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Home My WebLink About0055 ACORN DRIVE - Health Osterville P " i i a Q I„ f .011 /ao f Commonwealth of Massachusetts 71R.. Title 5 Official Inspection Form ® I: Subsurface Sewage Disposal System Form - Not!for Voluntary Assessments 55 Acorn Drive Property Address ►-► Charles McCabe Owner Owner's Name -- — -- --- — — — i7? information is required for every Ostervllle _ MA 02655 . December 6,.2016 page. City/Town State Zip Code Date of Inspection f®� Inspection results must be submitted on this form. Inspection forms may not be altered im-any way.Please see completeness checklist at the end of the form. Imgut when filling.o.out forms A. General Information on-the computer, use only the tab 1.' Inspector: ^ ,' key to move your cursor do not Patrick T. Sullivan .use the return key. Name of Inspector - Ready Rooter Excavating ab Company Name P.C. Box 89 Company Address r Forestdale MA 02644 City/Town State Zip Code 508-888-6055 S112843 Telephone Number License Number ' B. Certification I certify that I have personally inspected the sewage;disposal system at this address and that the- information reported below is true, accurate and complete as of the time of:the inspection.-The inspection. was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant'to.Section 15.340.of Title 5,(MO CMR 15.000). The system: Passes` ❑ Conditionally Passes [] Fails [� Needs Further Evaluation by the Local Approving Authority r r a December 7, 2016 Inspector's Signature Date The system.inspector shall submit a copy of this,inspection report to the Approving Authority (Board X. 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 it the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form'Subsurface Sewage,Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Formallot:for Voluntary . Y Assessments 55 Acorn Drive -- Property Address Charles McCabe Owner Owners'Name information is required for every Osterville MA 02655, December 6, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection.Summary. Check,A,B,C,D.or E/always complete aII of Section D A) System Passes: have not found any information which indicates that any of the failure criteria described - in 310 CM'R.'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. 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 over20 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 wit domplying 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: . 'j ❑ Y E]9.N ❑ N_Q (Ezplai'n below): - l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts.'. _ 6 Title 5 Official Inspection Form - Subsurface Sewage DisposaF System Form - Notifor Voluntary Assessments ; r -55 Acorn Drive Property Address Charles McCabe owner Owners Name information is � M required for every ti 02 665 `' December 6, 2016_ COisY/Towlnle page. ate Zip Code Date of Inspection B. Certification (cont:) K r j [] pump Chamber pumps/alarms nat'operational- System,will pass`with Board of Health''approval-if pumps/alarms are repaired. m Conditionally Passes(coat)B) Syste ; ❑ Observation of sewage backup or break oufjor high static water level in the distrbution box due to broken or obstructed pipe("s)or due to a"broken; settled,or uneven distribution b,ox:System will pass inspection if(with approval of Board''oflHealth) ❑, broken pipe(s) are replaced, r`_i ❑ Y ❑' N ;❑ ND (Explain below): (], obstruction is:removed f ❑ Y , ❑ N . ❑ ND (Explain below): y ❑ distribution box Is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below).. K 4 r ,a ❑ The system required pumping- more than 4 times a year due to broken''or obstructed plpe(s): The system will pass inspection if(with approval of//fib Board of Health) x broken;pipe(s).are replaced' i ❑ Y ❑ N " ❑ ND (Explain below) " obstruction is removed p Y ❑ N ❑ ND (Ex lam below) ; : t 4 - , 3 . C) Further Evaluation �s Required by the hoard of Health ; ❑ Conditions ex"is which requlre.further evaluation by the,Board of Health In order to determine If the syste(n is;:fai ing to protect public health,tsafety orrthe.environment� 1. System will pass unless Board of Health determines in accordance with 310.CMR T5.303(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 feetof a surfacewater ❑ Cesspool or privy is within 50 feet of a bordering vegetated'wetiand or a salt,marsh `- isposal System Pale 3bf 17 15im•3113 - ! _ Title 5 official Inspection Form Subsurface Sewage D i Commonwealth of Massachusetts' - Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 55 Acorn Drive Property Address Charles McCabe Owner' Owner's Name information is # required for every OStervllle " MA„ 02655 December 6,.2016 = page: City/Town Stater Zip Code Date,of Inspection B. Certification' (cont:'j w . 4 e 2. System will fail unless the Board of Health (arid Public Water.Suppliee, 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 100jeet>of a surface water supply or tributary to a surface water supply: ❑ aTheaystem:has a septic tan and SAS s 6h':and the SAS� within az 1.of a public Water suPPIY The;system'.has a-:septic tank and SAS the SAS is within 50 feet of a pnvate°water k.'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: n **This'system passes if th'e.well water analysis; performed at`6 DE.P certified 18boratory;�40.r fecal coiiform.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. ;5 f D) System Failure Criteria Applicable to All Systems:y .{ You must indicate`"Yes" or"No"to each of the following for all inspections: Yes No ®' Backup'of sewage into facility or.systero component due to overloaded or t clogged SAS or:cesspool` Discharge or,ponding of effluentto the surface of the ground or surface waters due.to an overloaded,&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 M,day flow _ t5 ins•3113 ,Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts T; Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Acorn Drive Property Address Charles McCabe Owner Owner's Name information is required for every Cisterville. _ MA 02655 December 6, 2016 . page. CityfTown State Zip Code Date of Inspection B. Certification. (cunt.)' Yes No Z Required pumping more than 4 times in the last year NOT due to clogged or, , obstructed pipe(s). Number of times pumped: ❑- M 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. El Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z 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 Mess than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with_a-design flow of 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 systern 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'ind cate either"yes' or"no" to each of the following;.in addition to the questions in Section D., Yes No the systemis within 400 feet of a surface drinking water,supply, ❑; ❑ the system is within 2004eet:of a tributary to a surface drinking water supply, the system is located in a nitrogen sensitive area (Interim Wellhead-P(otection Area= IWPA) or a%mapped Zone II of a public water supply well i. If you have answered"yes' to any qu stion 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 th'reat 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•3113 - - Title 5 Official Inspection Fomm:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 55 Acorn Drive Property Address Charles McCabe Owner _ . Owner's Name information is required for every Osterville _ MA 02655 December 6; 2016 page. CityrFown 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 x. Pumping information was provided by the owner, occupant, or Board of Health 0 0 Were any of the system components pumped out in the previous two weeks? ® ❑ Has the.system rqce�lived normal flows in the previous two week period?. . ❑ Have large volumes of water been introduced o 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`focility 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. Syste'm: ln.fotMation Residential,Flow Conditions: Number of bedrooms (design)` Number of bedrooms (actual). ' 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 355.GPD t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts t„- r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Notfor Voluntary Assessments - � 55 Acorn Drive Property Address Charles McCabe Owner — =— ---- —°--=- Owner's Name information is required for every. Ostervi,lle MA 02655 December 6,,2016 page. . City/Town, State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents:. Does'residence have'a garbage grinder? El Yes 0 No Is laundry,on a separate sewage system? (Include laundry system inspection information.in this report.) ❑ Yes No Laundry system inspected? ❑ Yes, ❑ No Seasonaluse?, ❑ :Yes ® No Water meter readings, if available last 2 years usa e-. d 2014= 581 GPD* g ( 9 9 (gP )) 2015= 372 GPD* Detail:, "Irri ation.on meter. Sump pump? ❑ Yes M No Last date of occupancy: Current Date dommercial/ln'dustrial Flow Condition's: ° Type of Establishment Design flow.(based,.6n 310 CMR 15.203): Gallons per day(gpd) Basis of deli rrflow seats/' ecsons/s .ft.. etc. :. g ( P q ) Grease trap presents jf ❑ Yes ❑ .No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No r Water meter readings, if available: t5ins•3/13 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts offl. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Acorn Drive Property Address Charles McCabe Owner Owner's Name information is required for every Osterville MA 02655 De6ember„6 2016 page. City(Town State Zip Code Date of Inspection D. System Information (cent.) ' Last date of occupancy/use:, Date Other(describe below): General Information Pumping Records: Source of information: Read Roo� ter records Pumped"Spring,2013 Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped; - gallons_ ` How was quantity pumped determined? Reason for pumping: Type of System: iz' 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) [� Inhovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)-and.a Copy of latest. inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval_ ❑ Other(describe): t5ins.•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal system.-Page 8 of 17. Commonwealth of Massachusetts NSF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 55 Acorn Drive Property Address Charles McCabe Owner Owner's Name information is required for every Cisterville MA 02655- December.6,2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont) , Apprbxim'Otei age of.all components date installed (if known) and source of information: Septic-tank installed 1977. D=box and SAS installed April 2, 2013.,Certificates of"Compliance on file at Health.Dept.._ - . Were sewage odors detected when arriving atthe site? ❑ Yes 2 No Building Sewer(locate on site plan): 2.5 Depth below_grade: feet -Material of construction; [] cast iron 40 PVC . other(explain)`. Distance.from,private water supply Well,or suction line: n/a feet .. Comments (or!condition.of joints,-venting, evidence of leakage, etc.) Septic Tank (locate on site plan) ; Depth below:grade: 1;9 feet Material of construction: concrete ❑ rnetal. ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank,1s,metal; list age: ears Y. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.6'.x 5.5' x 5' 10000 qallons 4 Sludge depth: t5ins•3/13 -- Title 5 Official Inspection Form:sutisurface Sewage Disposal System•Page 9'of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments 55 Acorn Drive Property Address Charles McCabe Owner Owner's Name information is required for every, Osterville. _ MA 0265.5 December 6, 2016 page. CityrTown — State. Zip Code Date of Inspection D. System Information (cont.). Septic Tank (cont..). 29 Distancefr m f -- o to o sludge to bottom f 0 0 outlet tee or p 9 . ' Scum,thickness 4+" inlet,.2" at outlet. _ 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 2 -- - Taperneasurebrid.dip tube.. How were dimensions determined?.',',.. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. liquid levels as related to outlet invert, evidence of leakage,-etc.):' Inlet concrete baffle viewed with.mirror. Located under concrete block patio,Outlet PVC tee in place. Zabel 1801 in place in outlet tee needs to be cleaned every year. Liquid level at outlet invert.. Riser brings cover.within U.' of grade. Recommend maintenace pumping and filter cleaning within 6 months. Grease Trap (locate on;site plan): Depth below grade: feet t Material of construction: 0 concrete metal' ❑fiberglass' ❑ polyethylene other'(explain): %Dinensio' ns"... v T , 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: pate f5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17 Commonwealth of Massachusetts T,itle 5 Official., Inspection. Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments 55 Acorn Drive. .. ---- — Property Address Charles McCabe Owner Owner's Name information is required for every Osterville __ _ MA 02655 December 6, 2016 page. CityrTown 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 ❑ fib glass ❑ 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 Iasf um in P P 9:. — Date. Comments (condition of alarm and float switches, etc.), y *Attach copy of current pumping contract(required)- Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official inspection Fonn:Subsurface Sewage Disposal System•Page 11.of.17 i <fN Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Acorn DriVe Property Address Charles McCabe Owner . Owner's Name information is required rot every Osterville MA 02655 December 6, 2016 page. City/Town. State ' Zip Code Date of inspection D. System Information (cunt.) Distribution Box (if present must be opened) (locate on site plan):` Depth of liquid level above outlet invert Comments(note if box is level and distribution to-outlets equal,`a`ny evidence of,solids carryover,.any evidence of leakage into or out of box, etc.): {` H-20 DB-5.,Oher inlet, four outlets: Speed levelers in place. Very light solids carryover, not affecting system operation.,No-hi h staining over outlet inverts, Riser,brings,coverwithin 10" on ade. 4 r , Pump Chamber.(locate on site plan). f, J- ,y Pumps in working order: 0: Yes No* ' Alarms in working order: [).ryYes E] No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc ): r F If,pumps or alarms are not in working order, system is a cot)ditional pass., ` 3 Soil.Abso ption System (SAS)(locate on site plan, excavation not required): If SAS not,located explain why 3 l5ins 3/13' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts -_ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t, 55 Acorn Drive A r iv e Property Address Charles McCabe Owner Owner's Name information is required for every Osterville . MA 02655 _December 6, 2016 - . page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Type: leaching pits number: 20-ADS leaching chambers number: ARC36HC leaching galleries number. [] leaching trenches number, length: ❑ leaching fields - number, dimensions: ❑ overflow cesspool number:. — ❑ innovative/alternative system Type/name of technolo 9Y ' - Comments (note condition of soil, signs of hydraulic failure, level of p'onding, damp soil, condition of vegetation, etc.): Four rows of five units. Inspection port has no standing liquid at time.of inspection. Light staining 3" from base. No sign of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Numberand configuration Depth —top of liquid to inlet invert` Depth. of solids layer .. i Depth of scum layer - - Dimensions of cesspool Materials of construction Indication of groundwater Mow ❑ Yes ❑ No. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 13 of 17 Commonwealth of Massachusetts Title 5 Official lnspection Form sl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Acorn Drive Property Address Charles McCabe Owner Owners Name information is required for every Osterville MA 02655 December 6, 2016 _ page. Cityrrown 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:): %f i . 15ins•3/13 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusefts F Title 5 Official In Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments . 55 Acorn Drive Property Address Charles McCabe Owner Owner's Name .information is Osterville required for every. MA 02655 December 6, 2016 page. CitylTown State Zip Code Date of Inspection D. System Information (,cont.): Sketch.Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference:landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water'supply enters the building. Check one of the boxes below; �. hand-sketch in the area below [] drawing attached.separately -i _ I I tC� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Acorn Drive Property Address Charles McCabe — -Owner Owner's Name information is required for every Osterville _ MA 02655 December 6, 2016 page; Cityfi own State Zip Code Date of Inspection D. Sysfiern Information (cost.) Site Exam: El Check.Slope ❑. Surface water Check cellar. ❑ Shallow wells >7:4 Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® _ Obtained from system design plans on record 'If checked,.date of design plan reviewed: 03/20/2013 Date ❑ Observed site (abutting property/observation hole'within.150 feet of SAS) Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) Accessed US68 database-explain: maps_massgi.s.state.ma.us/oliver.php You-must describe how you established the high ground water elevation: Test'hole in 2003 to elv= 32.6.found no ground water. Base of SAS at elv-44. 7.4'separation. Accessed local_glouhd water contours and to o mapping: No-high ground water in area of system.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. . t5ins'•3/13,.- Title 5 Official Inspection Form.S�i6surlace Sewage Disposal System•-Page 16of.17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 55 Acorn Drive Property Address Charles McCabe. Owner Owner's Name — - -- information is required for every Osterville MA 02655 December 6, 2016 page. City/Town State Zip Code Date of Inspection E. .Report Completeness Checklist Inspection Summary: A,B, C, D, or E checked Inspection Summary D ('System Failure Criteria Applicable to All Systems) completed System Information- Estimated depth to high groundwater 'Sketch of Sewage.Disposal System either drawn on:page 15 or attached in separate file t , t5rns•3%11 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE' OCATION ��,«, SEWAGE VILLAGECC-ot..� ASSESSOR'S MAP&PARCEL �J INSTALLER'S NAME&PHONE NO.�,��5�� -T-�• .�c,•A„�,� ��" SEPTIC TANK CAPACITY�CXaC7 C,-A , ,." LEACHING FACILITY.(type)WQ (size) NO.OF BEDROOMS OWNER T J PERMIT DATE: a j/ ?j 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 360 feet of leaching facility) Feet FURNISHED BYVe.6a-(a� �c ��—y T-d C,e cqzmJ� r �a I . co 73<6 01 OIQ oq a � No. o Fee QV —/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for Disposal 6pstem (construction permit Application for a Permit to Construct( ) Repair( ) Upgrade(,Abandon( ) ❑Complete System �dividual Components Location Address or Lot No. �S'41vC,:as'� �T`w� 1 Owner's Name,Address,and Tel.No.^i Assessor'sMap/Parcel 4 Installer's Name,Address,and Tel.No.Sn�-� 6��v Desi s.Name,Address,and Tel.No.So'Z-a�—3QS'C> Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building =:5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flowprovided S gpd Plan Date ` a S I o2<5 t : Number of sheets t Revision Date Title Size of Septic Tank ( 6 � rType of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) yp 2�• �G 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. S' n d Date Application Approved by 4 Date Application Disapproved by Date for the following reasons Permit No. 2 o //j N Date Issued 1 ' No. 13 - b L� ° -"� � Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / Yes PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Misposal *, pstrm ConstrUttion 3dermit Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑Complete System D4dividual Components Location Address or Lot No. 5 5-jC6e_,a r_-_ Owner's Name,Address,and Tel.No.7w_36G-cwkq Assessor's Map/Parcel 6$"r Installer's Name,Address,and Tel.No.Sig 6c -S` Designer's Name,Address,and Tel.No.SC`Z-ac-t-3Qs— Type of Building: Dwelling No.of Bedrooms Lot Size ` 1 r ' C� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4?�� gpd Design flow provided ' gpd Plan Date 3�?��T��( _Numb)er of sheets Revision Date Title Size of Septic Tank kg= Description of Soil Nature of Repairs or Alterations(Answer when applicable):�,& e c°Zc l cs- 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. Sign` Date ,�,f, Application Approved by I ( Date t Application Disapproved by v Date for the following reasons Permit No. 2 o Date Issued y -)� / --------------------------------------------------------------------------------------------------------------------------------------- Th F COMMONWEALTH OF MASSACHUSETTS r BARNSTABLE,MASSACHUSETTS CPrtifitate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded((/j Abandoned( )by `` r� z k L, at q�Gc� r Y r cam'„\i has been constructed in accordance with the provisions of Title 55 and the for Disposal System Construction Permit No.2 U 13-1 Ot/ dated y - IT Installer�� nt ice' s oc�-`tip Designer i #bedrooms ,1 Approved design flow 30 gpd The issuance of this�pe)rmit shall not be construed as a guarantee that the systemyA.1-functio•, ,e Date `-� �`-3 InspectoN \ �7 No. Z /0 y Fee /00 - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MispoSal fppStrm ConBtrUttion Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( ) System located at c� �•. �/� v e v,�\� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio mus be completed within three years of the date of this permit. Date I Approved by y i Town of Barnstable Regulatory Services Si. Thomas F.Geiler,Director & = Public Health Division 9. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date:' r+��{ Sewage Permit#a�13"(Oci Assessor's Map/Parcel 1a2 b Installer&Designer Certification Form Designer: CSl\1 Installer: ��c�5�,r �' Address: Po )_0 1 Address: Br .c a5 � D2t�3 i ��. - Vie, Vw-4<�>Q COY On Rn �� 13 ��.oc�v� 'r .r�t �c was issued a permit to install a (date) (installer) septic system at 95'Au fn TY. , 0 S4 .w l l te. based on a design drawn by ll (address) LW& T Q,C\6 dated 91IS113 (designer) I 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. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Lo s. Plan revision or certified as-built by designer to follow. Stripout(if r cted and the soils were found satisfactory. �°`� LINDq J. ctic PINTO I en(Installer's Signature) O 65 F �FS G/S T • SIGNAL ENG IA; esigner s Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE. OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\office forms\designercer ification form.doc aF� Town of Barnstable P# J 6� e 5 Department of Regulatory Services 'Public Health Division Date MAM 200 Main Street,Hyannis MA 02601 Date Scheduled cJ Time Fee Pd. r Soil Suitability Assessment for S e Disposal Performed By: Witnessed By: LOCATION& GENERAL INFORMATION Location Address S, CCU 61`�_ r,� w Owner's Name �Ac. �< z;J` Address Assessor's Map/Parcel: �Q Q� Engineer's Name C S 3J V.r a.,•E� NEW CONSTRUCTION REPAIR Telephone# 3 Land Use e.5ld t.,Jha� Slopes(%) ' o Surface Stones N b e Distances from: Open Water Body P� ft Possible Wet Area `� ft Drinking Water Well ` ft Drainage Way `pt ft Property Line _ L_ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) P -3 , o _ 1 TP Parent material(geologic) Qc_&i") �VW�Sh Depth to Bedroclt Depth to Groundwater. Standing Water in Hole: I Pt Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: __ _ ___in, Depth to soil mottles. Depth to weeping from side of obs.hole: - in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level „ Adj.factor- Adj,Groundwater Level,, PERCOLATION TEST Date Thne,__�__, Observation Hole# I�'I Time at 9" Depth of Pere Time at 6" Start Pre-soak Time @ 'rime(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC r - - DEEP-OBSERVATION HOLE LOG Hole# ( -L Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsistency.%Oravell p'-�y 1� 41 T� --I-LU -cz DEEP OBSERVATION HOLE LOG Hole#']t��- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%O 11 _ O )A MSL )p, 3)I '07- I`�-`L3 i3` �-M trS Io y•(� sf� D i In -C Sid l0 1G� shy DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. • I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Flood Insurance Rate Man: % Above 500 year flood boundary No Yes ._✓-___ Within 500 year boundary No=., Yes,. Within t00 year flood boundary No, � Yes ; Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? S If not,what is the depth of naturally occurring pervious material? Certification I certify that on of (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 3 10 CMR 15.017. Signature Date 13 Q\\ EPTiC\PERCFORM.DOC f . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a t [ev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 Acorn Drive �3� 7 Osterville Owner's Name: Charles McCabe Owner's Address: Date of Inspection: 4/23/2007 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 . 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 DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: asses ° Conditionally Passes } Needs Further Evaluation by the Local Authority Fails 'Ins ectors Signature: r P g ��-----� Date: /-5� The system inspector shall submit a copy of this inspection report to the Approving Authority(Bo d of Hea`1'rili or DEP)within 30 days of completing this inspection.If the system is a shared system or has a designTflow of g000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regime`I office 6-Ithe DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,R. the appfpving authority. Notes and Comments . w. r" �x ****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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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"Confollowing P ss"section need to be replaced or repaired.The system,upon completion of the replacement or repproved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for th 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 proved by the Board of Health. *A metal septic tank will pass inspection if it is struct;ly 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 Ot or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o uneven distribution box. System will pass inspection if(with approval of Board of Health): oken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pump' more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval f the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by t4 Board of Health in order to determine if the system is failing to protect public health,safety or the environme 1. System will pass unless Board of Health de rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner whi h will protect public health,safety and the environment: Cesspool or privy is within 50 feet f a surface water _Cesspool or privy is within 50 fed 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. r j, The system has a septic tank and SAS and the SAS is,mkithin 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 nitrateitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the diialysis must be attached to this form. j f' r 3. Other: r'` Page 4 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ 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 and overloaded or clogged SAS or cesspool �r Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the 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. _ _Z Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 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 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.] L �(Yes/No)The system fails. I have determined that one or more of the above 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 th6 criteria above) l i r! yes no _the system is within 400 feet of a surface drin K g water supply _the system is within 200 feet of a tributaryto 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 wed f 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 C�jntact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 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? f 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 than 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 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(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: 55 Acorn Drive ` Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): G,1;11 1�1)\ Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):cif yes separate inspection required] �► ,,�,;c - c� �t,;•�� Laundry system inspected(yes or no): Ac Seasonal use:(yes or no):r,,Q D C, Water meter readings,if available(last 2 years usage(gpd)): `Q cx!,G rZ. r^, Sump Pump(yes or no): � Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq. ft etc.): Grease trap present(yes or no):_ Industrial waste holding tank presen yes or no):_ Non-sanitary waste discharged to a Title 5 system(yes or no): Water meter readings,if availab Last date of occupancy/us (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or n ): ti If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPX OF SYSTEM Septic tank, ,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: Were sewage odors detected when arriving at the site(yes or no):L _ v f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 BUILDING SEWER(locate on site plan) Depth below grade: 7 Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: 4ZA _ Comments(on condition of joints,venting,evidence of leak ge,etc:): SEPTIC TANK: `t/ (locate on site plan) Depth below grade: Material of construction:_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: �F x' Y. Sludge depth: "D " Distance from the top of sludge to bottom of outlet tee or baffle: .3 jr, Scum thickness: Distance from top of scum to top of outlet tee or baffle: e°_ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: %" v Nv,c5c3 r"01— .� Comments(on pumping recommendations,inlet and outlet tee or baffle concrition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(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 outle�rfee or baffle: Distance from bottom of scum to botto of outlet tee or baffle: Date of last pumping: / Comments(on pumping recommenAtions,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidenges of leakage,etc.): f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 TIGHT or HOLDING TANK: (tank m/bepped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal_ ass_polyethylene_other(explain): Dimensions: Capacity: gallon Design Flow: gallq s/day Alarm present(yes or no): ,/ Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX: (if present must be op,E+hed)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chambe ,condition of pumps and appurtenances,etc.): I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type �Zleaching pits,number: (o 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.): �•��'C�`J• ®�c9J�`�.�� I^/ ��'�I��.*Y—/ •0��Viwy'��'e F\�\�"�'�f\ ��•A��e+�• wJ�•�wy!""�� I ��c��a� xv.v^G.�" CP .ear, wy" i�``C`ks- tg..-'tz., , CESSPOLS: (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(y9d or no): Comments(note condition of soil, igns 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 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. I 4 7 Z3 � 3� � • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Acorn Drive Osterville Owner: Charles McCabe Date of Inspection: 4/23/2007 SITE EXAM Slope Surface water Check cellar✓� Shallow wells Estimated depth to ground water 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: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: �,.,�,, �,c,- r— . �,s ; You must describe how you established the high ground water elevation: c " �/n��-C,-�.�'�• ��r�r �' cJ,+'�"�c�[.s..r-� inner- - `r��. `_�1.�l� UJ� t.�..ic•-.Cr... C�.7 N .�f'.a COMMONWEALTH OF l0/IASSACHUSETTS EXECUTIVE OFFICE OF ENVIRON AL AFFAIRS m DEPARTMENT OF E IIQNME iAL ROTECTION z -4�. n W �n A F d a Zpp4 MAP, f�� pQR �. �pWNEpor �1N��P� L OT TI E 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 L-QS-� O Owner's Name: BEATRICE GRASS Owner's Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Date of Inspection: 3/31/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS C08817 Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditiona asses _ Needs Flu Evaluation by the Local Approving Authority _ Fails Inspector's Signature: Date: 3/31/04 I The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner all 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 SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS'TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Title 5 Incnertinn Fnrm 61i slwo 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any infonnation 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 PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a 7 f Page 3 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 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 enviromment. 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 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 %2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the 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 _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 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)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 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: 1 Does residence have a garbage grinder(yes or no):YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): W—a -2-S 00 U Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM WAS PUMPED IN NOV.2003 BY MACOMBER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a 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): n/a Approximate age of all components,date installed(if known)and source of information: 27 YEARS PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness:3" 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: 15" 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:,n/a 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.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R 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: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD 1' OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 1' OF LIQUID IN IT.BOTTOM IS AT 8'611. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 9 Page 10 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 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. tn/ Alb s q .-092 20 to -z Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 ACORN DRIVE OSTERVILLE,MA 02655 Owner: BEATRICE GRASS Date of Inspection: 3/31/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. 11 TOWN OF BARNSTABLE LOCATION ��-.r� 'y,,�C SEWAGE# W~ JY-7 VILLAGE <0—)9!2rr V`NVjc-- ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. `Mew SEPTIC TANK CAPACITY S LEACHING FACILITY:(type) (size) tc=k=0 c„+a� (— NO.OF BEDROOMS OWNER PERMIT DATE:/S J'- -7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the,Bottom of Leaching Facility . S- Feet Private Water Supply Welland 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 �.. /m?3 f6 7 A // Pe � _ , n �f �3.�n Z1- X� 4 1- 0 q7 3 - 0 ^X. L0,CAT10U. ' SEWA E PERMIT NO. V I L A G E INSTALLER'S NA��ME & -ADDRESS B U f*L D E R OR OWN E DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � ��,�-7 1 � I 01 No....... �.7....7.. �� FED...... ............ q . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... Town... ....... .........OF..Barnstable ....................................................... Appliration -for Utipniittl Workii Towitrurtion Vrrnift Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........ ---Ostervil1e ............................#8...Acorn..Driye............ Location-Address r Lot No. k' 4yd..and.--Ronald...J_..._Silya............. 56 Linda sane, Hyannis ............ Owner ddress a .........Cregg..Medgrios...••._ __ Hyannis� ass . Installer Address Type of Building Size Lot.:11.t.87-........Sq. feet Dwelling—No. of Bedrooms---3...................... Expansion Attic ( n� Garbage Grinder PO) Other—Type of Building ..._ 'A LNo. of persons--------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . W Design Flow------------------50.....................gallons per person per day. Total daily flow.........300 gallons. WSeptic Tank—Liquid capacity-1..#_0QAllons Length---------------- Width................ Diameter_----_-._.--. Depth.__............. x Disposal Trench— 0. .................... Wi tli........._.� Total Length.................... Total leaching area........-----_-----sq. ft. Seepage Pit ---f----_-----. Diameter./,AAO .... Depth below ' let.................. Total leaching area....._ ----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) -- 4, - /. <Ay, — 'y►// 77 Percolation Test Results Performed bY--------- -----------------------------------------------•-------------.-. Date---------------------------------------- ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......._.---....._..__.. L=, Test Pit No. 2-_--.-._-----_minutes per inch Depth of Test Pit-------------------- Depth to ground water-..._.-----.-.._-----_.. it it ----- - / -- Descriptio f Soil.-- 0-4.... t, w ------------- -----------------------------------------------------------------------------------------...--------------------------------------------------------------------------------------------- V 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 Article XI 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 o he th. Sign Date Application. Approved BY. fig --- - -----------•--------- 7 1.S` 7 ----------•-------•-----------------------------------Date-------- Application Disapproved for the following reasons:.......... ........................ t_...__ •--------------------------------------------•-•••••••-••••••-•-••--••••-••••..•--•••••.....••--•----- ---------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ ] Date / Er 7 c ...... N ...7.. Fim............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD Or HEALTH ._Town.............OF .....Barnstable ............................... ------------...................................... A Vliralion -for Bi�ipoiial Mork o. Tomitrurtion Vamit Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal Syste"m- 'a'k: ............ Acorn_ Drime...0ste-rville ...................................#8...Acorn...Drive....................................... ............ ......................... ...... ............ ............. Location-Address 't'Silyia� jtxann is Lot .............. .... . ...and.-Ronald J ...........56 Linda Laney... -------------------*----------------- ....................................I...... ....................................... Owner Address Cregg..Mgdgri OS ...................... .................................................... ..........Hyannis, Mass ................................................. Installer Address U Type of Building Size LotAI.07.Q--------Sq. feet Dwelling—No. of Bedrooms-------3-----------------------------------Expansion Attic n)D Garbage Grinder n)D Other—Type of Building Ranch_____________ No. of persons....__.._................._. Showers Cafeteria Otherfixtures --------------------------------------------------------------------------------------- Design Flow---------5P.............................gallons per person per day. Total daily flow---------390 ....gallons. ------------------------- 1:4 Septic Tank—Liquid capacity.tt.0-OAllons Length________________ Width.._.............. Diameter_---------.--.-- Depth---------------- Disposal Trench No N 1 -------�,e,Total Length-._-__--_-___.____.. Total leaching area...................sq. ft. Seepage Pit No.—/ * -------------------- ............... Diameter------ ............ Depth belWplet- r Tit 11 hiiw-are-------------------sq. ft. Other Distribution box Dosing tank 77 Percolation Test Results Performed by------------- ------------------------------------------------------------ Date----- ------------------------------ Test Pit No. 1................minutesper inch Depth of Test Pit...____.___._..__... Depth to ground water..---------------------- (14 Test Pit No. 2----------......minutes per inch Depth of Test Pit.................... Depth to ground water........_..._--.-------- 9et ......... ......-------�.57 -------------------------------- 0 f S Descri�tio ------ ------------------------ -------------W........... _P--------;?---------/01�---------- Z------ --------W -----__-- - I--- --7 z. ... ...... . ....... ---------------------- ------------ ..............-----------------------------------------------------------------------:------------------------------------ ------------------------------------------- �Ql - ---------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------ --------------------------------------------------- ------------------------------------------------------------I------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees, to, install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued Dy the ardVf hyth., Sig IV- - ------- - --------------------------------------------------- .......4--15:n77----- -7 Application Approved By------- ------------------------------............. .........V------------------------ --------------------Da-t-e-------------- Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ........................................ .................................................................................................I ----------------------------------- -------------------- Date Permit No. Issued........................... ............................ ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD qIf HEALTH ...... ........ ......OF........... ........................... ................. � limp rrfif iratr of f1T fiam,4 TO �71FY,Aat tht'Individual Sewage Disposal System constructed or RIi'paired vt ,y .........b ....... .. .. ................. ............I tal e .................. .......... ...................................... • I ale a t--- --------- ......... ---- --------..... ------------ ---------------------------------------------------- ............ .... ..........4Z I ----- ---- ------------ has been installed in accordance with the provisions of W-jvtle State Sanitary $vde�des(;41)W in the d" ... --------!....................... application for Disposal Works Construction Permit No----------------------------;............. date ------------ THE'ISSUANCE OF'THIS CERTIFICATE SHALL NOT BE CONSTR-UEQ,AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... ... . .........Z2......... ............ Inspector---------------. . . ..................... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD Q9 HEALTH 7 04 ........................................ OF.......... No........ ............... FEE........................ ) - #. tt% Permsjpn 4n1ereby 'gr;a4t d__�---_------------e _N i ...............---------------------------------- ............................................................... to Cqns69('( Ivgi�_io4A Sew*p� s ) 4 po,.al at No ............................................................... Street as shown on the application for Disposal Works Consfructlon&,er-,nit V 0. ----- Dated........9=..85�-__7.77..... .5 . 0 e....I.....I.?.i --- ................................... ---------- ------ Board of HeVi DATE.................../ / 7 . .......................................................... FORM 1255 H0813S & WARREN. INC.. PUBLISHERS A nea I PR D )zIVE Dr 7S.'oo R:zs.00 T:$3 co 39z7 1--rlo,8 870 sQ rT, PR. PoSEp 10 BU/4.D/1V6r OTol /p SEP7'c TgNK c6,acp PIT PRoPoSED SEWA�•E" . Loe.4T,/onf OSTE2V/LGE� M.q.5.5. � SCALE / �= 30 04TE AP,e�C 077. SNaw'n/ on/ 9 �GqN /'e2 JoSE'�H S/G✓/.9' CT ux -4Np /Zfcox,0ED iN CEjZTiFy TNRT TNT PrtoPasc .00/4O/N& .S.NOWN ON 771Y/6 044AI Pv 1_.1J`?� CQnI Fvr2M-s lo THE SET BAC,C �� _ �``JI�� RE4��►��.�'M�"r/T.� a F -TfiE Tow�v o a �\4.•f;'s{,Flu,\S 1'L.p D S. 5 I w�A - i TI o rJ E(Z LCCs. N D u TOP OF FOUNDATION 24"diameter concrete covers 05TERV I LLE, EL=50.0 raised to within 6"of hmsh grade TWENTY(20)ADS CONFIGURC3GHCRATION ATI I N IN F LEACH (or as noted) Inspection Port and cap with magnetic CHAMBERS IN BED CONFIGURATION C FOUR(4) MA marking tape to within 3'of grade ROWS OF FIVE (5) UNITS EACH �c y a 5a5tmgEL=48.3± EL=47.8± EL=47.047.8 25 �m� OA N ZS 47 0± Eri5trng 465± 45.3± D-50X d &15tmg 45.9± t- 45.6f 45.l7 ; N LOCU5 .00 44.90 N m 3 Exisdn9 � � Existing � Gas Baffle 44.00 Inspection Port(See Note#4) rL co }-- Longe�t Run TWENTY(20)ADS ARC36HC ',4'± PLAN VIEW CDU Q°ca 9+_� 25'' (36/6BD2)LEACH CHAMBER5 IN BED J Eri5tmg D25-6 COIVF16URAT/ON WITH FOUR(4)R014,5 SCALE: I " - 10' EX/5T/pNG /0�00 CALL O/N ((1-1-20 Fdted) OF EL=36 F/VE(5)CHAMBERS S 1 T E LO C U S Sf/ T-1/ / A NK D-UO)( LEACH CHAMBERS .6+Bottom of Test Hole NOT TO SCALE FLOW P ISO F I LE I .) Assessor's Map 120 Parcel 49 2.) Deed Book 18000 Page 233 NOT TO SCALE 3.) Plan Book 187 Page 93 Lot 8 LEGEND CON 5T f�U CT I O N NOTES 4.) Th15 property Is In a Zone II of a Public Water Supply EXISTING SPOT GRADE 5.) Flood Zone: C 24x5 PROPOSED SPOT GRADE I .) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 CMR 15.000): EXISTING CONTOUR STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT Living Bdrrn Bdrir 24- PROPOSED CONTOUR AND DISPOSAL OF 5EPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. W WATER SERVICE LINE --o OVERHEAD UTILITY LINES 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE 15 POTENTIAL FOR Garage u UNDERGROUND UTILITY LINES VEHICLES OR HEAVY EQUIPMENT TO PA55 OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 Ktchc n �� \ G GAS SERVICE LINE LOADING. IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. L I OEDGE OF CLEARING 3.)TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS SHALL BE INSTALLED ON A STABLEw1a� --•-•-�-- FENCE MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. A GOB Q J.Q��G O TEST HOLE LOCATION 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK,THE DISTRIBUTION BOX, AND F LOOK PLAN P �� ST SEPTIC TANK THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN G"OF FINAL GRADE. LEACHING LOT 6 BENCHNIARK DB DISTRIBUTION BOX FIELDS, TRENCHES, AND OTHER 501L ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL k FLL-T50.00 op Corner F7Undatlon SAS 501L ABSORPTION 5Y5TEM NOT TO SCALE o HAVE AT LEAST ONE(1) INSPECTION PORT CONSISTING OF PERFORATED 4"PVC PIPE PLACED �Gj� Area= 1 1 ,670 S.F.± (Assumed Datum) VERTICALLY TO THE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC hg p0 --- MARKING TAPE, ACCE551BILE TO WITHIN 3"OF FINAL GRADE. . O 5.) PIPING SHALL CON515T OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A ° \ 46.0 I CERTIFY THAT I AM CURRENTLY APPROVED BY THE MINIMUM CONTINUOUS GRADE OF NOT LE55 THAN 2% FROM THE BUILDING TO THE SEPTIC TANK, DEPARTMENT OF ENVIRONMENTAL PROTECTION AND NOT LESS THAN I%OTHERWISE. SYSTEM DES 1 G N CALCULATIONS -91 PURSUANT TO 3 10 CMR 1 5.01 7 TO CONDUCT 501L S EVALUATIONS AND THAT THE 501L ANALY515 HAS G.) DISTRIBUTION LINES FOR THE 501L ABSORPTION SYSTEM SHALL BE 4"DIAMETER SCHEDULE 40 5EWA6,EDESf6N PiOWR50LIXfD.•3 BEDROOM DWELLING @ 61. BEEN PERFORMED BY ME CON515TF-NT WITH THE PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED l lO GPO/BEDROOM=330 GPD REQUIRED �O REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE S DESCRIBED IN 31 O CMR 15.017. I FURTHER CERTIFY AT END OR AS NOTED. s� X� 00, O' SEWAGE DESIGN FLOW PROVIDED: TWENTY(20)A05 UNITS!N BED � � ) y%eO O THAT THE RESULTS OF MY SOIL EVALUATION ASF 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO(2) FEET BEFORE CONFIGURATION IN FOUR(4)ROWS OFF/VE(5)UNIT5 EACfi. O N o `��9 0 oto0 �0 INDICATED ON THE ATTACHED 501L EVALUATION ° Ito k\' FORM, ARE ACCURATE AND IN ACCORDANCE WITH PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED TO N m 0 e, °o ASSURE EVEN DISTRIBUTION. Vt=L(330/0.74)/(4.8 FT2/FT)/5.0 Lt7 = /9 A05 UNIT5 II 4- g aa�` 3 10 CMR 15.100 THROUGH 1 5.107 REQUIRED(20 PROVIDED) 11 a �p� J<` Existing Septic Tank tote 8.)GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES a p / �h� J" 48.6 Utilized(See Note,02/) IN ORDER TO PROVIDE A WATERTIGHT SEAL. 355 GPD PROVIDED>330 GPD REQUIRED Ex15tmg Leach Pit to be Lv SEPT/C TANK CAPACITY REQU/RED 330 GPD X 200% =660 GPD REQU/RED 4G: ° Abandoned(see Note A22) 9J HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE �- Linda J. Pinto, Certified soli Evaluator DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM, 4a.z 5EPTIC TANK CAPACITYPROV/DED: EXISTING /000 GALLON 5EPTlC TANK a GataA ,a\ \\ 4n.5 10.) IN ACCORDANCE WITH 3 10 CMR 15.22 1, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH A GARBA6ED15P05AL 15 NOT PERMITTED WIT/i TH/5 DE5/GNFLOW �-�, CSN ON MAGNETIC MARKING TAPE. f �.T1 1 1.)THERE ARE NO KNOWN WELLS WITHIN 100'OF THE PROPOSED 501L ABSORPTION SYSTEM. 4a.s -� 4a.1 0 LINDq J he PINTO 12.) FROM THE DATE OF THE INSTALLATION OF THE 501L ABSORPTION SYSTEM UNTIL RECEPT OF c, �� C vim+ THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND FLAGGED TO PR-:VENT O, �? USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. 17.0 G/S T 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS o 9S 48.5 47.8 S/ONA ENG CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE 0 Op'. DESIGNER. 43. 14.)THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE TEST HOLE LOG 5 /� \ � O -2 006 BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT TFE 57 SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT `� / Zy 0 iP-1 ® �p hh�0 Surveil Work bp. AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE 15 REQUESTED. O Test Hole#i (EL=47.I±) G `C� �3 6� A & M Land Services 15.) LOCATION OF UTILITIES 15 APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FDR Depth Layer Soil Class Soil Color Comments 618 Route 28, Suite 3 DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO lZ � West Yarmouth, NA 02673 COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT IS NOT LIMITED TO, REQUESTS TO CIG5AFE, 0"-14" Fill Pb- (508) 737-1777 Email.- anmland®comcast.net ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. 5 I TE PLAN 14"-18" O/A Medium Sandy Loam I OYR 3/I I G.)CONTRACTOR SHALL VERIFY THAT ALL WA5TEUNE5 ARE CONNECTED BY WATER TE5TIN3 1 8"-20" E Medium Sand I OYR 4/2 WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. 20"-23" B Fine-Medium Loamy Sand I OYR 5/8 Prepared for: 23"-70" C I Fine Sand I OYR 5/G Perc @ 50' SCALE: I " = 20' 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY 70"-120 1 C2 I Medium-Coarse Sand I OYR 5/4 Charles Jr. * Carolyn M. McCabe SEPTIC SYSTEM COMPONENTS. P.O. Box I G, Ostervllle, MA 02G55 18.) INSTRUMENT SURVEY CONDUCTED FOR PROPOSED WORK ONLY. 51TE PLAN SHALL NOT BE Test Hole#1 (EL=47.4±) Propo5ed Sewage D15p05al System USED FOR STAKING, OR ANY OTHER PURPOSES. Depth Layer Sod Class Soil Color Comments 55 Acorn Dr., Ostervllle, MA 19.)THIS PLAN DOES NOT CERTIFY, GUARANTEE OR WARRANTY COMPLIANCE WITH DEEDED OR ZONING BYLAWS, SPECIFICALLY, BUT NOT LIMITED TO, 51DELINE SETBACKS AND BUILDING HEIGHT 2"I 2" Pill 1 RESTRICTIONS. OWNER 15 RESPONSIBLE FOR OBTAINING SUCH A DETERMINATION FROM THE 2-1 G" O/A Medium Sandy Loam I OYR 3/I Prepared by: APPROPRIATE AUTHORITY. I G"-18" E Medium Sand I OYR 4/2 18"-23" B Fine-Medium Loamy Sand I OYR 5/8 20.) IF SOILS DIFFER FROM TH05E SHOWN IN THE SOILS LOGS, DE51GN ENGINEER 15 TO INSPECT 23"-70"70 1 2G C2 Medium-Coarse Sand I OYR 5/4 C I Fine Sand I OYR 5/G CSN THE SOILS PRIOR TO PROCEEDING WITH INSTALLATION. "- " ,, /►-1/ 2 1.)EXISTING 1000 GALLON SEPTIC TANK TO BE UTILIZED. PVC TEES TO BE INSTALLED ON INLET DATE OF TESTING: 03/20/13 P#13895 INSPECTION NOTE: 1,� Engineering AND OUTLET PIPES IF NECESSARY, AND A GAS BAFFLE INSTALLED IN THE OUTLET TEE. SOIL EVALUATOR: LINDA J. PINTO, P.E., CSN ENGINEERING BOARD OF HEALTH AGENT: DON DESMARAIS, BARNSTABLE HEALTH DEPARTMENT PRIOR TO FINAL INSPECTION BY THE ENGINEER, SYSTEM O 20 40 GO 22.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND PERCOLATION RATE: LE55 THAN 2 MIN/INCH IN "C"LAYERS NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. P.O.Box 2030 Phone:(508)299-3250 ABANDONED IN PLACE. AREA TO BE COMPACTED TO MINIMIZE SETTLING. Teaticket,MA 02536 Fax:(508)548-5478 NO GROUNDWATER ENCOUNTERED SCALE I"=20' C:\C5N\RR-Acorn\RR-Acorn-5D5 Plan.dwg Date: 03/25/1 3 Scale: As Shown I By LIP Check: MTA Project No. C51\1032 I