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HomeMy WebLinkAbout0050 ACORN DRIVE - Health 50 Acorn Drive Osterville - A= 120-049. / — ` No. � t./� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal *pstem Construction Vrrmit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. <O A Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /;2 q �f- Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 0 N _ L l/Ir)�Vllc$Or�J Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) r Other Type of Building ie 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided j yCf gpd Plan Date `7 l S—'La2(`� Number of sheets Revision Date Title B� Size of Septic Tank ` W&r1eU% Type of S.A.S. 2 —5 CXD %I&V C 4Y 1-1 r K—/U Description of Soil Nature of Repairs orAlterations(Answer when applicable) Ter f-c )' 2 H —1 C) AN C6�N��1_� s (Jl N 5 fiCx�-P 6W O CL N r yJ O bt"f(V V+F a n� WOK t/v G ��2—.)Le l odce� Date last inspected: Agreement: ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 2 AO Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ."-0 Date Issued � Ac No. � C ' .w. . ! Fee �r THE COMM.,dhW;EALTH OF MASSACHUSETTS Entered in compute PUBLIC HEALTHr;DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' ". 7 01pplitation for.33iB m Construction Permit, Application for a Permit to Construct( ) Repair(,1/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Co ,% " Owner's Name,Address,and Tel No, Assessor's Map/Parcel �2 Lyl g %>�e, Installer's Name,Address,and Tel.No. Designers Name.�Address,and Tel.No. Type of Building: t Dwelling No.of Bedrooms Lot Size:; sq.ft. Garbage Grinder( ) Other Type of Building (t°S1 mf-KA No.of Persons � Showers( ) Cafeteria'(_ )' W , Other Fixtures r^ ; Design Flow(min.required) 7, gpd Design flow provided SYCI gpd Plan Date "�"'/ - G, C) Number of sheets 1 Revision Date 211 Title Size of Septic Tank 1w's/-►" Type of S.A.S. 2- I- C1� aN(� y?'/P //-/U Description of Soil R Nature of Repairs or Alterations(Answer when applicable)Z 0c,¢on, 1 '3,' k� !o &�cln on,&I</G,N t yc _ (Al Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system,in operation until a Certificate of ' Compliance has been issued by this Board of Health. Signed - Date Application Approved by Date �E / Application Disapproved by Date for the following reasons Permit No. wGy/ „s Date Issued - err THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of C0mpliante 1 THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) ( Repaired(" ) Upgraded( ) Abandoned,(. -)by D-A 3(o s)N -1:6 A at �(� Ar ev nl T-_)(t U VP 0gtm 0 e has been co strutted m accordan.e, A dwith the provisions of�Title 5 and the for Disposal System Construction Perrfi't�_. r dated � .�lt Installer � A , ��-,((+ �^�, N(' Designer _C661) /vt C9�r!l i #bedrooms �j _ y _ S`' k Approved design\flow *_5" (�. gpd The issuance of this permit shall nog bey onstrued as a guarantee that the system will funcltion as e�si e dd.. � r- Date �,� t,�d Inspectorf t ;� I'r✓ �6 ,_ No::i2 Fee f'45 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS r !""`�► Misposal *pstem onstrULtion Permit 'Permission is hereby granted to Construct( ) Repair( {{Vf Upgrade( ) Abandon(- ) System located at () �r�r� 'D( (x�Pp �11 tp, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty too comply with Title 5 and the following local provisions or special conditions. , Y ' Provided:Construction must be�completed within three years of the date of this permit. Date / �t "`�.l Approved by Ta' 4 1r. ; TOWN OF BARNSTABLE LOCATION SEWAGE# ASSESSOR'S MAP&PARCEL VILLAGE atkFrd( INSTALLER'S NAME&PHONE NO."'D,4 rAQJ,,& -J-- SEPTICTANKCAPACITYi�r5�}tic� LEACHING FACILITY:(type) Cyyb (size) /;7.03 IC 2 NO.OF BEDROOMS OWNER �✓ ��z PERMIT DATE: 7&6'0 COMPLIANCE DATE: ? Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 4 3�,6 oin/ Tex 1/a'C'< �s�� y7 Town of Barnstable F r io Regulatory Services Richard V. Scali,Interim Director antwsrnsi.e. MAMg 'Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form ' Date: Sewage Permit# =0%9_30 Assessor's Map\Parcel L Designer: Installer. - - Address: Address: 1"1� 1✓ On ,� was issued a permit to install a v was ( e) (installer) septic system at -50 rk) (�aP J MP based on a design drawn by (address) DW19 >0- dated (designer) Zi certify that the septic system referenced above was installed-substantially according to the design, which may include minor approved changes such as=lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. ;r" _a y. I certify that the septic systepi referenced above wag installed with major changes (ize greater than 10' lgterai relocation of the SAS or-anyvertical relocation of any conipohent of the septic system).but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip-out(if rewired)was inspected And4le soils were foun&iatisfactory. I certify that the system referenced ab e{was constru )liaike?'with the ternns of the IAA approval letters (if applicably' N. a� UAVII�` <y IVIASON . staller's Signature) o Flo:lsss � , . _ 't�i TAR� Affix I?esi ' s,Stam ][ere (Designe s Signatuu� ( � P PLEASE RETURN"TO BARNSTABLE PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH TINS FORM.,AND AS BUILT CARD ARE RECEIVED BY THE BAMSTABI.E PUBLIC HEALTH DIVISION1 THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc l F_ Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 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 on the computer, use only the tab 1. Inspector: key to move your U cursor-do not Carmen E. Shay use the return key. Name of Inspector Shay Environmental Services Company Name P.O. Box 1576 Company Address Mashpee MA 02649 City/Town _ State Zip Code 508-294-7498 3080 Telephone Number License Number B. Certification a 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: ❑x Passes ❑ Conditionally Passes ❑ Fails. ❑ Needs Further Evaluation by the Local Approving Authority 5/14/14 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 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. aC...... (1!• T:N..C! ....r-.....C..L—...tn....C...........11:..........1 C....•......Il...... ..i 9 i■ Commonwealth of Massachusetts Owner Title 5 Official Inspection For information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CM 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System consists of a 1000 gallon tank,a D-box and a 6'deep leach pit 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): r .c:-_.•urn rw.,c nQ.:..:w.........a....,r......:c..w....w.....,c.. .......n...-,,..-:.c.s......n.....,n s � - Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address _ Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town. State Zip Code Date of Inspection B. Certification 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): • 4 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 a 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 K:..... 1II T:M..C!(F..:r.l 1......., r.......C........i......C...........11::.........1 C..........Il......7..t T Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: , ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 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 El © 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 ❑ ® 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 '/2 day flow Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name ' Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ R 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0 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 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. .c:-„. .n T:".,c nm.:-::..........cam..r.......n.w...s......o.........,n:....w....:c............n-...,c.s+-s. Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 Cityrrown 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 0 ❑ Pumping information was provided by the owner, occupant, or'Board of Health ❑ ❑O Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ Z Have large volumes of water been introduced to the system recently or as part of this inspection? Z ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A), Z ❑ Was the facility or dwelling inspected for signs of sewage back up? (] ❑ Was the site inspected for signs of break out? 0 ❑ 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? 0 ❑ 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: ❑X ❑ Existing information. For example, a plan at the Board of Health. FRI ❑ 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): 3 330 DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): .G...... l A T.N..C IIK..:.................. r.......C..A.....i......C.........ll... �,C...........A ..C..i A-/ I ` } Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owners Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection D. System Information Description: Tank, D-Box and a 6'deep leach pit°present. n Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ❑x No Laundry system inspected? ❑ Yes ❑x No Seasonal use? ❑ Yes ❑x No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 9 No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203). Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - ❑ Yes ❑ No . Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: IC:.... «i<!1 T:Y..C IIK..:..1 i..........i.....r.......C..4.....<......C....e....,fU..--....1 C..........Il....�T..<<7 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Board of Health 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: ❑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)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): .c:..... .::n .,c nma,.::a...._...:....r.....,.c..•..:.s...,.,c.........,n:...._....:c....•......n......o s•ro Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1985 per plan on file at the Board of Health Were sewage odors detected when arriving at the site? ❑ Yes © No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: x ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented. Septic Tank(locate on site plan): Depth below grade: Tank is 12 inches down. feet Material of construction: X concrete ❑ metal ❑fiberglass El polyethylene ❑other(explain) If tank is metal,list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑. No Dimensions: 5'x 5'x 8' Sludge depth: 311 y Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Properly Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 23" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1/2" Distance from top of scum to top of outlet tee or baffle 4" . 14" Distance from bottom of scum to bottom of outlet tee or baffle 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.): Tank in good condition. Inlet and Outlet Tee/Baffle in good condition. 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 , s Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville - MA 02648 5/14/14 Cityrrown 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 t , Comments(condition of alarm and float switches, etc.): y "Attach copy of current pumping contract(required)..Is copy attached? ❑ Yes ❑ No .c:..... un nu..c nm..:..:i...._.....:...,r.......c..,.:s.....,c....•....,n:....�....:c............n.._.. .s+o Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive ' Property Address Elizabeth Harris Owner's Name Osterville MA 02648 ' 5/14/14 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 D-Box present Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any' evidence of leakage into or out of box, etc.): D-box level equal with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes - ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: .c:-...44:- ru.,c n.c..:..r i...-........-r.......c..:.-.s..-.,c.......-..n.-..-....: 41 Commonwealth of Massachusetts " Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owners Name Osterville MA 02648 5/14/14 Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑x leachingIts number: 6'diam x 6'deep p, pit ❑ leaching chambers number: El 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.): Pit had 1/2 day flow available per stain line. 3.5' liquid observed. No evidence of backup noted. Riser present. y .. 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 .c:.....•.:.n ru.,c n.e..:..i i.....,..r...:.r.......c..w....s......c ....n..,.... _i c...........n.....,io..o � Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 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.): IC.�.. lA T.H..C/11A.J..11.........1: r.......C..1......i..w..C...........11:..........1 C....•......Il...... �i♦9 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris S Owner's Name Osterville MA 02648 5/14/14 cityrrown state Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately i aoo -plronit ^ Y7=33 ALM 7 � O• • vILLAGIE�.-'��c-'11.G��� d►S.SESSOEi'S �ISAP Se LOTf6��ACt��' Z14S_rALY_E*VS".&NAIR Ah PIRCOWIR WCJ_:..fr 3HPTIC 7 Azrrc EAPAI�`1=Ty( L BX�YYilPC PACYLr'rYtygrci Nd_ OF BtE>FL43<7.3F.S _. P[L1�A'rE wHLm..O'R. PunLIC' wA.-r832. Bi?# 6L OVkFriTEIY. tr .e-s-'�'7'�` 7� YSAT'E P'ERIdII'L'isszvsrr.. .. '=-.�� 15p...'��_ EYA"FE COba:PL_A11WCR,IS'SURTda 'e y.- V A[tDANGE EiRANTEDs Yes: l.ip �/`� - Aa a � I y a 111( T.N..C 114..:..1 I........ ....... ....i......C...........tl:..........1 C....a......Il...... C..i '! Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope © Surface water Check cellar © Shallow wells Estimated depth to high ground water. Over 15 feet. 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 0 Observed site(abutting property/observation hole within 150 feet of SAS) ❑x Checked with local Board of Health -explain: TopoObtained records for the site and surrounding properties. ❑ Checked with local excavators, installers-(attach documentation) ❑x Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Perc log available at Health Office and Inspector has performed perc tests in this neighborhood. Before filing this Inspection Report, please see Report Completeness Checklist on next page. .C:..... ll T.H..C.l11C..:..:I..........N....r.......C..A.....i....�C..........,fl:..........1 C.........: Il....:.AC..i 7 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - required for every page- 50 Acorn Drive Property Address Elizabeth Harris Owner's Name Osterville MA 02648 5/14/14 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist M 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 O Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file K:.... M A T.H..C lVC..i..l I..........Y .......C..:..... ....C...........11t..........:h.........lt......19�i '! ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments c�M 50 Acorn Drive Property Address Robert Barry .Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 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: A. General Information When filling out / forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name !� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number M A O B. CertificationN I certify that I have personally inspected the sewage disposal system at this address and that tth'e information reported below is true, accurate and complete as of the time of the inspection. Tl- insp tion was performed based on my training and experience in the proper function and maintenance of on sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1.8340 0 Title 5 (310 CMR 15.000). The system: it ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/24/2011 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 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. l� l ti t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewag isposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M •' 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. City/town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, ¢ safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water . )p ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 w jMr 4y Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 • 5/24/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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, a provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the t 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 ❑ ❑ 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 -77 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osteryllle Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: NA Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2009:16,000 g ( y g (gp ))' 2010:7,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5/24/2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CM 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•11/10 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 50 Acorn Drive M Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. CitylTown 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: 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. x ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i. X Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osteryille Ma. 02655 5/24/2011 every page. CityfFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy,of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon 411 Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. Citylrown 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 28" Scum thickness 0" 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 14" 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.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 i Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 6. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osteryille Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.j 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every 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 No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: f t F t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth.of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 50 Acorn Drive Property Address Robert Barry, Owner Owner's Name information is required for Osteryille Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line observed 36" below invert. 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•11/10 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 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every 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.): r r r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r • • i • • • 11 told • { .. • r +3 ? ( y yhA f7�� j33�4$ g�£t MR. r a. {g $Y • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 50 Acorn Drive Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every 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: Bottom of LP 20' 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: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 50 Acorn Drive M Property Address Robert Barry Owner Owner's Name information is required for Osterville Ma. 02655 5/24/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 8, 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF.BARNSTABLE G �� LOCATION , '`;' SEWAGE # VIL ASSESSOR'S MAP & LOT12, �'5- INSTALLER'S NAME 6z•PHONE NO. M 1 C_ ' SEPTIC TANK CAPACITY 1,n- LEACHING FACILITY:6ype), ill (size) 1000 NO. OF BEDROOMS ?PRIVATE WELI,'bR PUBLIC WATER.V:*:, R OWNER . - l�J � DATE,PERMIT ISSUED: ``Y � DATE COMPLIANCE ISSUED: 1^l �:.`� VARIANCE GRANTED: Yes No �� Y17 1 !� e No 75 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE R 1 a o o 4 9 sc Appliratiun for Uiupuuttl lVartai Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair)(X ) an Individual Sewage Disposal System at: 50 Acorn Drive Osterville ....................•----------......--•---••---•-----......--------------------.........•..••---- •-••-•--------------------------•-------••---•-•-•------•-•---•--••--•----•••-•-------...------•-- Location-Address or Lot No. ....•......hert •-B rry-----•-•----------------------•------------•-•-.--•- Owner Address JoPoMacomber Jr. Installer Address UType of Building Size Lot............................Sq. feet 1.4 Dwelling-X-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................ x Disposal Trench—No. .................... Width-------------------- Total Length.------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY-------------------------------------------------------------------------- Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit...----------------- Depth to ground water------------------------ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �. ------------------------------- - -------- •----------- •------------------•- ------------------•---•-- ----------------------------- Descriptionof Soil--------------------------------------------••-------...--------•--------------------.-.--------------------------------------------------------------- -------- vI........... and...&...Gravel......•----------•--------------------------------------------------------•------•----------------•--------------------------------•----•-•-----------. W ------•-------- ----------------------------------------------------------------------------------------------------------------------------------------.� -----•-- x Omit cesspools.z­insta__T1__-_-_-_1_-_-�"0TG.... U Nature of Repairs or Alterations—Answer when applicable._.___. _: .___...._. gall-on tank 1 —distribution box 1 -1 0J gallon Peach'--pit " ' """""" - 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 has b e issue by t e rd of health. g Si ne 1.2.x.3.Q./..9.4...:------ Date ApplicationApproved BY ........ ................................................................. 7&........ le^ Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------- Permit No. ....... 5'_.-..1.0.............. Issued Du[ r � No...'T� ----.Ino Fxa.._.. THE COMMONWEALTH OF MASSACHUSETTS ti BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Ui_rVv!3a1 Wor1w Tunstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair)(X ) an Individual Sewage Disposal System at: 50 Acorn Drive Osterville ..............•-----------•----•-------•-•----.......------•-------•---•---•---•..........----•--- ----•-•••-•-••••-•-•••---••-•-•-------••-•-•-•-------.......-•---•-------•---••--•-•-•••••....--•- Location-Address or Lot No. --.........Pobert-- arrv.._....••-----•--••-••-•------•......-••--...._•_.... -••--•---------•------••-•••-....--•••----•-•---••----- -er - Owner Address a J.P,Macomber Jr. Installer Address VType of Building Size Lot............................Sq. feet Dwelling jt No. of Bedrooms--------------r_____________..____________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures -----------------------------------•----------------. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter---------------- Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area.........._.........sq. ft. 3 Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------------------------------- ................................. Date............................ ...........W Test Pit No. 1________________minutes per inch Depth of Test Pit____________________ Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 •-•••--•-••------------•----•----•••••••--•-••••-•--•----------••---• ....................................................................................... 0 Description of Soil......................................................................................................................................................................... x Sandi & Gravel . V .---------------•--•-...-•-••-••••------.._..•--••-•----•••-•---•--••••-•••--••••-•------••••••--------•-•••••...-----------•----•-•..... W __ U Nature of Rge airs or Alterations—Aziswer,when applicable rC�ITt -C1sspoo -13s---Trisl;� ....... I'uuli"' gall�n tank 1 -distribution b ', t -1 0-00 gallon leach 'pit. '_________"'_'_""_""' ------------------------------------------------------------------------------------•---------------------------...------------------.._.....---------------------•-------••-•--•---•-••-----........._. 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 has beentissued by the board of health. Signed ....t- � �/a7i. / fl/.'1 �; ------------------------------------ -7..2. 3- �.g.4 ..-- Application Approved BY - .... --t- .f- ---- -- — 6 Application Disapproved for the following reasons- -------------------------------------------- --------------------------------------------------------------1e------------------ -------------------------------------------------------------------------- ----------------------------- ------------------------------------------------- Due Permit No- ------?57-- 0................................ Issued ............................. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 TOWN OF BARNSTABLE Q-Te r#tfira e of Q-11oxnpliance THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by J.P.Macomber Jr. ------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------- Installer 'a .------50 Acorn Drive Datetuille,Mass. ---------- ----------.--- ------------------------------------------------- - 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. ..... :-..� --------------- dated ---------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ :,� ......_......... .. Inspector-r.- � --------------------------------------------- ----------------------- r----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ TOWN OF BARNSTABLE No..... `� FEE$ 30 00 .........'.......�.. .---....---......._..... Diupuuttl Workii Tunutrudiun "Vrrutit Permission is hereby granted.........!7-_P.MaCornbE!r•Jr._-____ to Construct ( ) or Repair (XX) an Individual Sewage Disposal System atNo._ o•••Acorn---Dr: ve___Osterville...Mass-----------•-----------------•••---................................................................ Street as shown on the application for Disposal Works Construction Permit No�.J._.jA,_____ Dated-----_�__..--�--���4.•.......... •-----------------•--•---•-••............ _..._...•.-------------------•-•••......--_-••-- I r Board of Health DATE................... ^/ .............•--•----------------... �/ FORM 36508 HOBBS♦!c WARREN.INC.,PUBLISHERS ['y}+����JJ�t �'^.>-.w,.:..y.-,•,r.i:,t y.n..•ss<.+s:...*.:�.--`:z'uAon`Rvrr•+•:':yw..+mtwawa•.r.r,.:'a'asaw'�?::.��.sruca....... -•:_•,•._. .r ..Yw-et.•..,.+r..�:�+.t.-..:n'..•ry.�•e.at�.a,..•.-. .. . e - e .wC� , +' eK ,�a' v t � . T T�`" �.w•...� .•eWa::a+.•-ra::. r,oyr... , _ .. - "W1r�-•er .a:r' , ..-:•:.a,_,: _ .. . - r..a:-wo.,.,r rw-.. _ ._ . �.. .� .. .. , e . .. 1yS .•e^t ^s.:' ^��wcr,a.�:r:ma._,�_- w. .wr•• ..r. �� ( 1nst:di a-ip,l Shall co.%Ipty FI i;r? •j.0te Envii•rlrjRj:'ntr�{r.C'CIE: ttlF To Of rx.. / • r / yi' 1, 1►`�c is syster, �s pj c�„us a s n be installed until a licensed town instatfar t i - - - t Jl. Sept' i r: 'A an hall at /� '� '�,� 'l�'a'•' - -.ves approval lnd n?, iil5tj�i$tl•; ,i:.rmit from the applicable e0{i�ij / j G— ? l cv to itlstfaliaiton,i► O ir;ralie: is r:l:; --rify the iC}catjc!^ cif utilities.sewer �nve!ts. sewer'i?lE'• 9 �/ '1 �S(� .�,.`i.`t '• existingpie'iilC components��,Mf t'.•: irzstaiiaiic►r.•. �t�l i.��'\ " � �7 l N, 1l�Iv�J rlCCV ravtt'1'Se+NE,/ i it, is t(r be,4 sn. -'..hedule�o t'vC at Ir'8" ii-`r for !;-• first Z feet o.t'' ri �1 ; :.u.• r -• distribution box snail be level. All ;;:ping connections to fie glued- _ to � �.�•► - _ plic design ;3iar. is n•-t to be ;1 , ., for property IinP determi.:ati,.l or for any attj tiurpose avv-'r t,i .j t� proposed septic system installation. -' Ali' itle V..omp;,r:en!s are to meet Title V specifications. �.+K/.rrs.>ww..r►*e�+�w w+:. «a...rac..� ,1 'r) �O \ 14 F g V(\ i P&-king shall be p,ci il.,i'.ed over iltle V compunrints unI£'3', "n-npoil'ni's aw Hc't: i0aded. existing teaching ;.r cg;;pooi::s#.aft ►1e p,.atnped and€ti?r:€ with;r;ate r: t! er 1'ttle L' i �� Gti1 t aka<itidunrnent pr,,7ced;:,t5 i.eachin; :'d cesspcoils► and c;titarriinaled soil: -within the proposed SAS sh11; ,e .-moved ano rc,:.laced with r-.ean Sand pet 'itie v Wp�66cations 10' fro,T, . water service fine. S'ewe(ilme$c,ros,.i;n +it water lttle> :i: � yP.!jfiC rnrnpo�ents areT�? ,.. t her sieevEd :,ith anapptoprra2ety SI : hedule 40 PVC witl' ends g:cutefl. TI?e :eater servi:• tilt .SiF.t?VP. I)k'Ir1g d .iStdilC �,+ tr /' r' ` • _ _ ! # _��`as „ing Vie line. a O (�QWp .Wa � �C.,. lnv K i garbage grinder exists in 6te svur.=::re, it is to be if the ;,- stem is not de igned to acrf,mmoci;te a Barba?e grin-ter, Tti,.. Ir►S'f2ilt'! 1r rN'spCn5rbf2 roe :.iifP "�f Fx.Cavattoit arJtsr.. 31 .5 :sr :!lf' ,.rDPat't•i 3rt q ���j `:. prutectirg the structtira>i;�'?g' t =truet.�r4s cc r'ng t =ration t,+.,ces< .�.,►►r' ,ehti.. 1:;,-j ,-.rlly represents that a sep v '•,stem can be irKtaik_11 or,, 1'1 prap 'y njeet;ng T:TIP f 1 ` r �� � . „ . :,;�11� .. ,�., Y`���. �i4?� �•�` , .,. (ecTairements. w r ; Th,,- tlroperty owner t:hait review desig,,[Titeria to approve. tl,r_ totml numbs: of bedrooms anr. At- _ design f!ocv. Instaliatic-p of the septic�.,, .te m as pfoposed and receipt of pa'r;nPnt for the desigi, 5haJ be cieer)led appr;,,al of the de-Mgn�.ritc fia by the properly owner or a,!,:Int cif. v) /V� '• :•1i TilP valicitty nfi this Pirr, Falf ext►ire with the exµiratlotl of tliQ icrwrl tn:taliat;iarr permit issut' i /�� ` � ,( • c,/ e� I DDD �1' this- plan or the validrt if this play shah exoii-P op i"fie expirat on of t''t. (.Nt I �lcclt£ of LOPI tc W' •i --j• '. v._-._ issued for t1lc illlt4alB. � 1'i t.;lC�'•:C� ^;'•?'F:Y. r;•j .l�a:i �i:=tti DAVi 17 MASON V \ —ro ' ; o Fic No.106fi ., ate; - , ' �v � r N. F ,r Z 0 �u✓'1b /le Ail. ► 1 , 7 1 4N 311—J` .,lmv. � r'Qs,.-• .-.. �.._..._..':.�,a:�swafa+...-.y,-r3...q'+.�.-.waw�swwe-r e•+-zri:R.,�...,_.v.+•xMr-�wwvcsw�t rrm�au�vx�.� 1 �- R - � ..!! 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