison 6 Owner's Address: Same j + ;C Date of Inspection: February 16,2005 Job#05-27m Name of Inspector: PATRICK M. O'CONNELL ' Company Name: SEPTIC INSPECTION SERVICES CO. , Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 - rn CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a D) � approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system tt _X_ Passes �� OF• A•'9��. • ti':Conditionally Passes - •, G , Needs Further Evaluation by the Local Approving Authority TRI K m Fails = :—+ L co Inspector's Signatures ••. p Date: 2/16/05 ��,� r Rj1F,1�• OQ��• The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hela��titotr,,`` DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 1 b,0or gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office I!bthe DEP.The original should be 00 sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. , Notes and Comments: System in good condition,observed no standing water in infiltrators. . 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. t Title 5 Inspection Form 6/15/2000 page 1 F Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 Inspection Summary: Check A,B,C,D or'E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection.if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed = ND explain: Titles C Tncnnrtinn Fnrm 4/1 si�nnn 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: T41. C inonunfinn Rnrm ail Ci�nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow — _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. — _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X_ Any portion of 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. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply.' _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. T41. S lncnurfinn P--4/1 4z/7nnn 4 it Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant, or Board of Health _X_ Were any of the system components pumped out in the previous two weeks ? _X_ _ Has the system received normal flows in the previous two week period? _X_ 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) _X_ _ Was the facility or dwelling inspected for signs of sewage back up ? _X_ — Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site ? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] { T41u G rnenartinn Fnrm 4/1;mnnn 5 i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Wing's Lane,Cotuit p Owner: Rita Morrison Date of Inspection: February 16,2005 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 Number of current residents:3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—73,000 gal.2004—89,000 gal.=221 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/s ft,etc. : q ) Grease trap present(yes or no):_ Industrial waste holding tank resent es _ P (y or no): Non-sanitary waste discharged to the Title 5 system ( es or no Y :) Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records: None GENERAL INFORMATION Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy —Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank =Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date for new leaching system: 3/16/93 Were sewage odors detected when arriving at the site(yes or no): No II T41. C TnOn.ptlnn Vn _411 C/')rlllll 6 L Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron X40 PVC other(explain): Distance from private water supply well—or—suction line: 30' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 6" Material of construction:_X_concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions:8.5' long x 5.2' wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles intact and clear,liquid level at bottom of outlet pine Recommend pumping tank every three to five years to properly maintain system GREASE TRAP: No (locate on site plan) Depth below grade:— Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): — ' Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum_ to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titlo 19Tncnartinr� Fnrm A/i v,7nnn 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan), Depth of liquid level above outlet invert: 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.): No solids or high stains Liquid level at bottom of outlet pipes PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): c T41. G Tncnonlinn T:nrm All VIOM 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit _X—leaching chambers,number: Four infiltrators leaching galleries,number: j 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.): Leaching pit still in service has little or no effective leaching Infiltrators have no standing water (100%effective leaching) CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: No (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.): Title G Tncnontinn Fnrm 411 c/,)Ann 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Wing's Lane 50 47 47 Water service 56 33 13 #6 h� Titl.f T.v—pt;^n 17—M 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Wing's Lane,Cotuit Owner: Rita Morrison Date of Inspection: February 16,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 12 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_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: Low area on opposite side of road considerably lower than bottom of SAS. Tina C Tncnar4inn Fnrm�/1 S/7!1l1/1 1 I L TOWN OF'BARNSTA.ELE - C� f .00ATION �!�`l S vi SBWAGir # TII:.LAGE �C) �"�f" ASSESSOR'S &LOT— -- - NSTALIXWS NAME&PHONE NO. I SIpI'IC TANK CAPACrrY ,EACH�rc Ix,�C�. r: (type) Size) /oao� / d- 3 WILDER OR OAR 'ERMITDAT'E: COMPLIANCE DATE: iepasatinn Distace.Between the: rlaximurn Adjusted Groundwater Table to the Bottom of Leaching FaLility eet Ylvrate Water Supply'V�A and Leaching Pacil ty (If my wells exist on site or within 200 feet of leaching faclUty) ;dge of Wetland raid Lear.Wpg facility(ifany,wetlands exist within 300 feet C�Ia nng facilsty) Feet 'urnished by....._ . . 0 0 A -F-22 L 6-C-3-F1 ' s. ' i THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) A �CM LI DATA ` TOWN OF BARNSTABLE A o C�3i'n5i5 � ►-e_ �E# n�P "AGE it ASSESSOR'S MAP&PARCEL I1*WAbE-R8 NAME&PHONE NO74*rt LIL 0 6 SEPTIC TANK CAPACITY /QCr-)� Qj LEACHING FACILITY-(type),-�, >i`t d- n OrrcOLY")(size) NO.OF BEDROOMS OWNER �, PERMIT DATE: C® - ICE DATE: o-7 Separation Distance Between.the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well aii4�, eaching Facility(If any wells exist on site or within 200 fed,o£`leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Wing's Lane,. - 47 YWater - Service 56 33 b��Drt�eway t t TOWN OF BARNSTABLE 1 L A`I'IOId GUrV7G5 L..✓I• SEWAGE# PSfeaT'' bv1 VILLAGE �ey?y�`1' ASSESSOR'S MAP & LOTO( p IN �- 'S NAME&PHONE NO.r7:R}f;,-1C- /77 SEPTIC TANK CAPACITY /000 LEACHING FACIL=: (typei2c"t c+-, y- f/'lrv40r5 (size) NO.OF BEDROOMS, BUILDER ORRk Gtgg :�� 6t'f i�✓� PERMIT DATE: C@NP999XE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom.of Leaching Facility' _ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility] ry'' - Feet Edge of Wetland and Leaching Facility(If any wetlands exist ¢. within 300 feet of leaching facility) Feet Furnished by r 41 W1 nn � TOWN OF BARNSTABLE - C LOCATION I;CJd S SEWAGE # VII_!,AGE d l v t• 1 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. )7(3 SEPTIC TANK CAPACITY d 'LEACHING FACILITY:(type) y` -! : (size) [, 6L1 NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER i BUILDER OR OWNER j i � n�21 SK v DATE PERMIT ISSUED: DATE_ COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No `� L l 1 ;.;.. No... . .P , � .. Fa$..'30.00.......... THE COMMONWEALTH OF MASSACHUSETTS APPROVED v I •, g Cry Qm8m0tion Depsrtment �... BOARD O F HEALTH A LT 1-I TOWN OF B A R N STA B L ET_ -A_�- 1tratinn fur Di�ipninl World, C�>�nn#rnr#inn rrnti# Application is hereby made for a Permit to Coiist:uct ( ) or Repair (x ) an Individual Sewage Disposal System at: 6 Wings Ln cotuit •-•-•---•--.....---•--•-------•-•---•--•--••-------------•-••----------•----•-----------........•. ....................••-••-----...----------- Location-:address or Lot No. S. Morrison ......................_............................................-------••••---•-••---•--•---- -••----------------•-•----•-----••----•-•-------•-•---•.....•------••-•-•-•--..........-•••••-•--- W W.E. Robinson Sept°:r rservice P.O. Box 1089 Centerville MA ,-a Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....3....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0— Other fixtures -----------------------••--------•------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................ Disposal Trench--No. ..................... Width.................... .total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....--- Diameter.._................ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit....:............... Depth to ground water........................ (, Test Pit No. 2................minutes per inch Depth of Test Pit...-----....--...... Depth to ground water........--......:... -----------------------------------•-----------------------•--••---------•••-•-••-•-------......---......................................................... 0 Description of Soil.......sand....................... --------------------------•-------------------•-•-•-•------•-..........------ V ...................... --•----•••----•...............•-••-•-------•-•---------•-•--•---------------••-------------------•-------•••-•-•-----------------••--------••---...--•........---.....-•-........ W UNature of Repairs or Alterations—Answer when applicable.............................._.....--.--....................................................... ...... nstall__.(-4_)__-stone-packed__infiltrators-___-(-off_•existing__septic__tank_ -. _ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h en issued 4te board of alth. Signed ✓'� ...... .......................... 3P1..... 9 .... Dare Application Approved BY - 'r^'"., . --------- . ................................................... ..*.-�/...-...�1.3.......... Dace Application Disapproved for the following reasons: ...................................................... .......... .................. ................................................................................... .................................................. ........................................ Dace PermitNo. / '>_�-' /J.,----------------------------- Issued. .................................................................... Dare .:,yam.. ...3'•''�.�<'-�r-'�„x..�,7,.,,�"Y�-�-�.,.._'�i.:y-�--.,..�.eLi^w.•.�v.+..,,.,-.:.k.-.^...,.w.w,;l;,.-..•...',;.. ,:v.sa...,e•..^r�,y:a'•w,..,,..1y3'y�l.;7R:.�'Jw�a::l:r��d,SfS''s�``v�.�d"5..+.i"�fy 1 `""�`4 c" r� No.... �_ M. Faa. 30.00........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �_714'7-p--,. . : A pliratio t fur Diripuuul Wurk,i Tum,�rns�"tun rrmt� Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal System at: 6 Wings Ln cotuit .............................•-------........---•-•---......---------------•--.......--••------•-. -•-••••-•----•----••------••-•........-•-.....----••---•-•--••---••-•-•-•-••-••--•----.........•-- Location-Address or Lot No. ..............................................-------•--------- -•-•-••--•------••-•••----••••••-••-•--•-•---••••......_.....-•-•.....: O�cncr Address a W.E. Robinson Septic Service P.O. Box 1089 Centerville MA Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--.--3-_--•-•-----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter................ Depth................ xDisposal Trench—No. .....:.............. Width.................... "Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..................................................._......_............... Date........................................ ,.� Test Pit No. 1................minutes per inch Depth of Test Pit--------..___....... Depth to ground water........................ Gi.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----------------------------------------•-----------------••---••-•--------------•-•...............................................................----...... QDescription of Soil.......saxid........................................................................................................ --------------•-----------------..-..-.-..---- U ............................................ --------•--------•---•---•--...-•---•......---•--------.....-------------------------------•-•----••------•--•--------..............-••••-----............ W •--•-----•----------------------------------------------------------•----...........•-••-•---------•------------•- --•-------------••-----•---•-•----•••----••••------------•---••-•-•--••------•--..... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..._.install.-.(•4)...atozxe-backed._ nfil_tratar.5.....(oif..existiz�a._se�ataG.fi xlk•).:..................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasrbeen issued by the board of health. Signed =. .tt !. .... ...... ............................................._:._ .*..,... .,.::........................._.. Dace Application Approved By ................ J -�. ... --.. .............................i...............`.. r3'..-,I/. rer3... .. Application Disapproved for the following reasons: ................ ............... ........................ .. . ..._............... .......................... ..................................................................... ................... ........................................ Date Permit No. ............ .. .. � 1�-�.....:....................... Issued .................................................................... Dace _._.._-----_.._.._,.._.__.__.___.___---______.__—__._.____ --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Er#ifira e of C11ompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by......WaZt---Robinson--- ept ,C...Sexvice................................._--------------....._..._-----------...._..-------....................... ..................................... 6 Wings In Cotuit I°'t"lI`r at ........................................................ .......................................----..----------.... ................................................................. .......................... . ....... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._(: ...-../V.................._. dated ........................_................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....._............._3.-J-4-4,�..._..................------........... Inspector .. _.............................................._....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 30 00 No....G�..�.a -��/...._ FEE........................ Disposal Workii Tonotrudion Vprrmit Permission is hereby granted_....N. •--Robinson.SaP_t!r-.cPrVicP---------------------------------------------------••---............. to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at No....6 Winds. Ln......Cotuit•__.___-____ Street as shown on the application for Disposal Works Construction Permit No.73:!-111--__ Dated............................ ..............................•-� �__D.......................................................... / Board of Health DATE. .. 1.�..� --•.....-•--------------------- FORM 36508 HOBBS&WARREN,INC..PUBLISHERS No..........._ ®�a�. . . .�;Fps... .............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..N..... OF............B1Q.R-N.. -TRB-LZ............................... Appliration for Dispaoal Works Tnntrnrtion ramit Application is hereby made for a Permit to Construct, h ) or Repair ( _ ) an Individual Sewage Disposal System at: ..�Y.M e:.-S. ...L4-'A)-Z.....n-CD-7-0-1.r............. .........Z-.7...... ---- .................................................. Location-Address or Lot No. C-�- - .. ....................................... .............••............................ ..... ---------.......................... Owner Address av-----------------•.--.--•-•-------------•-•--------------- •.............•••-••......-•-••..................--•--................................-•-••-•. Installer Address Type of Building .� Size Lot aQ.�:.5Q.....Sq. feet U Dwelling—No. of Bedrooms:__. 3................................Expansion Attic '( ) Garbage Grinder (APO) a Other—Type T e of Building ............ No. of persons............................ Showers — Cafeteria a YP g ---------------- P ( ) ( ) Q' Other fixtures ....................................... ---------- ----•--------------------------------------------------------------------- .. W Design Flow........,1!_0.......................gallons per erlay. Total daily flow.-----_..T.30...........•-----.-_.._ lons. 9 Septic Tank—Liquid capacity_��.gallons Length8...(.".. Width' :/d`'.- Diameter.. p `0 Disposal Trench-No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../........... Diameter.,./47........ Depth below inlet..3._.5........ Total leaching'area../88----sq. ft. z Other Distribution box Dosing tank ( ) _ '—' Percolation Test Results Performed by.R&A)A-C.2 li ...-�9.: -lam ,P t�__.. :.Ss.. Date.. UAT.E...2-1 1$> 1 Test Pit No. 1_42—...minutes per inch Depth of Test Pit._1............. Depth to gtound water.._A2_�1.A„c.G"__. Test, Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,ground water........................ •-•••-. -•••-----•------•-•.......................•••---•---•....-••-••-•--••••.....-----...................._...............................-------- 4r Description of Soil••.Q h...l.t ......A.AJ.n.---------5 4)a5_4 .......................................................i ^ L Q ----------------------- - a�a�L � �. 7 - - u7n 14-L._...t..I UNature of Repairs or Alterations—Answer when applicable..... .. ... .. .. •-------------------•---------------------••----------------------------------------...............•••....... --. 1 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT I Z 5 of the State Sanitary Code—The undersigned further agrees not to glace the system in operation until a Certificate of Compliance has been issued by the board of health. Sig 'd_. .._..= ......._.... ..........•••••. •-••••-- _ Date _ ..Application Approved BY - ,F -• .-•.. _. ... ...._.. `_��:�_ .. :.. Application Disapproved for the following reasons----------------------------------------••--••---•-•••--•---•-•----•--•----•----•-----_....Da......•---...... -•------••.......................•--------...-----...---------------------•-------------•---•-------...----•-•-••--•••-••••-•---••-------•-•----•-•--.-------------------------------------------------- Date PermitNo......................................................... Issued.--�.(..s ............................. Dite THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFation for Uispvii al Works, ( onstrn.rtiun Famit Application is hereby made for a Permit to Construct lW' ) -or Repair ( ) an Individual Sewage Disposal System at: _. .._G4-J-V._4 ..... . .. ........... ..........Z:_0..r....... ......--------•---•-------.........---•---------•- Location-Address or Lot No. -�=- ............. ....---------•............................... .. __._.. Owner Address a .....e ¢ --------------------------------------•---__ ••---------•--••----------•-•-- Installer Address UType of Building , Size Lot....... /_ .....Sq. feet Dwelling=No. of Bedrooms.f_.. _.:. ____________________Expansion Attic ( ) Garbage Grinder (Ak) Other—Type of Building _____________________:.:=: No. of persons........... Showers a yp g - p ( ) — Cafeteria ( ) Otherfixtures .............. • •---•.... • -•....•--.••_----- ----......._.._.......--•...._...-•_. e-pk ao.K W Design Flow.......././.,o.......................gallons per IMUri per day: Total daily flow.......... .................... . lons. WSeptic Tank—Liquid capacity_I '.gallons Length'_riK`'_ Width__y .?O!". Diameter________________ Depth_.-___.`.-9_." xDisposal Trench—No_____________________ Width.........:_:__.:.... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._.__. ____.. Diameter._._ _0.. __._. Depth below inlet_._5.s.,��'._._.:. Total leaching area---_-- _.sq. ft. Z Other Distribution box (10-5 Dosing tank ( ) 0.4 Percolation Test Results Performed by- 0 e,iA C'_X>.._ 4.:. ? _ ___. 4__ _{_- Date___ fl. l_ ....2___'`�.7.219 .� 'Test Pit No. 1__, _2:-•___minutes per inch Depth of Test Pit._Y.............. Depth to ground water.._A). Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 's ••-•••••. r __._ ................. -__..........._._...........- O Description of Soil__._'"" `r_ e.:4_t_f_ ... /!_s_�.......... L - �Q14r................ v I fir' i� sI - ✓/ /ce _..--- - U ..Nature of Repairs or Alterations—Answer when applicable._____ __ ____ __ __ ........................................................__..........................._...._........_ .......... _-- - -- ----------; �. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with , the provisions-of TITLE, 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 board of health. Sig ed _ - _-- -•- -- - - -------- ----------------------- __-- --------- ---- -••.. D to A lication Approved B _._. .: _ 0,1_4,44 '- �' >e" PP PP Y • '� -•_ -__--------- ' • Date Application Disapproved for the following reasons:.-- -•----------------------•---------------------------------------------...•-••-----......................... -------------------•--•--•••-•--_._.M-•-•-•-••----- -----------------------==-------------------------- --------------- �._.....-----•--- � Date Permit I`do.__._..._.. ----. Issued......./� a c1..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tntifiratr of f ompliFanrr T S Tn RTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by - t._._ .... Installer i. .Y. at------- . .. .. /ill. ! '" f ,�z.�-------------------••-------------- ---- has been installed .in accordance with the provisions of TIT Q�)50f The State Sanitary Code as described in'the for-Disposal Works Construetion Permit No.___. ___ _ �_:__.. dated...._,�-` '________ THE ISSU*', ICE OF T141S CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE 4AT THE %1 SYSTEM NEWEL FUNCTION SATISFACTORY. DATE....................�....:. �1.......................................... Inspector............ THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH* ,may y� s/ ...�............OF......... '�. _ .[.�__ _.9 �................... � Noc7f 14�. "-• FEE............._.......... �t��.ar,� k� �un�trnrtuan rrntit Permission is hereby granted.._"_.___:____'. to Construct;(''" or Repair ( ) an Individual S rage Disposal System atNo. '� ..... - -'-A--------•---1 1..1U: .y ....... ' ' - - ..... .'`'--------------------------------•---.......-- Street as shown on the application for Disposal-Works Construction Per >t N _:_ �'______ Dated__._/ 41��_ -........ % - . .... Board of Healt DATE............................................................................... FORM 1285 HOBBS & WARREN, INC.. PUBLISHERS LO� ATIO SEWAGE PERMIT`-Ni :' r" w f ice' S 5 VILLAGE I INST,A LLE 'S NACIE A ADDRESS 0 UIID (R OR OWpER �i lilt «:� DATE PERMIT ISSUED Ll, 7 DATE C 0 M P L I A N C E ISSUED f t. - ti s � �+F c k . �.: ' _ V' ` 1 • �� t /y i J�� `e A � •. t /, v�J .q. 1 - � �� '�_ � J EXIST. TS7 HOLE WELL TUNE a.a /9s79. -PA M I1R,°SAY -. .T ? CTf� EL_EV, /8.0 . .. �b�g l05. LOT ='A r S 25of/- 4 i A4 v 14Q•,, 1JN1 SANS { vJ �4,a + EXIST. 6 . F ' ELEV, •0, RESERVE DST. o 7 i ;r "'N o $ t' •�..'�;�`�•...,�_ `4A,�9— ®/JX {• - i- 70 WELLLEACH i`� 32;1 Sty -TANK , `. -, • PIT - as ,,� � ' � fiEST �,'- �. ,� .i � LOT . -105 tot. l8t ' .e Y r t f_ ,G r3,U/"�DIIVG 5E770A- C� SC.4LEr.` ` � � •� J � , � P2o,ao SFD , CO/.%S T2 UC 7Y:0k a SHALL CO/�JFa2M.. TO MASS :{UES��-�N FLa[it/ ?y �( GAL DAY. 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