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HomeMy WebLinkAbout0105 ACORN DRIVE - Health LAA 05 Acorn Drive, Osterville = 144 - 023 { k F a j a TOWN OF BARNSTABLE �' 2 ;,, LOCATION A C Q ti -R, SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 07aQ /77 A �- SEPTIC TANK CAPACITY / �y I LEACHING FACILITY: (type) f , u j r&1�0"size) 5 K 7.r, NO.OF BEDROOMS OWNER PERMIT DATE:,6�aT Itz// COMPLIANCE DATE: 'n 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 S Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ' r , sol a No.ZO Fee_)�Ca THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOW "OF BARNSTABLE,, MASSACHUSETTS Yes ftpf ration for Mie-posal *pstrm Construction 3PPrmit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ®� A C,5rn Q r•`I /Owner's Name,Address,and Tel.No.I Ll f A-C64(h P �-w�Lj l°¢ ?J�4�s I-►` R®� �00M ®S�/ t`l�'` L.P;-�os� Assessor's Map/Parcel Installe 's Name,Address,and Tel.No. � �/` Q<►.ts�eLj Designer's Name,Address,and Tel.No. �( F4 Can u� �y �tiV►f I6 "`4 , 3�z- 5�6 F S SwVty So's-- gye-3�i`4 CA��; Type of Building: e► Dwelling No.of Bedrooms 3 Lot Size �ot ��'� i' sq.ft. Garbage Grinder( ) Other Type of Building pytre11 Ph G, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) o gpd Design flow provided .313 gpd Plan Date j iA 7 I I( Number of sheets ` a Revision Date Title—:514e, tC.In?G ri Pkcin 11 rr ( Size of Septic Tank r 1 t Type of S.A.S. fnC, Description of Soil 6ep_ P�t— \� 4Q( Nature of Repairsf or Alterations(Answer when applicable)( r1'�C,�/1/ I tc.GY" [�r f� ��GG,N% ��✓ t��f 1 T sc+p L�s 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 f alth Si d /6G Date Application Approved b Date Z ?o I r ` . s Application Disapprove Date for the following reasons I Permit No.001 ��Z Date Issued /012-Y /Zo!( rr No.ZO I 7 Fee (Ca' _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - T.�-IOF BARNSTABLE,,,MASSACHUSETTS Yes 2pplitatlon foT D3 isposal *pstem ConstrUtti l permit 7 Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Q cvfn Owner's Name,Address,and Tel.No.j 6 s {�CG(r-N Assessor's Map/Parcel 142 0 2.3 h f V- p_r` op ! Installer's Name,Address,and Tel.No. {- V Q4^S4lf'f Designer's Name,Address,and Tel.No. R ' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other T e of Buildin t + No.of Persons Showers Cafeteria Y g P w ( !�u Other Fixtures _ Design Flow(min.required) l 330 gpd Design flow provided .3q3 gpd Plan Date �t/� 11 f Number of sheets nn d� Revision Date Title ,L!i t?-. t rJ e Inl wca L C`C0 az- Y`G Y1 a Size of Septic Tank 1eYU0 Type of S.A.S. ;pp� (�a DAc+ -10 !At, CG1 0 Description of Soil 6Ge. +eA r cI f Nature of Repairs or Alterations(Answer when applicable) rl C-V1/ i Date last inspected: Agreement: I 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 of alth Si d Date Application Approved b Date O Z Application Disapprove¢ y Date for the following reasons Permit No.Z_b/ I— 3 Z. Date Issued /OT 7 )Zo t/ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by r� at t/STG 11.►)tt 1 r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _OI 1-J� L dated 6910 �Zu Installer 1)ti'l-ul r Designer r AS ZS j # F bedrooms Approved design flow �� gpd The issuance of this permit shall not be construed as a guarantee that the system� will action esigned. /- Date �� Inspectors-- ' \ t ' ---- ------ ----------------------------- ----------------------------------------- ---------------------- No.Z01 �— �j�Z — Fee (QC-) . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal .6pstem Construction permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at/t)h A.('e,.QnJ �©WI' 0"5 T_tx_- cif 1, t 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:Construction must be completed within three years of the date of this pe t. Date / � /Za(/ Approved Town of Barnstable `"E'°w o Regulatory Services Thomas F. Geiler, Director .BARNSTABLE, MASS. Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form ✓312- VoXNO, Date: D t vu 1)6igner:Z21g Installer.CM C Address: Address: N e f ' I tv-. was issued a permit to install a , (date) (in alter) septic system at I 5 �aC ��fb" i!�\\k based on a design drawn by (address) dated — (desi 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 box and/or septic tank. 1500 Gi , S •l, Zvi s4&((e A I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or y vertical relocation of any component of the septic system)but in accordance with State an& Local Regulations. Plan revision or certified as-built by designer to follow. � ZN OF MASS9 ,_ �o DAVID o�G� o D. X0 FLAHERTY, JR. � (Inst le _ ignature No. 1211 • ���►sTEa�`� '(Designer'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- i"t.,j. J BUILT-CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form . Town of Barnstable P# ' Department of Regulatory Services Public Health Division Date MASK lFo Mtd a1 200 Main Street,Hyannis MA 02601 Date Scheduled `— ' Time t Fee Pd. `100 Soil Suitability Assessment for age Disposal .. .. Performed By: �✓ � Witnessed B r LOCATION& GENERAL INFORMATION Location Address �2/` Ir ' Owner's Name J �� Address S d.1N�l t6 Assessor's Map/Parcel: O ,Z� Engineer's Namezw ° NEW CONSTRUCTION REPAIR Telephone# ��J'�2<' + . Land Use:- 1f42s/ 'd Slopes Surface Stones A f TGw Distances from: Open Water Body '✓ fit Possible Wet Area i/�ft' Drinking Water Well L Drainage Way— �11A ft Property Line • �3 ft 'Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands 1n proximity to holes) r i Parent material(geologic) e/`"e?7 Depth t0 Bedrock Depth to Groundwater. Standing Water in Hole: �! Weeping from Pit Face Estimated Seasonal High Groundwater /0 <!�? �� �✓ DETERMWATION FOR SEASONAL HIGH WATER TABL,EA Method Used: Depth Observed standing in obs.hole: In. Depth to soil moUles: Depth to weeping from side of obs.hole: 1614In, `Groundwater Adjustment f Index Well#heading Date: Index Well levelAdj.ttetor., dj.dreutidwater level f[� PERCOLATION TEST Ditto cl'I-19 TItne Observa'on Hole# Time at 9" ._,,Zr - Depth of Perc � Time at G" ni Start -6 Pre-soak Time @ �l Time(9" ") � cbw End Pre-soak /l•. Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) o 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:\SEPTIC�PERCFORM.DOC 1 � � DEEP.OBSERVATION HOLE LOG Hole# —� Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. o i tens Y.96'Graven - ZD e:A" z-S -7 i \, DEEP OBSERVATION HOLE LOG Hole# 2 K 33•� Depth from Soil Horizon Soil Texture Soil Color Sail Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, GG onsisten 96 Grave 77 DEEP OBSERVATION HOLE LOG Hole#- S �¢-S Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co i to G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consi ten Flood Insurance Rate Map: 1 / Above 500 year flood boundary No_ Yes Within 500 year boundary No K Yes Within 100 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? .e5 If not,what is the depth of naturally occurring pervfous material? Certification I certify that on 6 (date)I have passed the soil evaluator examination approved by the Department of Envlronmen 1 Protection and that the above analysis was performed by me consistent with . the required train' ,e se andPIT en ce escribed in 310 CMR 15.017. SignatureDate • Q:1S.EPTiCVERCFORM.DOC - --' �1M4 F. oftrEro�y Tow Barnstable Barnstable i? A"mmiaaCft Regulator,, S;' rvices Department 1 t B"NST Bts � 0 Pu ; is ` ealth Division m 200 Ma. S r feet, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO E ' C RTIFIED MAIL 2 0000251783166# 70083 3 i 9/08/2010 Robert C. Loomis �L"J 0 p o � 105 Acorn Drive Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 = r The septic stem located at 105 Acorn Drive- M A was last in ect p y , sp ed on June-28, 2010, by Patrick O'Connell, a certified septic inspector for the.State of Massachusetts. The inspection of the septic system showed that,the sysieM"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: s Backup of sewage into facility or system corriponentdue to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. I t You are ordered to repair or replace the septic system within Sixty (60) days from the. date you receive this notification. i Failure to repair/replace the septic system within the deadline period will result in future enforcement action. ER OF THE BOARD OF HEALTH F o as McKean, R.S., CHO Agent of the Board of Health . Y Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is Osterville MA 02655 June 28, 2010 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any p way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road Company Address + Marstons Mills MA 02648 + City/rown State Zip Code 508.428.1779 SI 12855 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 16.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority LU June 28, 2010 Job# 10-180 cn E '' (M 0 Irispector's Si ature Date M The system inspector shall submit a copy of this inspection report to the Approving Authority(Board . o of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or c� 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 0 o and copies sent to the buyer, if applicable, and the approving authority. F-- o �.,****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. ell !Sins•09108 Title 5 Official Inspection Form:Subsurface Sewage Dispos I System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28, 2010 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): r 0. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17. Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owners Name information is required for Osterville MA 02655 June 28, 2010 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. r ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® El clogged 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form kiSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28, 2010 every 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ ' the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28 2010 every page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ 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 obit? ® ❑ 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is IDS erville MA 02655 June 28,2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes'separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Forth: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 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped 6-8 months 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•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28 2010 every 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: Installed 7/11/77 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): �y. Septic Tank(locate on site plan): 1' Depth below grade: 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: 8.5'long x 5.2'wide- 1000 gal. Sludge depth: l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28, 2010 every page. Cityr 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 Scum thickness F Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): Liquid level was found at top of tank. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts) _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No' Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owners Name information is required for Osterville MA 02655 June 28 2010 every page. Citylrown 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: , y t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit ❑ 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.): Leaching pit is in hydraulic failure. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r- 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Cistervllle MA 02655 June 28, 2010 every page. Citylfown 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.): t5ins-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 14 of 17 ` 1 Commonwealth of Massachusetts Title 5 Official Inspection Form W's Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is Osterville MA 02655 June 28,2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing.attached separately J`/`119 ♦ \ \ ♦ \ 4 \ \ , ♦ \ . \ \ \ \ . \ \ \ , \ \ \ I / 36 25 2/ \ \ \ 4 \ 4 \ ♦ \ \ \ \ Acorn Drive Commonwealth of Massachusetts . - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: N/A feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) El 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: r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 .0 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Acorn Drive Property Address Loomis/Donlon Owner Owner's Name information is required for Osterville MA 02655 June 28 2010 every page. Citylrown 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 15ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHLJSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ti DEPARTMENT OF ENVIRONMENTAL PROTECTIO ONE WINTER STREET,BOSTON, MA 02108 617-292-5500 (-- �, Tow 31998 _ 46 sr Ir WILLIAM F.WELD dv 64 TRUDY CORE,, f liBvemor Secryeta�n• c1 ARGEO PAUL CELLUCCI DAVI- KSTRUHS LL Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A j CERTIFICATION ' ten t•,`� C `�1 Property Address: to) �s ) Address of Owner. av, "'kt`c-, Date of Inspection: I — Z nn�'CI 0 (If different) {{ Name of Inspector• d�c;n,(- QldowiS f am a DEP approved stem inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: pit C_ f Mailing Address: cc,h his Telephone Number: pp i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported.below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and E maintenance of on-site se age disposal systems. The system: j Passes _ Conditionally Passes _ Needs Further Evaluation By the Local proving Authority _ Fails Inspector's Signature: Date: The System Inspector shall s mit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit r the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 1 INSPECTION SUMMARY: Check A, B, C, Or D: I Aj SYSTE ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BJ SYSTEM CONDITIONALLY PASSES:. s iff One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon I completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no,or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of F Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/23/97) - Page 1 of 10 f DEP on the Worid Wide Web: http:IMrww.rnagnet.state.ma.us/dep }� { ej Printed on Recycled Paper .. ..-„ _ .,..._ .�. _. . ...:,.s.. ,•.. ..:. �, � .,. - '- ... -.... .,.,� comet:a� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property A dress: �� � I I `C h �l���' )���r�� �•,_. Owner: Date of InspecTron: B] SYSTEM CONDITIONALLY PASSES (continued) i i Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the j Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than.four times a year due_to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ! obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ,., Conditions exist which require further evaluation by the Board'of Health in order to determine.if the system is failing to protect the- public health, safety and the environment. i 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 4 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN'A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: E _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless.a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER E . I C I (swieid 04/23/97) Page 2 of 10 - i • l i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ? CERTIFICATION (continued) Property Address: ��� 49 � Owner: Rt"kx, cOA-f-rI6C-- i Date of Inspectfbn: l D] SYSTEM FAILS: You ust indicate either "Yes" or"No" as to each of the following: f I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. I i l Yes No - I Backup of sewage into facility or system component due to an 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. i . E Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS_or cesspool. f Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. i _ — 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. i f Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i Any portion of a cesspool or privy is within a Zone I of a public well. I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. }( E] LARGE SYSTEM FAILS: You must'indicate either "Yes"or"No" as to each of the following: I The following criteria apply-to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System)and the system is a'significant threat to " public health and safety and the environment because one or more of the following conditions exist: fi Yes No i 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-1WPA) or a mapped Zone II of a public water supply well) h i The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. # a i (revised 04/25/97) Page 1 of 10 f. 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Ad Bess:. Owner: LA ck � Date of Inspection: —cis, r _ Check if the following have been'done: You must indicate either"Yes" or"No"as to each of the following: i Ye No i _ Pumping information was provided by the owner, occupant, or Board of Health. I None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. 11 _ The system does not receive non-sanitary or industrial waste flow: I _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of f Sub-Surface Disposal System. - _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] i I f i - f i . i (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property A dress: �Ib Sn ft�C-60C COY Owner: Q Date of Inspection: FLOW CONDITIONS RESIDENTIAL- i Design flow: p. Jbedroom for S.A.S. } Number of bedrooms: _ Number of current residents: Garbage grinder(yes or no p Laundry connected to system (yes or noi— Seasonal use(yes or no):-�— Water meter readings, if ava•able (last two (2)year usage (gpd):' Sump Pump(yes or no): Last date of occupancy:, �q ,a-7 t COMMERCIALII N DUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: i i Last date of occupancy: ! OTHER:(Describe) Last date of occupancy: E GENERAL INFORMATION I r PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons l Reason for pumping: TYPE O 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: ��YJ Sewage odors detected when arriving it the site:'(yes or no) { i p i (zaviaed o41/ls/97) Page 5 of 10 ! . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t bs �h �- Owner: Date of Inspe on: 'J--21—C ( BUILDING SEWER: i (Locate on site plan) Q I Depth below grade:JQ �- Material of construction: �t iron _✓40 PVC_ other(explain) Distance from,rp(riivate water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) , SEPTIC TANK: { (locate on site plan) .Depth below grader Material of construction: _concrete _metal _Fiberglass _Polyethylene __other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of Judge to bottom of outlet tee or baffle. Scum thickness:_��N �nf! r� Distance from top of scum to top of outlet tee or baffle: _ i Distance from bottom of scum to bottom f o t tee or baffle: A9 i How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, de hoof liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Ur1J GREASE TRAP: t (locate on site p an) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: ! Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: , Comments: outlet tees or baffles depth of liquid level in relation to outlet invert, structural and ou q i i n of inlet a P' n forpumping, cond t o (recommendation o 1 integrity, evidence of leakage, etc.) i r 4 (rwisod 04/25/97) Page 6 of 10 f - I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property ddress: b� Owner: I tih I-.o &-q-c e�-- Date of Inspection: l "ZA—Cl g 1 - l TIGHT OR HOLDING TANK:(Tank must.be pumped prior to, or at time, of inspection) ` (locate on site plan) I Depth below grade: Material of construction: _concrete_metal _Fiberglass _Polyethylene —other(explain) 1 Dimensions: Capacity gallons ! Design flow: gallons/day Alarm level: Alarm in working order_Yes;_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ! ! 1 C DISTRIBUTION BOX I (locate on site plan) ! i 1 Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) E 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 chamber, condition of pumps and appurtenances, etc.) -- I 1 fi (revised 04/25/97) Page 7 of 10 . t I i o S i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C I SYSTEM INFORMATION (continued) i Property Address:l05 Owner: (Zy4,�•� -�J�'l,C.�� Date of Inspectibn: i SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: I I Type: 1 leaching pits, number:L leaching chambers, number:_ leaching galleries, number leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool,_number: Alternative system: k Name of Technology: Comments: _.. (note condition of soil, signs of hydraulic-failure, level of ponding, condition of vegetation, etc.) i Crw� CI, I - I CESSPOOLS: (locate on siteqpl ) i j, Number and configuration: 1 Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: I Indication of groundwater: inflow (cesspool must be pumped as part of inspection) I , { Comments: l (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i i ,I , PRIVY: (locate kteplan) I i Materials of construction: Dimensions: j Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . i (revised 04/25/07) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C I SYSTEM INFORMATION (continued) i .. I Property A ress: �bs Ph Owner: cuJ ``.•� �t CIC_ Date of Inspedi n: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i A �71 ( ' p <elo �� I flf" i + l I • i i r i I (swiaad 04/25/97) Page 9 of 10 f i _ G ; 1 ' t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Ib Such ����� �S�exUi ll Property Address: Owner. �n4.1^ I Date of Inspection: - t lob No Av Depth to Groundwater_ Feet t Please indicate all the methods used to determine High Groundwater Elevation: E ! Obtained from Design Plans on record ! i Observation of Site (Abutting property, observation hole,basement sump etc.) I Determine it from local conditions Check with local Board of health j Check FEMA Maps Check pumping records Check local excavators, installers �II � I A/ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) r I 1S -�wc� A, t � /l 6rouk � eV�,�oL,fPI-F � i - 1 1. (revised 04/23/97) Page 10 of 10 � rj!5 3 � LO�C A T ION SEWAGE PERMIT NO. 4 —S ('. VILLAGE ��, iq•9. Q.7- N S T Al L E R'S NAME & A D D R E S S J. CRAIG MEDEIROS Trucking & !BulldRing 142 I;o-rporation Street Hyannis Mass. 775 0828 8 UItDE R OR OWNER. .. DATE PERMIT ISSUED ; 7 DATE COMPLIANCE ISSUED -7/j���7 t No..----. ..` � ............— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........Town...---.._..OF......Barnstable........................................... ApplirFatiun -fur Jigpuiiaal Works Toustrurtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: #18 Acorn Dr. Osterville #18 Acorn Drive ------ -------••-------•-•-------•-----.................. ..---------•••--•----------•-•••-•----------...........-----•-----•. ........................ Location-Address or Lot No. Floyd -J Anci--.R4na d...J_..-_Z.ilyia------... --. �Z_.Linda..La._..H�r�nnis Owner Address w J. Creg---MedemiDz.......................................... ...rinrg,---Rd-•......Hyamis........................................... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..... .....................................Expansion Attic�� ) Garbage Grinder (ri0j Other—Type of Buildin nO le No. of persons............................ Showers — Cafeteria a' Other fixtures ----------------- --------------- W Design Flow..........5P------------------- ------ Mons per person per day. Total daily flow....3OQ.._.___________.__._... _----gallons. WSeptic Tank f Liquid capacity�d' ffgallons Length................ Width------.......... Diameter---------------- Depth---------------- x Disposal Trench—No .................... Width........... f �otal Length..................... Total leaching area--------------------sq. ft. Seepage Pit No________ ________ Diameter_/.�... ----�IDepth belo inle ......._......... Total leaching area--.-..-_-.---__-.sq. ft. z Other Distribution box ( ) Dosing tank ( ) Z7 — � ✓1 . 7 6 f-�m 7 aPercolation Test Results Performed bY.......................................................................... Date------•-•--------------------------- a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit..................... Depth to ground water.._.----_--..-.---.---. LL Test Pit No. 2......•---------minutes per inch Depth of Test Pit.................... Depth to ground water_.....---_--..---------. �+ -•--------------- 0 Description of Soil------------------ ---- -----------------------------------..-.--------.-..-.---- --------------------------------------------- x w UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------- ........... ,. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 boa d of ealth. ned.-- . '_. 'c``" •---•--•-_-•-••--•---- .. ----------' .......-----•- Date Application Approved BY--------- - ...... -• •-- -•.-- ----- - >�=.Pi =D7---7-----•••- Application Disapproved for the following reasons------------- --•••--••••--------•--•---•--•-••••-•-----•-•----------------------------•---------------------•--------•....•••--= ------------------------------------------------------------------------------------ Date PermitNo............................................ =......... Issued........................................................ <r:� ,°• Date L-------------- -- - -- ---- ---- -- - - ---?-------------------------- ------------ �r No......3_f .... FEic..... .........� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...._..... ...'I'om.......:.....OF.....P4rnstabl e ........................................................... Y, Appliration -for Di,ipoiittl Workii Tomitrurtion Vrrmit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:' Acorn Dt'e- ®s dry lle 18 Acorn Drive ---............................ ---------------•--------------••------•- Location-Address "' , or Lot No. ob F d-_J a_._And...�OXIald. =------ ---56._ .x'?,.de,__IaA...Hyannis..................................... ( ynp /� �nOjwner Addressss, •--------- -¢-- X-h Se -- 4t .i.i1.os------------------------------------•----- --.Sl SV -A--- -•- --= 15.i!.....-......................-----------.... Installer Address Q Type of Building _ Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms-----3-----------------------------------_Expansion Attic r�o ) Garbage Grinder (nc) a0ne-Other Other—Type of Building 0 _________________ No. of persons.--_____-_R __-...._._.... Showers ( ) — Cafeteria fixtures . t ------------------•--------•--------------_--•-------•---•---•--- WDesign Flow...........59__________________f_.-___..gallons per person per day, Total daily flow____ OQ..................:-------------gallons. WSeptic Tank Liquid capacity{ IlIons Length-•--•----------_ Width--------- . - Diameter------- --- --- Depth.-------------- x Disposal Trench—NO ......... Width_____._._._(' otal Length.................... Total leaching-area_....-.-_--_-----_-_sq. ft. Seepage Pit No_________ Diameter_/ "'/D p _._ ________ in area.--_---_-.-.___-_sq. ft. e th belrn Inl Total leach z Other Distribution box ( ) Dosing tank ( ) ' ''" '" ~" Percolation Test Results Performed by _--__-- ______________________ .................. Date---------------------------------------- W ,a Test Pit No., l'____............minutes per inch Depth of Test Pit. ----------------- Depth to ground water..-.----_.-_.---_-.____- �14 Test Pit No.12----------------minutes per inch Depth of Test Pit.................... Depth to ound water-__-.---_--_-_-. . __ �/ --• gr W r .. Description of Soil----___ `_ ........ x U •-••-•------------------ W r U Nature of Repairs or Alterations—Answer when applicable--------- ' ... __:--------------_- ...... ------------------------------- -----------------------------------------------------------------------------------------------•-------------------- '-------------------------------------------- Agreement The undersigned agrees to winstall the aforedescribed Individual Sewage Disposal. System n accordance with the provisions of Article lI 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 boar of ealth. ned----- ----- ------ -------------------------------- ' Date Application Appro ed BY----- ----- t.. $d`-----` ------------ Date Application Disapproved for t t.e following reasons:-------•----------•----------------------- ---------•------------------------------._...- --------------------• •-----------------------------------•--------------------------------------------------•-----•--•--_._....-----------------••-----•-- -----•---•-•-•-•--••--•--•----...----------•-•----••-------••-•--- :».^ h Date Permit No. -= .................... Issued---------------------------=' =----------__-••--- Date 1 THE COMMONWEALTH OF MASSACHUSETTS f � BOARD O HE H ........ �!......... >* .. OF........ ......................... Tntifiratr of f Tvm*V1ianrr TH IS 0 CeRTI That he I�tdividual Sewage Disposal System constructed ( or Repaired ( ) by `" c ----------••- ---- Ins r at ,., ' ------•--------------- has been installed in accordance with the provisions of Arti of The State anitary Cod as otescribed in the v.:•. application for Disposal Works Construction Permit No.�. _ • _,•;. ,;:dated .:_'`_ __----XL/ 77____ THE ISSUANCE OF THIS_CERTIFICATE`:SHALL°NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM,WILL FUNCTION SATISFACTORY. : ' - DATE.-. 7--1--- Inspector------- -•---•-•• ------ ----------- --- THE COMMONWEALTHrOFKMASSACHUSETTS BOARD O HEALTH ?/ ..... .........OF............ ...... . ... - ---- •..... . .. FEE....................... Perinisston i y granted-- `` to Constr or Repair'( an dividual Se�g •sposal Syst atNo., ---------------------------------- -- - ------ et » as shown on the application for Disposal Works Construction P it,No. _ ted__________________________________________ Board of I ealth DATE--- ------- ------------------------------ ----- --------._. FORM 1255 -mows & WARREN. INC.. PUBLISHERS - /-�0-o2n/ Dm- vc ¢o�wiDE " f 177/ 10 1 \ 1 1 � /.2� 000 sq �.t -- ¢�2 - Ao7- �/6 \ I „t I j 0 � o �oT .20 /'ev�odEo /o A �1" a StASE�JR6E ' f , CFi2 T Goc,47--1 o,V cos7 it WtZZ- 5C44-5- /. .3 0' yyrE 1`lA y z4 1977 ' /�Lgv i2Er=• Q�in/G GaT ''�/8 Si`/own/ o n/ A t�GAn/ FC/L T sEP.�,� T SiG.✓/:9 ET UX .�4Np,2Eo�pED fin/ 93 �v E DWARD G --- E. r Cze7I A y 7H47 77-/E P oPo PoSEj� Qr1/44//16- -5;�owN 'Al 77-1/5 /S { .�ffiV .�;t LoCgT� oN 7'�E' G,eDt�NO AS s,yevyN ; ae*+ L,'ER�'cu•I �J/VD 77-IA7' i> Con/lc/ZI-7.3 To 7'�V . _ SEjdf}G� �E?�tll2t7"/ENJ�S o,� THETov�n/ 1",A124 1977 /2CCx G9.vtt-6o evEyo LOT 21 LOCUS DATA BED CURRENT OWNER ROBERT C. LOOMIS LOT 19 ,i .,. , ` �\ PORCH #1 PLAN REFERENCE 187-93 / 1 li LIVING 32 BH / I j'� \ [PROPOSED "D" BOX DEED REFERENCE 12443-118 i GARAGE KITCHEN i v , REMOVE EXISTING DINING i ZONING DISTRICT RC LEACHING PIT FROMlool LOCUS PROPERTY OVERLAY DISTRICT ZONE II — WP ,� \ 1 '-33— — i p� \ FIRST FLOOR FLOOD ZONE "C" 250001 LO LOT 20 ASSESSORS MAP 144 / O \ \ DTH #2 0� <PARCEL 023 \ LOT AREA 12,000± S.F. // h 5� \ \ \ _36+� DTH #1 1� -4-4-5- —3'7 ) �� B H SITE & SEWAGE �\ 40 -�y, ss 9; DTH #3 OO, BATH/ BED BED REPAIR PLAN `41 \\ �' 3 0( 21� CLOSET #3 #2 CLEA AREA 11105 �\ \ - UT s. A CORN DRl VE � N IN \ PAVED \ h 10' SECOND FLOOR \ #105 "� OSTER VI LLE \DRIVEWAY \ p�G`� EXISTING BARNSTABLE, MASS �o. \�\\ Q BEDROOM I \ \ DWELLING i DATE: 9-27-11 \y`y\ 40.1 x APPLICANT: �h'!y\ GARAGE BRICK PATIO Mr. ROBERT LOOMIS ��o. 105 ACORN DRIVE 2011-0122 OSTERVILLE, MA 02655 J EXISTING 1000 GALLON SEPTIC SHEET 1 OF 2 LOT 16 TANK TO REMAIN p� BENCHMARK -b TOP OF CONCRETE PREPARED BY: �.��oF� �� NOFMAssgc ELEV CORNERPATIO34 93FROUTE8 a�� �o DAVID ��, , LOT 18 EAS SURVEY INC. o EDWARD � Q� A � FLAHE J141 RT. 6A STONE � No. 1 �OQ N -10 No. 28980 Q �° 0 20 30 40-P. O. BOX 1729 G'ST�R��F FG T �� SgN17AR�PSANDWICH , MA 02563 �o PH. 508 888-3619 1 GINCHHIC 20 FEET LOCUS ( ) 27 ' ' I NOT TO SCALE: CELL (508) 527-3600 � " RAISE COVERS TO WITHIN 6" OF FINISH,GRADE OBSERVATION SYSTEM DESIGN SWEEP TO PORTS TO GRADE SILL ELEV. 42.13 FINISH GRADE / MAGNETIC TAPE PIPE ENDS ' GRADE WITH AND VENT DESIGN FLOW GRADE ELEV: 35.0 SCREWCAP ELEV. 34.2 FINISH GRADE 3 BEDROOMS AT 11 Q GPB/D 3,3Q GPD \\ \_ _ \ . //C.� / � ELEV. 34.6 ELEV. 33.8' .._, GROUND ELEVATIO 35TOP 3 .7 `� ` `� /.��//� �LG.� REQUIRED SEPTIC TANK 1' 3.8' OF COVER ~' 4" PVC SCH 40 24'®S-0,09 TOP ELEV 30.0 5.7 OF COVER ol " 21 _z-- -----660 GAL. EXISTING TO REMAIN INV.- - 4 PVC SCH 40n6..S- 0,01 SEPTIC TANK REQUIRED - IJM-_GAL, 32,14 10"TEE 14"TEE INV.- . TIE ENDS !6 EXISTING S,T, TO REMAIN - ID29,__GAL, 31,97 " & VENT P GAS BAFFLE H-20 D83 SIZE OF LEACHING FACILITY REQUIRED 4'=1" LIQUID LEVEL D=BOX SET HIGH CAPICATY INFILTRATORS LEVEL DESIGN PERC RATE --Q__MIN,/INCH _ INV,-29,82 INV,-29,89 a LONG TERM APPL, RATE_2JA-GPD/S,F, �� T REQ. INV.=29,85 a SIZE OF LEACHING SYSTEM PROVIDED: 37,5 28.67 .- c " o OSE (18) H-20 HIGH CAP INFILTRATORS ui to 330 1 0.74 SF/GPD = _446 S.F. MIN. REQ. EXISTING 1,000 GAL TANK TO REMAIN CHAMBERS TOTALING 112.5 LINEAR FEET ELEV, 23.6 DATUM: 75"x34"x16" STONELESS BED FORMATION NO GROUNDWATER TPIT#2 USING 18 HIGH CAPACITY H-20 INFILTRATORS (VERTICAL DATUM: BARN, GIS MSLt CONSTRUCTION NOTES: THREE ROW OF SIX PANELS ) PIPE ENDS 4.73 SF / LF X (6.25' x 18 AND VENT ) - 532 S,F - 2 OBSERVATION PORT 532 'x 0.74 G/SF - 393 GPD BENCH MARK USED: CORNER OF CONCRETE 1, CONTRACTORS INSTALLERS SHALL VERIFY GRADES AND VjHOFs PATIO ELEVATION 34,83 / / SCREW CAP TO GRADE �� sq ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING °y 93 GPD PROV a 330 GPD REQ, - 63 GPD RES, WORK ON THE SITE, �o DAVID �� SITE & SEWAGE 2, NO 1 DETERMINATION DEEDE OR ZON NG REGULATIONS OWNER / D , TO COMPLIANCE APPL CANT 3 H NO (GARBAGE DISPOSAL / GRINDER ALLOWED) WITH IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY, 1 r REPAIR PLAN 3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING G/STEREO 105 TA MATERIALS OVER THE SEPTIC TANK IS PROHIBITED, sgN1 T `P i GENERAL NOTES: ---2.83' -2.83'�►-2.83--1 �I ACORN ORl l/E 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. I D.T.H. #1 D.T.H. #2 D.T.H. #3 TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS s,5• DATE: 9-7-11 DATE: 9-7-11 DATE: 9-7-11 1 IN I I FOR SUBSURFACE DISPOSAL OF SEWERAGE. END VIEW GROUND ELEV. 33.8 GROUND ELEV. 33.6 GROUND ELEV. 34.5 x O S TE R VI L L E 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE NO GROUNDWATER NO GROUNDWATER NO GROUNDWATER ACCESSIBLE WITHIN 6 OF FINISH GRADE, WITH ANY REMAINING I CERTIFY THAT I AM CURRENTLY ` ACCESS PORTS BROUGHT TO WITHIN 12" OF FINISH GRADE. APPROVED BY THE DEPARTMENT B A R N S TA B L E, MASS 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE OF ENVIRONMENTAL PROTECTION CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE TO CONDUCT SOIL EVALUATIONS FILL FILL LOAMY SAND UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEY AND THAT THE RESULTS OF MY 66" 10YR 4/3 DATE: 3-27- MUST WITHSTAND H-20 LOADING. SOIL EVALUATION ARE ACCURATE g 48 LOAMY SAND 8„ 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION AND IN ACCORDANCE WITH 310 B APPLICANT: OF ALL UTILITIES PRIOR TO ANY EXCAVATION. CMR 15.100 RO GH LOAMY SAND 10YR 4/3 LOAMY SAND 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE R 7.5YR 5/6 10YR 5/1 7.5YR 5/6 Mr. R OB EFR T LOOM I S OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. `=_=� -- ELEV =28.3 66" B 72" 34" 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET. PER EDWARD STONE, CER IFIED SOIL ELEV =31.7 LOAMY SAND 105 ACORN DRIVE FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. EVALUATOR 7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF 7.5YR 5/6 O S TE R VI L L E, MA 02655 SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE ELEV =26.1 90„ 46" THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND C LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. GROUNDWATER ADJUSTMENT MEDIUM SAND C MEDIUM SAND SHEET 2 OF 2 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN 2.5Y 7/6 MEDIUM SAND 2.5Y 7/6 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT NO OBSERVED GROUNDWATER 2.5Y 7/6 ELEVATION OF THE OUTLET PIPE. DEPTH TO BOTTOM OF HOLE 10' PREPARED BY: 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES NO G. WATER 120" NO G. WATER 120 NO G. WATER 120" 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS VARIANCES REQUESTED ELEV =23.8 ELEV =23.6 ELEV =24.5 E A S SURVEY, INC. BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4" PVC 141 R T. 6 A 11 HALLIBES SHALL BE SLOPED 11/4S INCHULE PER 40 PVC SEWER FOOT MIN. EXCEPT EFORDTHE COVERROVEROS.A.S. DTH #1 laI ESITAHOLENDCTES DEEP B. O DON DESMARAIS p FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL 5.7' PROPOSED IN LIEU SOIL EVALUATOR P. O. BOX 1729 BE LEVEL "` OF 3.0 MAX. ALLOWED INDICATES ED. STONE 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION ' P-1 �46' PERC TEST BACKHOE OPERATOR. SANDWICH MA 02563 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW ACC EXCAVATION AND APPROVAL. NO MOTTLING SOIL TYPE: _1_ PH. (508) 888-361 9 13. MAGNETIC TAPE OVER ALL COMPONENTS. NO WEEPING PERC RATE: <2 MIN. PER INCH CELL (508) 527-3600 120" INDICATES ADJ. GROUNDWATER LOADING RATE: 0_74 GAL/SF/MIN t 1 l� ,t r r i l - -nL - - 0 S 0 O O law 44 - —nlsuticr�-- — -• j � --- (ao----. IPI=9p h o- o: ( r - i Ili j:C: _4ao C_____1 -¢enoveo vua.Tmo.iS _ _� .E•[IST.US Oa�IllOVS-.-- - -- I • �'plj '1pS /kf�RJ�I GQ..05t>rL�/1 C1.L;._MQ - cwoleow�m . i :LCOAA116 Lw-/4'—