HomeMy WebLinkAbout0060 ACORN DRIVE - Health 60 Acorn Drive
osterville
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•A Commonwealth of Massachusetts �a� ' b°Z+
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 60 Acorn Drive
t•r�
Property Address
Michael Garbacik $
Owner Owner's Name 'n'F
information is required for every Osterville '� Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may.not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
/on the computer, � 54 3 D3 J
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return
key. Name of Inspector
B&B Excavation , +
Company Name
374 Route 130
` Company Address
� Sandwich $ Ma 02563
City/Town State Zip Code
(508)477-0653 SI 13747
Telephone Number License Number
4a
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate-and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
/ ® Passes ❑ Conditionally Passes ❑ Fails
r
❑ Needs Further Evaluation by the Local Approving Authority
5=17-18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name'
information is Osterville Ma 02655 5717-18
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D & E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
z
The system was in working order at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass..
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
/ Health.
*A metal septic tank will pass inspection if it is structurally sound; not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
1,ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal Systemi Form - Not for Voluntary Assessments
^M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
'i pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
1
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ _Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
w . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is Osterville Ma 02655 5-17-18
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis,.performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a"private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a_facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
El ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well -
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osteryille" Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper"maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of.bedrooms (design): 3 Number of bedrooms (Actual) _3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. City/Town state Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): See below
Detail:
2016-46,000gallons 2017-38,000 allons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).-
Grease trap present? ❑ Yes ❑ No
Industriaivaste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 60 Acorn 'Drive
Property Adc ress
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner- last pumped 2 years ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil'absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
New SAS added to existing tank in 2007
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2' _
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1 —
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000gallons
Sludge depth: 3
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth`&Massachusetts
W Title 5. Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 33"
Scum thickness 2„
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in
need of pumping at this time but should be pumped every two years for maintenance.
Grease Trap(locate on site plan):
Depth below grade: _NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth.below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
=, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 011
-
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not
show signs of back up.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M5 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3-3050
infiltrators
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was
dry when viewed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
^M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): "
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 60 Acorn Drive
M
Property Address
Michael Garbacik
Owner Owner's Name
information is Osterville Ma 02655 5-17-18
required for every
page. City/Town 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
r
C
Al-16'
131-33'6""
132-26'
C2.57' A
133-28'6"
C3-43'
0
3 2
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
J
Title 5 Official Inspection
pact on Foam
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma- 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface,water
® Check cellar
® Shallow wells
Estimated depth to high ground water: No GW @ 132"
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: June 8t'2007
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:.
You must describe how you established the high ground water elevation:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 60 Acorn Drive
Property Address
Michael Garbacik
Owner Owner's Name
information is required for every Osterville Ma 02655 5-17-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked.
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
4
LOCATION 66 Acorn car.v•. SEWAGE# 2607-26i
,�✓ILLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME:&PHONE NO. ���� ('Gs��ru►e��a��t�-7?1'9��
SEPTIC TANK CAPACITY 1C00 t .lwn
LEACHING FACILITY:(type) � ��t �� r3 (size) 3f3't 2
NO.OF BEDROOMS
OWNER 1"1,&1, v ��
PERMIT DATE: 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 wiihin 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 C64Jr1 C.,4uG "-'NCX.A'1%q
A\- tG '
No. 7 �� o �. : / 20
W Fee /04!::?
THE COMMONWEALTH OF MASSACHUSETTS „ Entered in computer: V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rppli cation.for dig og *p5tent (Cougtruction VerttY"
Application for a Permit to Construct O Repair(' Upgrade O Abandon O ❑ Complete System Individual Components
Location Address or Lot No. W" /' ed wner's Name,Address,and Tel.No.
Assessor's Map/Parcel /,2O 2-�2 r-,g r/r
Installer's Name,Address,and Tel.No. �`' �n`�a �'�•� r Designer's Name,Address and Tel.No. dwu
�� fps` .�
ys ,��f �--) J A 3�
�- ,7T-79-716 A,A) )&2-VJ-4ff 019
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. 'Garbage"G•rinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �� gpd Design flow providedV gpd -
Plan Date J-0"vim �. •)cve-7 Number of sheets / Revision Date
Title t So Je —m,J ,/
Size of Septic Tank Iad-O eo` Type of S.A.S. 3 _r4p eto4el��_ 30Pd
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) a jo Z 17
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 Bo o e h. /
gned Date
Application Approved Date
Application Disapproved by: Date
' for the following reasons
Permit No. cfz�®a Date Issued
— a
No. o° s".l; Fee
"jl`H COMMONWEALTH OF MASSACHUSETTS .-t,�` Entered incomputer: V
. .� .�:.•. Yes
PUBLIC HEALTH DIVISION;- TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYication for Migogaf *pgtemc Cori.5truction P�Individual
e
Application for a Permit to Construct( .) Repair(grade( ) Abandon( ) ❑ Complete System Components
Location Address or Lot No. �Lc,R ,2Owner's Name,Address,and Tel.No.Ad 6d r SQc,,
Assessor's Map/Parcel 1/20 ig
Installer's Name,Address,and Tel.No.S �, Designer's Name,Address and Tel.No. q 3
hype of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder (�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
* Other Fixtures
Design Flow(min.required) .3 3r gpd Design flow provided 7yo gpd
Plan Date—ruW. -e /add Number;of she f Revision Date
Title S. f P�7 d '` dld 157e,• )
Size of Septic Tank 406'0 C� Type of S.A.S.3"—Tw 111.w 1w— 30 5 V" �✓ 5��.
Description of Soil 51-t p147 y
--'Nature of Repairs or Alterations(Answer when applicable)
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 o'Health.
( ;gned t . Date Q�t
Application Approved bL Date I
Application Disapproved by: Date
for the following reasons
Permit No. 900 7 Date Issued / ! 0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (1/) Upgraded ( )
Abandoned
�( )//be�y 17ar.�7JT, ea-, �°-"4,e
/
at G� /l—01V ,(�a 0•57/r-r 0 /,- has been constructed_ /17
in accordanceM
with the provisions ofTitle5and the forDDisposal System Construction Permit Noo.C i3/Udated 6
Installer /��ry�/fd7?i G�+�J7,,,t� Designer yy,-•��v�p
#bedrooms Approved design flow 3110 Z d
gP
17
The issuance of this dt s n
a onstrued as a guarantee that the system wi 1 function as designed. /Go !
Date Inspector �;
-------- r ——r— ! ————— —.-- —� -.- r — �/
�'t-w �vv— ----
No. 7 6 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
J111i!5po,5al *pgtem Co 5truction Permit
Permission is hereby granted to Construct ( ) Repair /Upgrade ( ) Abandon ( )
System located at 60 . cv✓ /J f2
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special con itio
Provided: Construction gmust be completed within three years of the date of this p
Date C'/f I f U Approve by_y ��
I
I i
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
ALM& Public Health. Division
art' Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer-Certification Form
Date: -a 7 Sewage Permits o tjO-7.261 Assessor's Map\Parcel�ad
Designer: Installer: zork D �\Xly 6)50-rN
Address: JU9 lOW 11 U t Address: �S- ���✓� 7 A =1
a r�y 109v1 �'l A 1 W,5l
On 6-N-0-7 Der 4/41
(c�w was issued a permit to install a
(date) (installer)
septic system at 60 .based on a design drawn by
(address)
(2_11rJ_ Gt.l dated A64 0
(deli_ er)
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 boy;and/or septic tank.
I certt, 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 & Local Regulations. Plan revision or
certified as-built by designer to follow.
. NjzN OF"fAss Ggcy
DANIELA. P
o OJALA
`- CIVIL N
1.
(Installer's Signature) No.465020
�SS�ONAL ECG
CD. .
G 1 7/rti/a�
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIN'iSION. 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: HealtIVSepticOesigner Certification Form 3-26-04.doc
TOWN OF BARNSTABLE
y4 4
4 • _
LOCATION 4ezd4\1 it-t SEWAGE #
14LLAGE C�.yt a ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY 4 �--c
LEACHING FACILITY:(type) /fit- -uJ�S (size) '7 oc�9 �
NO. OF BEDROOMS PRIVATE WELL OR UBL1C WATER
BUILDER O OWNE� L �i4-e�0�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes Noj
ado . . ;
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No.. ..1
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
rns le Conserva n Depa me BOARD OF HEALTH
TOWN OF BARNSTABLE
igned Date
Applirttlicit for Di-nVuiittl Wor1w Tunstrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair �>4 an Individual Sewage Disposal
System at:
--------------------
Location-t\ dress or Lot o.
.....-•----........ ................. -------- '-•---- `s erc ._.._ t °v -, GS'�_
Own r Address
Installer Address
d Type of Building Size Lot............................Sq. feet
U g— ----_Expansion Attic ( ) Garbage Grinder ( )Dwelling No. of Bedrooms--_-_-.-•---•----- ----------•.-___---
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixture ''JJ�j -�-------
W Design Flow---------------- gallons per person per day. Total daily flow.___-.-_-_-----97:_ '__ gallons.
WSeptic Tank—Liquid capacity- -gallons Length.-.___-___.__-_ Width-.------._i.-.._ Diameter-- ----------- Depth................
x Disposal Trench—No. --------Z....... Width___--.�...____. Total Length---cv ...... Total leaching area....................sq. ft.
Seepage Pit No.-----.-. Diameter------740'._..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--..-_---___-___--_----.
04 ------------------------------------•--------------------------------------------------------•.---••.........................................................
0 Description of Soil............. -•--------------------------------------------------------------------------------------------------------- ..............................................
x
U -•-------•---•--•-....---•---•-•--------------------••......------------. ----------•---•------...•-•-•-•-----------------•--------••---•-------------•----•----------.................................
W •-------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when appli ble. /-...-- �- A-----% _P1� _... 1!
f ?
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant as en ssu b board of health.
SignedB - ------ ------ ----®-------:----------------------------- /- .......... ��
� ` Date
Application Approved By ..... ...-r!........- � ------------- -- --------- -- --...f�... ... ........................................
................Date----------.-----
Application Disapproved for the following reafon.r: ------------------------------------------------------------------------------------------------------------------------------------
........................ .. .. ... ....... ... ---..........----------------------------------------------------- ..-.......
,(�' Date -
Permit No. Issued ---------- C2.
lDat
All
No.. ..... ...... ���
w. Fmc..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'"" S/TOWN OF BARNSTABLE
Appliration for Dhi-pwint Wnrkii Towitrurtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair (>4 an Individual Sewage Disposal
System at:
.......�p d----•-••/a C G,Z iU DiZ w Q 67—�16 tJ i c.c._�
-------------------------
.---------------------------------------
Location•i�3dress S t
--__ . or Lot No.
Owner ` Address
,-� ---------------------............................ �-'`...........------•�-4-----5------- u .?.9...�. c�---/--••••--�-�-••.�....----•••--•-•--D••-T-••I••-•,---/-•1•�-•---i--•�--.(...�..5....••----
Installer Address
U Type of Building Size Lot.....................
....... feet
t-. Dwelling—No. of Bedrooms------------------ --.__-_____---_-__Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ____________________________ No. of ersons-----_______-_____---.----._ Showers —
� YP g P ( ) Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------•--•--------- -------------•.-------
W Design Flow----------_----45S ..................gallons per person per day. Total daily flow..........._..._.:�'y� -&-----gallons.
WSeptic Tank—Liquid capacity.Z gallons Length-_---_--_-..._ Width---------------- Diameter----.----------- Depth................
x Disposal Trench—No. ........ ....... Width....`-�... Total Length. �__S..-... Total leaching area....................sq. ft.
Seepage Pit No----------- Diameter.... -.-_ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a •----•••--------•-----------•-------------••-•--••-•---------••-••---•••......-----•............••-•........................................................
0 Description of Soil........................................................................................................................................................................
x
U .....•-•••••••••••-•••---••-•••••----------•----•--------•-••••--••••--••-------•••--------•--•----•••-•-•------••••-•---•--•---------•--•-•--•..V...--•---•-•------•..................................
W
x -------------------------- ------••••-------•--••-•-•-••-•----------------------------••-•-.._..--•-----••----------------------------•-•---------•••--------•-•-•••-••-------------••••-•...._......._.
U Nature of Repairs or Alterations—Answer when applicable._-_.fin!-�%_� �L-�_.._:_4____... �1�� '.�_._.l>---------�..
............... c..............................N1 .................. / --�-••--_..... �- y �
p -
- - -------•---....-•-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance h'as�ssu dl by the board of health.
l >� - �y
Slgned ._.......rr/..::..... /�............._.............--------------- .......... /f----- -------........--------
�r LDate
Application Approved By .. ..................._:�_-------� /--�•`�--�' i-'----::!- .. ,_----------------
...............`--- ----------------------------------------
Date
Application Disapproved for the following reasons- -------------------- --A ...... ....._....._............._............-- .. ..............---......
------------------ ----------------------------------- � fi..- !........ ..............Date......._......_..
5.
Permit No. .... _ ...... _rl`, ------- Issued ......
I -
.....
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(11Pr#ifi ate of QuTnmiIianre
THIS IS TO CERTIFY,-.That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--..._..------------------------------------- �fi -�' .�rl- - GL c 7
Installer
---------------------------------- ---------------------------------------
CC_ ci
at ................ .Ct1J. ,rG�C -�(9 .5(1 ° --
has been installed in accordance with the provisions of TITLE 5fof The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..._�.�7... -_.f .. dated ........................-----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUEA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ �."' . '....�� � G tV 'I
-.... -- Inspector 714---------------- . ---------------------------
G'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� --' TOWN OF BARNSTABLE
tNo......................... FEE.---._...------•----•---
inttl Work$ �� tr�trtti�nrrittit
Permission is hereby granted.................�of .. 7-7---_------ J���..'.!��� /G�1
to Construct ( ) or Repair (Ile—) an Individual Sewage Disposal System
at No----------------------------------------------�U...........A-u'4W 0 tt.'O'/ ... p 0-5,-J-C:f kVI(t
Street {
as shown on the application for Disposal Works Construction Permit No..................... ...... ..........
• ! Board o@ Health
DATE417 ----------------••............•--•-
f / f t
FORM 36508 HOBBS✓!WARREN,INC..PUBLISHERS
SYSTEM STEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES
MARKED.:WITH. MAGNETIC TAP OR
TOP FNDN. AT EL. 51.6' COMPARABLE MEANS FOR FRE LOCATION.
ACCESS COVERS TO WITHIN 6' OF FIN. GRADE
Not M SCAM1. DATUM IS APPROXIMATE NGVD
ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORE' TO WITHIN r OF FINAL GRADE
J` WAIN 6' OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING
50.5' MINIMUM .75' OF COVER OVER PRECAST LOCUS
4 2% SLOPE REQUIRED OVER SYSTEM 50.5'
49.1 RUN PIPE LEVEL
3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
*EXISTING -• � ;. _FOR FIRST 2 2" DOUBLE WASHES? PEASTONE I_
E 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
**EXISTING 1000 \ , OR GEOTEXIfI�E FABRIC H- 1 O aro�
*EXISTIN 47.7 tt 6. stwSUMP
47.59 0� �aIP
GALLON SEPTIC TANK
GAS ooe,o 47.17' 5. PIPE JOINTS TO BE MADE WATERTIGHT. Rood
47.34' "
r- 47.09 - 3' AT SIDES. 6. CONSTRUCTION DETAILS" TO BE IN ACCORDANCE WITH
6• CRUSHED STONE OR MECHANICAL2' 4' AT ENDS MASS. ENVIRONMENTAL CODE TITLE V.
COMPACTION. (15.221 (21) 45.09
0
DEPTH OF FLOW. = 4
p. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
TEE SIZES:
BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
INLET=DEPTH 10 _ 3/4. TO 1 1/2" DOUBLE WASHED STONE
OUTLET DEPTH = 14" ( 1 X SLOPE) ( 1 X SLOPE)
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
FOUNDATION EXISTING SEPTIC TANK 36' D' BOX 10' LEACHING 5.59' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH" AND PERMISSION LOCUS MAP
*THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. OBTAINED FROM BOARD OF HEALTH. SCALE: 1" = 2,000't
LOCATIONS OF ALL UTILITIES AND ALL SEPTIC -TANK SIZE AT 1000 GALLONS AND 10. CONTRACTOR SHALL BE RESPONSIBLE -FOR CALLING
BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE DIGSAFE 1-888-344-7233 AND VERIFYING THE LOCATION ASSESSORS MAP 120 PARCEL 27'
PRIOR TO INSTALLING ANY PORTION OF BOTTOM TH-1 EL. 39.5' ( }
- SEPTIC SYSTEM OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
COMMENCEMENT OF WORK. LOCUS IS WITHIN_WP OVERLAY DISTRICT
LEG -ND 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
100.0 PROPOSED SPOT. ELEVATION
12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE-
REMOVED 5' BENEATH AND AROUND THE PROPOSED
+100.00 _ EXISTING. .SPOT ELEVATION LEACHING FACILITY.
16 PROPOSED CONTOUR
100 EXISTING CONTOUR BENCH MARK - NAIL SET SYSTEM DESIGN:
]IN FENCE ELEV. = 5.1.1 GARBAGE DISPOSER IS NOT ALLOWED
/ 12" JAPANESE MAPLE DESIGN FLOW. 3 BEDROOMS ® 110 GPD = 330 GPD
USE A 330 GPD DESIGN FLOW
Np° i�� SEPTIC TANK: 3-30 GPD (2) = 660
12" JAPANESE MAPLE - �� ��yy - **RE-USE EXISTING 1.000 GAL: SEPTIC -TANK
LEACHING:12" SPRUCE HOLE LOGS SIDES- 2 + 03 7 7 PDTH-2 ( 3
,
DAVID FLAHERTY R.S. j BOTTOM 29.3 x 10.3 (.74) = 223 GPD
ENGINEER: -HODYS TH-1 �'� � ;
WITNESS: DONNA MIORANDI, R.S. AND LRG TOTAL: 459 S.F. 340 GPD
W.PINES
DATE: MAY 24, 2007 10 0 0 DECK USE (3) STANDARD A3050" INFILTRATORS
PERC. RATE < 2 MIN/INCH - - WITH 4 STONE AT ENDS AND 3 AT SIDES
CLASS I SOILS P# 11760 EXISTING 3 BR
_ELEV. ELEV. DWELLING TOP: OF FNDN _ .o MA
APPROVED, DATE . BOARD OF HEALTH.
0" 50.5' 0" 50.3' EL. 51.6' GF
A. A O�
TITLE 5 SITE FLAT
LS LS OF
1"OYR 4/3 1OYR 4/3
/�
9" 49.7' 12" 49.3' 60 ACORN DR.
B. B.
LOT 11
LS LS 12,798f SF
0.3f AC (OSTERVILLE) BARNSTA--BLS, MA
33" 1OYR 4/6 47.T 36" 1OYR 4/6 47.3' \� / PREPARED FOR
BORTOLOTTI CONSTJ
c ,\�\c PEIM so S �o°°° / MICHAEL GARBACIK
� /
9
cn / 1v DATE: JUNE 8, 2007
MS MS
cn / -�010
2.5Y 6/4 2.5Y 6/4 / a
OF MaSSq off 508-362-4541
HOF cy fox 508 362-9880
/ SM �° ��,
A DANIEL S�gc9 A.
DANIELA. ��, OJALA
132" 39.5' 126" 39.8' �� OJALA N �No.4098o down cope en giro eerirr q, inc.
NO GROUNDWATER ENCOUNTERED Scale:1"'=20' a No.46502 41 °�o�R� C/VIL ENGINEERS
�0 ��, � LAND SURVEYORS
s 939 Main Street - YARMOUTHPORT, MASS.
0 10 2fJ 30 40 a FEET DATE OJALA, P.E., P:L.S.
DCE #07-086
07-086 BORTO_GARBACIK.DWG (DDF)