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HomeMy WebLinkAbout0182 ACORN DRIVE - Health 1 DII 1 1� A i0 M k. O l ,l t: �� �i i 4 I I! { 1 0 I TOWN OF BARNSTABLE LOCATION I�a �G o r.�, SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INS tER'S NAME&PHONE NO.�.�Qtip SEPTIC TANK CAPACITY LEACHING FACILITY: (type)Ue-4!Ck_—� (size) (! X(9> NO.OF BEDROOMS OWNERu�,\: 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 within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY C,,p y { e a a 1 J 'RIC Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments E 182 "B" Acorn Drives Property Address K3 Nicole& Christopher Jennings Owner Owner's Name - information is 3: required for every Osterville Ma 02655 -8/17/17 C? page. City/Town State Zip Code Date of Inspection D. System Information (cont) �ea Approximate age of all components, date installed (if known)and source of information: 2014 ` Were sewage odors detected when arriving at.the"site? ❑ Yes ® No r I on site plan):Building Sewer(locate p ) _ 16 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): 6„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) y If tank.is metal, list age: years' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes x❑ No Dimensions: 1500 gallon Sludge depth' 3 _ t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 0// Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •; 182 "B" Acorn Drive Property Address Nicole & Christopher Jennings ; Owner Owner's Name + information is required for every Osterville Ma 02655 8/17/17 X. 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, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 Citylrown State Zip Code (508)477-0653 S113747 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.]am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Z. Passes ❑ Conditionally Passes ❑ -Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/21/17 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 DER 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 182 "B" Acorn Drive - Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. CitylTown 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•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 System Form - Not for Voluntary Assessments ^M 182 °B" Acorn Drive Property Address Nicole & Christopher Jennings P 9 Owner Owner's Name information is Osterville Ma 02655 8/17/17 required for every page. City/Town State Zip Code a Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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): ❑ 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 L ❑ Y ❑ N ❑ ND (Explain below): ❑` obstruction is removed ❑ Y ❑ N ❑ ND (Explain'below): R 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 "B" Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 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 AlUSystems: 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 182 "B" Acorn Drive Property Address NicoleChristop her Jennin s Owner Owner's Name e s a e information is required for every Osterville Ma 02655: 8/17/17 page. City/Town 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 ❑ ®r 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 ❑ ❑ 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 E] 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. G t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 182 "B" Acorn Drive Property Address 3 Nicole& Christopher Jennings Owner Owner's Name information is required for every Osteryille Ma 02655 8/17/17 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 ❑ E 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? 0 ❑ 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) ❑ E Was the facility or dwelling inspected for signs of sewage backup? ® ❑ 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: 1 . Number of bedrooms(design): 4 Number of bedrooms (Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 454 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 ^M 182 °B" Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is Osterville Ma 02655 8/17/17 required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number f be o current residents: 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.) Laundrys ins . system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2016 = 55,000 gallons 2015 = 62,000 gallons Sump pump? ❑ Yes x❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpa) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - . .t ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 182 "B" Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is Osterville - Ma 02655 8/17/17 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General e aInformation Pumping Records: Source of information: Was system pumped as part of the inspection? I 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 "B" Acorn Drive' M Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) - Approximate age of all components, date installed (if known) and source of information: 1974 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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: 6 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 x❑ No Dimensions: - 1500 gallon Sludge depth: 3» t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 182 "B" Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is Osterville Ma 02655 8/17/17 required for every page. Cityrrown 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 1 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scurri.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 182 °B" Acorn Drive. Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gal-Ions 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•3113 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 ° 182 "B" Acorn Drive M Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 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 _ 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 no si n of backup or carryover. 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.): ' f e * 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 182 "B" Acorn Drive M Property Address Nicole&Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number:. x❑ leaching chambers �number: (6) 11x38x1 ❑ 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.): a Leaching was in dry and in working order at time-of inspection with no sign of 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•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 182 "B" Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: Dimensions , Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 182 "B" Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. Cityjown 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 Pt 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 0 -drawing attached separately A Q Psi - C1 ` z - A3= 2$ ' A�f= �-i, 13)= 24 f32= 31. 133, 37' l ( � 14_ 2.( '5 �r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 "B" Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 _ 8/17/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells t Estimated depth to high ground water: No GW @ 132" feet Please indicate all methods used to determine the high ground water elevation: x❑ Obtained from system design plans on record 2/1/14 If checked,date of design plan reviewed: Date 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Ilk Commonwealth of Massachusetts Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 "B" Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 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 3 . t I I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 182 Acorn Drive Property Address P Nicole & Christopher Jennings p 9 Owner Owner's Name X :x information is rg. required for every Osterville Ma 02655 8/17/17 01 page. City/Town State Zip Code Date of Inspection Yi>, 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. fmngoutf Important: A. General Informationfilling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification 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 ❑ Needs Further Evaluation by the Local Approving Authority % -, 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 �� V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. City/Town State> Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: t B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial,infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 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 ° 182 Acorn Drive qM Property Address Nicole& Christopher Jennings Owner Owner's Name information is Osterville x Ma 02655 8/17/17 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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): ❑ 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•3/13 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 GSM 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. Cityfrown 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 Tess 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 El ® 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 El ® . Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 182 Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma ' - 02655 8/17/17 page. CityFrown 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 ❑ ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 182 Acorn Drive Property Address Nicole& Christopher Jennings Owner , Owner's Name , information is required for every Osterville Ma 02655 8/17/17 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? I. ® ❑ 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): 4 Number of bedrooms (Actual) 1 DESIGN flow based on 310 CMR-15.203 (for example: 110 gpd x#of bedrooms):. 440 t5ins-3/13 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 ,M 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? - ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2016 = 55,000 gallons 2015 = 62,000 gallons Sump pump? ❑ Yes x❑ No current Last date of occupancy: Date Commercial/Industrial Flow Conditions:' Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial,waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 182 Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) t t Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system Single'cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract . ❑ Tight tank.Attach a copy of the DEP approval ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r. . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 182 Acorn Drive .,M n Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1974 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3. 2„ Depth below grade: feet 5 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.): . _ s Septic Tank (locate-on site'plan): Depth below grade: 2''2' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes x❑ No Dimensions: 1000 gallon 6» Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 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 30" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 6`k Distance from bottom of scum to bottom of outlet tee or baffle 13" 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 in need of pumping at this time and should be pumped every two years for maintenance. 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•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 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is Osterville Ma' 02655 8/17/17 required for every page. City/Town State 4 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 El metal ❑ fiberglass, ❑ polyethylene El other(explain): Dimensions: Capacity: gallons i Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: Alarm in working order: El 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•3/13 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 182 Acorn Drive M Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Cisterville Ma 02655 8/17/17 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): N/A Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): - * 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7M 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is Osterville Ma 02655 8/17/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: x❑ leaching pits number.: (1) 6x6 ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Water level was 5' below invert Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert ki 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,- Not for Voluntary Assessments °M 182 Acorn Drive Property Address Nicole& Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 " 8/17/17 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection form . +Subsurface.Sewage Disposal:System Form - Not for Voluntary Assessments . . 1'82 Acorn.Drive Property Address Nicole &Christopher Jennings Owner Owner's.Name information is required for euery Osterville Ma 02655 8/17/17 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-sk etch'..in the area+below drawing attached separately T(c r T �2-'f�. . ::2_ 38� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. CityTrown State Zip Code .Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells No GW @ 132" Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: x❑ Obtained from system design plans on record If checked, date of design plan reviewed: 2/1/14 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. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 'v Commonwealth of Massachusetts W Title 5 Official Inspection . Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 182 Acorn Drive Property Address Nicole & Christopher Jennings Owner Owner's Name information is required for every Osterville Ma 02655 8/17/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked x Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form'OPL.- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . I••w� 182 Acorn Drive Property Address Er Chris Jennings Owner Owner's Name fZ': information is required for every Osterville MA 02655 November 19, 2015 page. Cityrrown State Zip Code Date of Inspection y 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, 61 �f use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority December 4, 2015 Inspector's Signature 1 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. . US �.o t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Wgl7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is Osterville MA 02655 November 19, 2015 required for every page. Cityrrown 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: There are two systems on property. System inspected carries 1 bathroom and laundry only. Other system installed 2014 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. j Check the box for"yes", "no" or"not determined!X(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 yearsold* 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. i * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N [�ND (Explain below): t5ins-3113 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 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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 du_elto a broken, settled or uneven distribution box. System will pass inspection if(with approval of oard of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remov d ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box i leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): _ r The system required pumping more than 4 times a/ar due to broken or obstructedpipe(s). The ❑ Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced j/ ❑ Y ❑ N . ❑ ND (Explain below): ❑ obstruction is removed /r`� ❑ Y ❑ N ❑ ND (Explain below): l / z i C) Further Evaluation is R/equired 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .' 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November,19, 2015 -- — 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 thel 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 Ze SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: I / /alysis, This system passes if the well water a performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and -e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n( other failure criteria are triggered. A copy of the analysis must be attached to this form. # 3. Other: t i i II l D) System Failure Criteria Applicable to All Systems: i You must indicate"Yes" or"No"to each of the following for all inspections: i Yes No El ® Backup of sewage Tinto facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or pondng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in' the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow i t5ins•3113 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 z 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osteryille MA 02655 November 19, 2015 page. City/Town 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 q P P 9 Y 99 ❑ ® 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"y s" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit1iin 400 feet of a surface drinking water supply ❑ ❑ the system i within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syste , is located in a nitrogen sensitive area (Interim Wellhead Protection Areal PA) or a mapped Zone II of a public water supply well If you have answered"yes'jto 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Acorn Drive Property Address Chris Jennings _ Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 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 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins•3113 Title 5 Official Inspection Forth: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 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 6 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 Seasonal use? ❑ Yes ® No GPD 1= 67 Water meter readings, if available (last 2 years usage(gpd)): 2012014 167 GPD Detail Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203)/etc.): Gallons per day(gpd) Basis of design flow (seats/persons/sq., Grease trap present? . ❑ Yes ❑ No f Industrial waste holding tank pres/ent? ElYes ElNo Non-sanitary waste discharged othe Title 5 system? ❑ Yes ❑ No Water meter readings, if avp table: t5ins•3113 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 w 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owners records: Pumped 2012. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19 2015 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 01/25/1974. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2.5 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: 8.6' x 5' x 4.5' i Sludge depth: 3 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 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 32 Scum thickness V. Distance from top of scum to top of outlet tee or baffle 10 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions.determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Light solids present:. Root intrusion around outllet removed at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal /13 fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle�to rDistance from bottom of sc 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA_ 02655 November 19, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): 9 9 ( P P P ) ( P ) Depth below grade: Material of construction: ❑ concrete ❑ metal El/fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Capacity: ! gallons Design Flow: / gallons per day r Alarm present: �� ❑ Yes ❑ No Alarm level. J' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition df alarm and float switches, etc.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 - page. CitylTown 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 chambe , condition of pumps and appurtenances, etc.): * 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: W t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 - _ - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6' x 6' w stone ❑ 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.): 3" of liquid in leach pit at time of inspection. High water staining 4' below invert. Clean stone visible through sidewall with mirror. No sign of past hydraulic failure. Riser brings cover within 6" of grade. 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 j Depth of scum layer / Dimensions of cesspool i 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 Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 182 Acorn Drive Property Address Chris Jennings Owner Owner's Name information is required for every Osterville MA 02655 November 19, 2015 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids % Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 182 Acorn_Drive Property Address Chris Jennings Owner Owners Name information is required for every Osterville MA 02655 November 19, 2015 page. CityrFown 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 I v A ,� t5ins•3113 Title 5 Official Inspection Form:Sum Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts WwMTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 182 Acorn Drive _ Property Address Chris Jennings Owner Owner's Name information is required for every Osterville _MA 02655 November 19, 2015 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: >5 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: 11/05/2013 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: maps.massg is.state.ma.us/oliver.ph p You must describe how you established the high ground water elevation: Test hole for new system found no ground water @ 132" at gound elevation 5' below system inspected. Base of leach pit 9' below"upper" grade. 7' above depth of test hole. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•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 182 Acorn Drive _ Property Address Chris Jennings _ Owner Owner's Name information is required for every Osterville MA 02655 November 19 2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE OCATION �g Aron-i'Dr SEWAGE# �Lo t, VILLAGE i-e_ry il)e ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. I3 SEPTIC TANK CAPACITY I ®� a LEACHING FACILITY.(type) LC,(. (size) j 1 X 38 A NO.OF BEDROOMS 4 - OWNER PERMIT DATE: - I I - I`I COMPLIANCE DATE: j s I LI Separation Distance Between the: NON C e t-aCcX3rJ-vece) Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility CkN- pP4'C Feet Private Water Suprly Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Y� FURNISHED B �3 ��CC9inY� ® o ' o ` o sih s,rz--1 No. . D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpYitatiou for Misposar *pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i 62 V Owner's Name,Address,and Tel.No. c �eP4,11 e:1^V :� v�v avSS Assessor's Map/Parcel Akf2 W Installer's Name,A,d�dress,and Tel.No. Designer's Name,Address,and Tel.No. 1�c�J�lr 1�fO Jry TNe ,C6"N00--715-`! �nrs r z•e�✓inos (,,JC>'�L$ Type of Building: Dwelling No.of Bedrooms Lot Size /7,3YO sq.ft. Garbage Grinder( ) Other Type of Building hu,,)%r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) y 1-1t7 gpd Design flow provided ly 0i �- gpd Plan Date '2 1 1 i H Number of sheets 02- Revision Date T Title Size of Septic Tank J Type of S.Ay - , G s i-g}t>;e Description of Soil Gam,, n�.,nt VV c- //X•;3 X f t X 1,e4 T Nature of Repairs or Alterations(Answer when applicable) of o i' ,.r� c w e ��r e v-e \t c i �e -N-YL - 'c u ti f, . Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. e m Date :L Yl JE + Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued e�2 1/1 lb�-- No. �' Fee THE COMMONWEALTH OF MASSACHUSETTS ER etet red in computer: TO PUBLIC HEALTH. DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes j ,I application for Misposal *pstrm Construction Permit Application for a Permit to Construct(Repair(Upgrade( ).Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l 8�! f�co/nl I�f,.�P Owner's Name,Address,apd Tel.No. 0Si-Cfvc1)-t 6l ,d \5 J C-4 NSS Assessor's Map/Parcel Installer's Name,Address,and Tel.No. r r'Designer's Name,Address,and Tel.No. c�a�lc 5 A (G� l}ram a Nc Sc -yOCY7 3'�5 `NS ,N c c�r;.vS (�c�✓ IC S Type of Building: Dwelling No.of Bedrooms y Lot Size /7 35-0 sq.ft. Garbage Grinder( ) Other Type of Building In r,..ys r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) L)y() gpd Design flow provided y s6q, gpd Plan Date 2 / 1 N Number of sheets 7 Revision Date --r Title Size of Septic Tank /SOCK Type of S.A.f�' G Description of Soil G� N // )( 3 & )( Nature of Repairs or Alterations(Answer when applicable) t ' taDP. -6. Y -e Y' e C k n7C ©tee -Atit S C) LE'ceV Date last inspected: Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. gne q m Date 9- /1rl6 Application Approved by ,�L/ /� Date Application Disapproved by '� Date for the following reasons ,-- Permit N 10 Date Issued ---------- --------------------------------------------/---------- THE COMMONWEALTH OF MASSACHUSETTS . BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ►'� Upgraded( ) Abandoned( )bye<�� /a �,�v,<� at 7 A cC 11,J -0c ,<)-f /y, 1 has been cons cted'n a ce with the provisions of Title 5 and the for Disposal System Construction Permit No JVted Installer_ 0� [ SA 2&0ka,n1 T N C Designer 11v p rf 0 /1 #bedrooms Approved de ig�flow l H gpd The issuance of this permit shall not be onst d as a guarantee that the system i function as depg ed, 4 ' Date Inspector j ----------- --------------------'-'----------------------------------------------------------------------------- --------------------- No. � � Fee JI- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at 115 T A e r r w �1 f(y*p 0111 r 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. X. Provided:Construction must be completed within three years of the date of this permit. 12 / Date 1 i { 1 4) Approved by i 6/ f 02/19/2014 16:00 5084775313 ENGINEERING WORKS PAGE 01 Town Of Barnstable Regulatory Services Rie?hnrd V. Scali, Interim Director '$ Public Health Division c ' Thomas McKean,Director 200 Maijo Street,Hyannis,MA 02601 Of5ce: 508-862-4644 Fax: 508-790-6304 Installer & Designer_Certification Form Date: « � q Sewage Permit-4 • D 'D Assessor's MaptFas'eel Pape,,-Me.en+-e*- !ate Designer: Installer: �� « Address: d Z W. Cr,13; 4 ld 4 d Address: F-0- 1 on / r � &1,1. _ was issued a permit to iAstall a (date) (installer) septic system at 1 Z. A CA-7 1'fl- 0 r- d L4 based on a desip drawn by (address) dated (designer) l certify that the septic system, referenced above was installed substantially a6cording to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than. 1 G' lateral relocation of the SAS or any vertical relocation of my component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory, I certify that the system referenced above was constructed it compli ith the terms of the IIA.approval letters (if applicable) ydA1Hµ McPE7EEMg te. . . (Installer's Signature) CIVIL • ,� Mo.ss'1t89� A esigner's Signature) 7Kfflx Designer's PLEASE RETURN TO BARNSTABLE PUBLIC REALM DMSION, CERMICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH TI-US FORM All D AS= BUILT CARD ARE RECEIVED BY TEE BARNSTABLE PUBLIC IG3[EALTH DMSION. TEANR.YOU. Q:1SepticOesigner Cgexfioation Form Rev 8-14-13.doe , Town of Barnstable P# lime Department of Regulatory Services Public Health:Division Date 3 f6J9• 200 Main Street,Hyannis MA 02601 . 4 Date Scheduled Time i Fee Pd, 1' 0. 0d 4' Soil Suitabilio,Assessment fgr Se ge D spo; Performed By 4•l2✓ KC.q-,& f-e-e Q o � Witnessed By: LOCATION& GENERAL INFORMATION - L ocadon Address,*"fez GQ( • Owner's Name CI1r:s �► , S-kvwrt 9 Address Assessor's:Map/Parcel ( - (j I I Engineer's Name �� KC `Ke 'j NEW CONSTRUCTION ° REPAIR _ Telephone# SO U-7 3 Land Use. c �3-�71� Slopes(%) Surface Stones0''°'Q' Distances from: Open Wa4i'Body ED ft" Possible Wet Area:P L5P ft Drinking Water Weller�� ft . Drainage Way + ft , Property Line ft Other' 1 ft SKETCH:(street name,dimensions of lot,exact locations of test"holes&perc tests,locate wetlands in proximity to holes) ® � TGrvrtti 50 LV rn Parent material(geologic) y y Depth to Bedrock r"` K' Depth to Groundwater. Standing Water in Hole: N/ Weeping from Pit Foce Estimated Seasonal High Groundwater DETERMINATION FOR.SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.bole: _-• in. Depth to sail mottles: - in. Depth to weeping from side of obs.hole- in. Groundwater Adjustment ft. lndex.Weli#` Reading Date: Index Well level., _.� Ad,.factor Adj.Groundwater Level PERCOLATION TEST Date , Time Observation Hole# ( f Time at 9" _ Depth of Pere �J Time at 6" ., © �3 Start Pre-soak Time @ tO� 15me(9"-6") End Pre-soak Rate Min./Inch.' �' Z Site Suitability Assessment: Site Passed 0/ Site Failed: Additional Testing Needed(Y/N) i 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:VSEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole#=L_ Depth from Soil Horizon Soil Texture Soil Color Soil- Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones..Boulders.. _o ' v l o �� z F - 12-LF 5-3� �� LS 1� ✓L� B � C � 1`1S 25�14�E 1 zc�- z C2 l=LS Za Yr2,S DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders., . Consistency.% r v l0`C2��`z 2b -�3Z �2 =L S l0 aS/'J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. 0mvell i i _-_._ DEEP OBSERVATION HOLE LOG Hole# Depthlrom Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.8tones,'Boulders. Consistency Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500-year`boundary No-' Yes Within 100 year flood boundary No 'e- Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious exist in all areas observed throughoutthe area proposed for the soil absorption system? y If not,what is the depth of naturally occurring pervious material? Certification I certify that on �1 ( a-s (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CMR 15.017. Signature ^ Date Q.\SEpT-lCtPERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL OTECTION �t 2- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: Date of Inspection: (OS S C�—T` -�"7J Name of Inspector: le se print) Company Name: Mailing Address: A t Z(o 0 l Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience is the proper function and maintenance of on site sewage disposal systems,I am a DEP approved system inspector pursuant t Section 15340 of Title 5(310 CMR 13.000). The system; pursuant Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature* Date.. 06 The system inspector shall su9nv of this inspection report to the Approving Authority DEP)within 30 days of completing this inspection.If the system is a shared °ard of Health or Y system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments —�^ e 0- 1 c)13,a� ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z n 2 Owner: ` Date of Inspeetl ---Q� 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 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. CMR Comments: ` System Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced repaired system,upon completion of the replacement or repair,as approved by the Board of Health, pass. Answer yes,no or no termined(Y,N,ND)in the for the following statements.If"not de d"please explain. • i The septic tank is metal over 20 years old*or the septic tank(whether me 'or not)is strucbmWy unsound,exhibits substantial infiltra ' nor exfiltration or tank failure is immineattem will pass inspection if the existing tank is replaced with a compl septic tank as approved by the Bo of Health A metal septic tank will pass inspection t is structurally sound,not le." and if a Certificate of Compliance indicating that the tank is less than 20 years is available. j ND explain: i Observation of sewage back up kup or break out or bi static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or unev dis ution box.System will pass inspection if(with approval of Board of Health): , broken ' es)are replaced . obs on is removed S button box is leveled or replac ND explain: / The system re q ' d pumping more than 4 times a year due to broken or ob ted pipe(s).The system will pass inspection if(wi approval of the Board of Health): t broken pipe(s)are replaced obstruction is removed i ND explain: Ti+lo 4 inonsi.tin"v^rm An 4nnnn 2 r Page 3 of 11 N OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z lJi-yx Owner: - Date of Inspects -a. C. Further Evaluation is Required by the Board of Health: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to otect public health,safety or the environment. 1. System w ass unless Board of Health determines in accordance with 310 CMR 15303g)(b)that the system is not ctioning in a manner which win protect public health,safety and t7environme .� Cesspool or pri within 50 feet of a surface water Cesspool or privy. thin 50 feet of a bordering vegetated wetland or a salt marsh i Z. System will fail unless the Board of Health nd Public Water Supplier, y)determines that the system is functioning in a manner that protects th ubnc health,safety and environment: _ The system has a septic tank and soil absorption s m(SAS) 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 Zone 1 of a public water supply. _ The system has a septic tank and SAS and the S is within 50 of a private water supply well. The system has a septic tank and SAS and SAS is less than 100 feet 50 feet or more from a private water supply well**.Method used to termine distance **This system passes if the well water Ysis,performed at a DEP certified labors for coliform bacteria and volatile organic compo indicates that the well is free from pollution fro t facility and the presence of ammonia nitrogen d nitrate nitrogen is equal to or less than 5 ppm,providethat no other failure criteria are triggered.A c y of the analysis must be attached to this form. 3. Other: . , z Ti*is c Tnonor+inn Form 4/1 ci,)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z Aeprr. Owner: Date of Inspectl p D. System Failure Criteria applicable to all systems: You must indicate"Yes"or"no"to each of the following for al,_l 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 yr day flow R fps p Pumping more than 4 times in the last year NOLdue to clogged or obstructed pipe(s).Number _ ✓ 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 tnlmtary to a surface water supply. V/ 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!t the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system falls,I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails,The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must ate either`yes"or"no"to each of the following: (The following apply to large systems in addition to the criteria above) yes no — — the system is within 400 of a surface drinking water supply , — — the system is within 200 feet of a tr* u o a surface ' g water supply — the system is located in a nitrogen sensitive ....--(Trite ellhead Protection Area—1wPA)or a mapped,Zone II oft public water supply well If you have answered"yes"to any On in Section E the system is considered a signific threat,or answered "yes"in Section D above the a system has failed.The owner or operator of red a any large system conside significant threat under Sec on 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. T;*1& C Tnonorf;^"Rnrrn Ail;mnnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6M F Owner: USA - -DateofinspeidW Check if the following have been done.You must indicate"yesn or"no"as to each of the following: YSs 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 vohunes of water been introduced to the system recently or as part of this inspection? J _ Were as built plans of the system obtained and examined? they were not available note as N/A) rt� _ 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 Soll Absorption System(SAS)on the site has been determined based on: Ye no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] T;+Ia C Tnonartinn Rnrrn !/I cnnnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0Cv, Owners W A CA v� Date of Inspectio :'--j . FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 O Number of current residents: Does residence have a garbage grinder(yes or no):h 6 Is laundry on a separate sewage system(yes or no):LQQ (if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):t'W Water meter readings,if available(last 2 years usage(gpd)): N A Sump pump(yes or no): Last date ofoccuparcy: COMMERCIAL NDUSTRIAL establishment» Design flo Seed on 310 CMR 15.203): gpd Basis of design (seats(persons/sgi%etc.): Grease trap present(ye o):_ Industrial waste holding tank t(yes or no):_ Non-sanitary waste discharged to the systern �r Water meter readings,if available: Last date of occupancy/us • ��`1� OTHER(describe): Primping Records GENERAL INFORMATION Source of information: r 2� Was system pumped as part of the inspection(yes or no): 2� 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) _Tight tank —Attach a copy of the DEP approval Other(describe): 'e Approximate age of all components,date installed(if known)and source of information: � - 1 1 iR ��V•1 , Were sewage odors detected when arriving at the site(yes or no):VnD T41a IqTnonar/inn Fnrm 411 Q/MMA 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: VC6Z Owner: Dyk Date of Inspec BUILDING SEWER(locate on site plan) , r� Depth below grade: l 2 — 2-0 r� Materials of constriction:_cast iron Z40 PVC_other(explain): Distance from private water supply well or suction line: keo%,g r\ Comments(on condi •on of joints,venting,eviidpce of leakage,etc.)• c 12 Iry oV-C\.v O tC- NN SEPTIC TANK:j(locate on site plan) C o ry jet— �Q `e�,t S O C SSPool P Depth below grade: f.�� C e SSP o O Material of construction:_concrete metal_fiberglass_polyethylene S eC-{"t�O r N _o lain) If tank is age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ 1 Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet to e: Scum thickness: Distance from top of scum to t_T0outtnftee or battle: Distance from bottom of scum to bottom of outlet tee or bale: 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.): GREASE TRAP:_(locate on site plan) Depth be de:_ Material of cons lion:_concrete_metal_fiberglass_polyethylene _other (expo): Dimensions• Scum thickness: Distance from top of scum to top of outlet tee e: Distance from bottom of scum to bottom of o e; Date of last pumping: Comments(on pupqecommendations,inlet and outlet tee or ba8le con on„ tructural integrity,liquid levels as rela. utlet invert,evidence of leakage,etc.): Title i Tnannntinn Fnrm Ark ermnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f-Y-11 Owner:- Date of Inspectlo . TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dep low grade: Ma construction: concrete metal fiberglass_polyethylene Other(explain): Dimensions: - Capacity: gallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm' orldng order(yes or no): Date of last pumping: Comments(condition of alarm and flo switches,etc.): DISTRIBUTION BOX: (if resent must be o en i P P (1 on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distnbution to o ets equal, leakage into or out of box,etc.): evidence of solids carryover,any evidence of PUMP CHAMBER (lac on site plan) Pumps in working order s or no): Alarms in working Ord yes or no): Comments(note con " 'on of pump chamber,condition of pumps and appurtenances,etc.): i Title 4 inonontinn Rnrm A/1 i/)AAA 8 f Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z Ac Ofw �br_ Owner._ h ') ._ Date of Inspec o SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: leaching pits,number: 1 O C�O c. 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 o etc.)- l P Wig,damp soil,condition of vegetation, le I e CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: C p 11\Q tY A-V—.a Depth—top of liquid to inlet invert:- Depth of solids layer: Depth of scum layer. t/ 2 Dimensions of Cos Materials of conshuctiion: Az Indication of groundwater inflow(yes or no): � Comments(note co lion of soil,s' ion of hydraulic failure,level of ponding,condition of vege lion, o G� PRIVY: (locate on site plan) Materials onstruction: Dimensions: Depth of solids: Comments(note condition of soil,signs o failure,level of on ' P nditi n otation,etc.): ----------------- TiNs i Tnonartinn Fnrnn A/i;/innn 9 f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Cow f7. Owner. XAJr Date of Ins o 6 SXXTCH OF SEWAGE DISPOSAL SYSTEM . Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply ebters the budding. e-- a o 2' t—1 l' P)Z— t—{ 5 i In it Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: k c6 Z AC Owner: Date of Inspee SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water t Ot feet Please indicate(check)all methods used to determine the high ground water elevation Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain- Checked with local excavators,installers-(attsc4 documentation) Accessed USGS database-explain: S� - '�. 2, } 'Z��� C �} J. = - ,j Y m st descnbA how you established the high ground 1 water elev on: ` �J 0 r ` O 1^.e. © d rv. 0S k v` Q e- e g S 0 C9. ThIp It Tnoruwofinn T:nrrn 4/1 si-mnn 1 l v jUVIVLASSACHUsEws EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 - It OFFICIAL INSPECTION FORM—TITLE T FOR VOL ' .�. �; ! ASSESSMENT SUBSURFACE SEWAGE DISPOSAL iS STE FORMS PART A CERTIFICATION Property Address: O Owner's Name: L Owner's Address: 1 Date of Inspection: Name of Inspector: lease print) r Company Name: a Mailing Address: . Telephone Number: �(6 — S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and below is true,accurate and complete as of the time of the inspection.The that the information reported training and experience in the proper function and maintenanceinspection was performed based on my approved system inspector pursuant to Section 15340 o itle 3 3310 sewage disposal systems.I am a DEP CMR 13.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 2�— Date: 3 c) L 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 DEP.The original should be sent to the system owner and copies sent to the buyer,Sapplicable,and�approving of the authority. PP ving Notes and Comments i ****This report only describes conditions at the time of inspection and under the conditions of use at time. This inspection does not address how the system will perform in the future under the same that or that conditions of use. Title 5 Inspection Form 6/15/2000 page 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 A c orr\ D r Owner: Date of Inspecdo U (o 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: 4 ------------- System Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced or rePaued. ten; upon completion of the replacement or repair,as approved by the Board of Health,will p . Answer yes,no or not rmined(Y,N,ND)in the for the following explain. g statements. If"not de te please The septic tank is metal an er 20 years old*or the septic tank(whether me r not):e unsound,exhibits substantial infiltratio r exhiilttation or tank failure is ' ) structurally existing tank is replaced with a complying tic tank as approved by the B of Health, will pass inspection if the *A metal septic tank will pass inspection if it i tructurally sound,not indicating that the tank is less than 20 years old is vailable, g if a Certificate of Compliance ND explain: Observation of sewage backup or break o or high sta ' water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distributi box.System will approval of Board of Health): pass inspection if(with br en pipe(s)are replaced stzuction is removed distribution box is leveled or replaced ND explain: The system re fired pumping more than 4 times a year due to broken or obs pass inspection if th approval of the Board of Health): tructed,pipe(s), The system will broken pipe(s)are replaced obstruction is removed IND explain: Title IC incnantinn {7nrm�/1 Qnnnn 2 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: N— Owner: C*NDS I Date of Inspectl . C. Further Evaluation is Required by the Board of Health: 'tions exist which require fii then evaluation by the Board of Health in order to determine if the stem is failing to tect public health,safety or the environment. ys 1. System w ass unless Board of Health determines in accordance with 310 System Is not cdoning In a manner which will protect public heal C a 13303(1) that the th,safety and the a ronment: Cesspool or pn is within 50 feet of a surface water — Cesspool or privy' within 5o feet of a bordering vegetated g fated wetland or a h Z. System will fail unless the Board of ealth(and Publl ater Supplier,if any)determines that the system is functioning in a manner that pro is the pu c health,safety and environment: _ The system has a septic tank and soil ab on system(SAS)and the SAS is surface water supply or tributary to a surface a supply. within 1 feet of a _ The system has a septic tank and S and the SA is within a Zone 1 of a public water supply. _ The system has a septic tank d SAS and the SAS is 'thin 50 feet of a private water supply well. The system has a septic and SAS and the SAS is less 100 feet but 50 feet or more from a private water supply well4 .Method used to determine distance '''This system passes . the well water analysis,performed at a DEP c . ed laboratory,for coliform bacteria and volatile rganic compounds indicates that the well is free fro llution from that facility and the presence of nia nitrogen and nitrate nitrogen is equal to or less than failure criteria ar triggered.A copy of the analysis must be attached to this fo PPM6 Provided that no other 3. Other: Title C ine�nrfinn 17—!/1 evnnnn 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART A FORM CERTIFICATION(continued) Property Address: "L Owner: C t Date of Inspection: Q — D. System Failure Criteria applicable to all systems: You must indicate`Yes"or"no"to each of the following for ll inspections: Yes Nq _ �l Backup of sewage into facility or system co J Discharge or ponding of effluent to the surface component th due to overloaded or clogged SAS or cesspool / clogged SAS or cesspool ground or surface waters due to an overloaded or _V Static liquid level in the distribution box above outlet invert due to an overloaded erloaded or clogged SAS or L� depth cesspool is less than 6"below invert or available volume is , —�L pumping more than 4 times in the last year NO less dun A�Y now J of times pumped _ ,due to clogged or obstructed pipe(s).Number Any portion of the SAS,cesspool or privy is below hi ground water elevation. Any portion f cesspool or privy is within 100 feet of a surface water supply or tributary J water . Lary to a surface Any portion of a cesspool or privy is within a Zone 1 of a public well.j Any portion of a cesspool or privy is within 50 feet of a Any portion of a cesspool or Private water supply well. supply Privy is less than 100 feet but greater thaem Pn 50 feet liom a private water pp y well with no acceptable water quality analysis. Performed at a DEP certlfled laboratory,for coliform bacterIlkia as da s a if the water compoundsan Indicates that the well In free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria n r are triggered.A copy of the analysis must be attached to this form.l V (Yes/No)The system f�Mil .I have determined that one or described in310 CMP.15.303, therefore the system fails.more of the above failure criteria exist as Health to determine what will be necessary to correct the fade system owner should contact the Board of e. E. Large Systems: Tb considered a large system the system must serve a facility with a design flow of 10,000 d to 1 gpd. gP 5,000 You must cate either"yes"or ,no,,to each of the following: (The following teria apply to large systems in addition to the criteria above) Yes no — _ the system is wi 400 feet of a surface drinking water supply — — the system is within 200 fee a tributary to a surface drinking Watersuply — — the system is located in a nitrogen sense ' area(Irate d protection Area—IWpq Zone II of a public water supply well )or a mapped If you have answered"yes"to any questio�n ' ' eS"ction E the system is idered a significant"Yes"in Section D above the large system"has failed. The owner or o era or o gmficant threat,or answered significant threat under Section Khiled under Section D shall upgradeP large system considered a 15.304. The system owners d contact the a ro rate regional ofYice ofthee syD em ac ordance with 310 CMR appropriate epartment. Tills c r..o..o..r," c,.....4/1ci,)nnn 4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: v — nS C Date of InspeedG&J 0 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Y No _ Pumping information was provided by the owner,occupnrt,or Board of Heal th Were any of the system components pumped out in the previous two weeks? — —,f Has the system received normal flow s is the previous two week period? Have large volumes of water been introduced to the system recently or as art o _ P f this inspection? Were as built plans f the sy tem ob ed and a ed7(If they were not available note as N/A) �'�' i a� P an S�oc�.�e� _ Was the facility or dwellingL 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, of the baffles or tees,material of construction,dime ions,opened, and ufli interior of the tank inspected for the condition quid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information o maintenance of subsurface sewage disposal systems? n the proper The size and location of the Soll Absorption System(SAS)on the site has been determined based on: Yes no `( -- Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related'to Part C is at issue a r is unacceptable)[310 CMR 15.302(3)(b)] PP oxmnation of distance Title i Tncnnnlinn T:nrn l.�l annnn 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: L (' Owner: Date of Inspectloa: Ij p Cog FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-,3 Number of bedrooms(actual): DESIGN flow based on 310 CN515.203(for example: 110 gpd x#of bedrooms): 33 D Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):i7o [if yes separate inspection required)Laundry system inspected(yes or no)) O Seasonal use:(yes or no):_1K O Water meter readings,if available(last 2 years usage(gpd)): K) l sump Pump(yes or no): Last date of occupancy: "] [ ©S COM URCULRNDUSTRIAL establishment: Design flo on 310 CiVIR 15.203): Basis of design now(sea ons/sg8,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no . Non-sanitary waste discharged to the Title 5.syste yes or n Water meter readings,if availab er--''� Last date of occupant / OTSE scnbe): Pumping Records GENERAL INFORMATION Source of information: 11 1 Was system pumped as part of the inspection(yes or no): � If yes,volume pumped: gallons—How was uantity Pumped determined? Reason for pumping: \/� �n t (� ,�� '0 1/1f es S TYPE OF SYSTEM Septic tank,dtstpil sod absorption system _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes, attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(i o )and sour a of information: o Were sewage odors detected when arriving at the site(yes or no): h Title C Tnenovtinn T7nrn,4i:a,innn 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 fir\ Owner: C Date of Inspectio . in Q S BUILDING SEWER(locate on site plan)4 Depth below grade: I Materials of construction:—cast iron —40 PVC other(explain): C� Distance C_ from private water � t p ter supply well or suction line:�-t-jt�y� i Comments(o>� edition join ven ' evi e of at�,etc.): Q �o �S SEPTIC TANK:—(locate on site plan) Depth below grade: �� 1 Material of construction:v concrete metal_fiberglass_polyethylene If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):—(attach a co of certificate) PY Dimensions: 1< Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 1� ` 1 Distance from bottom of scum to bottom of outle tee or baffle: 11 How were dimensions determined: F-OnsInli-t Comments on ( pumping,ecommenofleake, and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence�leakage, etc.): e r- ------------- ASE TRAP:_(locate on site plan) w!� Depth below gra Material of construction:_ crete metal fiberglass__polyethylene_other (explain): — —. Dimensions: Scum thickness: _ Distance from top of scum o top of outlet tee or f Distance from bottom of scum to botto outlet tee or baffle: Date of last pumping: Comments(on pumpin commendations,inlet and outlet tee or baffle condition,s as related to outle ert,evidence of leakage, etc.): al integrity,liquid levels Tula C TnonaIII "'I'M A/1 C/lAnn OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ZCC Owner: 0 Date of Inspection: GHT or HOLDING TANK: (tank must be pumped at time of' mspection)(locate on site plan) Depth low grade: Material o onstruction: concrete metal fiberglass y _polyeth lens other(e"xplain): Dimensions: Capacity. allons Design Flow: allons/day Alarm present(yes or n : Alarm level: Al is working order(yes or no): Date of last pumping: Comments(condition of alarm float switches,etc.): i DISTRIBUTION BOX: / (if present must be ened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribufion to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): l "11 r' ------------- PUMP CHAMBER-i'! (locate on site plan) Pumps in worki4 order \ 8 (yes or no): \. Alarms in wofking order(yes or no): Comm e (note condition of pump chamber,condition of pumps and appurtenances,etc.): Taln i fnrnnrtinn �nrm A/1 ;/inAn 8 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: `�2 Owner: Date of Iuspec p' SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: leaching pits, 'number. t O O i� leaching chambers,number: L tt-'o 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 dra_ Y ulic failure leve e 1 of ponding, imp soil,condition of vegetation, , � ESSFOOLS• (cesspool must be pumped as part of'mspectionxlocate on site plan) Numb configuration: Depth—top quid to inlet invert: Depth of solids la Depth of scum layer. Dimensions of cesspool: Materials of construction: / Indication of groundwater inflow ea or no): Comments(note condition of soil,si of hydraulic failure,level of poridmg,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(n condition of soil,signs of hydraulic failure, level of ponding, dition of vegetation,etc.): Title i inonnntinn Tin'sn Fit v�nnn - .9 _ ._ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. ES CS Y Date of in-spectio fo SXETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply ehters the building. F , ICGNov4- coLp � rJ 36 3 V L vs �U 0 in OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A c o rn DC. Owner: O Y�$ o Date of Inspection• O SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water l7 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system Ys m design plans on record-If checked,date of design play reviewed: 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 O we (A c , Accessed USGS database-explain: 1 H Yo must describe ha\jow yoey-u established C1 hig6 ound w ter el vad V` Q �` , � a w - . w Title G'inonnMinn Form 411 si1nnn ]] TOWN OF BARNSTABLEi LOCATION / 0 &L SEWAGE # VILLAGE &Z/ ASSESSOR'S MAP & LOT -Ol! INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type). (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: o `f COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) \ Feet Furnished by 1 r \o� �' \ '� /® �� o i ... 'J 0 1 i - i THE COMMONWEALTH OF MASSACHUSETTS BOAR® O HEALT Appliratinn -for IN-4Vu.i al Works Tonstrnrtion Pumil Application is hereby made foTA Permit to Construct ( ) or,-Fepair ( } an Indi-id 1 Sewage Disposal System at: c i dress or Lot o.- Af Ow"e Address -- -----•- .... . �. '. ... . .............................. ......... . d....... ••.. . ... ................................................to er Address d Type of Buildigg/ - Size Lot............................Sq. feet U Dwelling—No. of Bedrooms../�7�_-__-_:� � ____Expansion Attic ( ) Garbage Grinder ( ) aq Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures ---------------------------------------------------- --------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length_______________ Width................ Diameter---------------- Depth------------ x Disposal Trench—No. .................... Width._.-_--___.._--_---- Total Length------------------.. Total leaching area-----:--------......sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area.......-----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed bY--------- --------------------------------------------------------------- Date........................... -------- -- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-_-----_-..-._-.----- �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit_.__ .......... Depth to ground water------------------------ P4 -----•-----------------------------------• --------- ------ 0 Description of Soil----------------------------------------------------x Pam- - - -}----------------------------------------------------------------------------------- U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable.-------------------------------------------------------_-.-_.-._--.---_.-...._----_--.------- ------------------------••------.-.-.--------- ---------------------------------------.--.--------------.-----------.------.-----.------------------. ------------•----.-------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sigd.. -- -- ------------------•----A-.......----------------------.....-- -------- ---------------- Dat Application Approved B l _ IP- PP PP Y yt- --� !°�.�__ .._�------ Application Disapproved for the following reasons:................................................................................................................. ..........................--------------------------------------------------------•---•-----•------••--•---•----•-•---------------•-----•------•------- ............................................... ate Permit No. Issued.._" G .... Date . 1 t 1• r a NO. .._ ----•--- Fwic t .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HSALT OF ,���slirtttiu�c��$>ar �i� rr�ttl >ar�� Cnla��tr�rti�� Pr��it �� Application is hereby made for Permit to Construct ( ) or. Repair ) an Indi id 1 Sewage Disposal System at c to dre s. or Lot o. ------ -----� ' w Address - = "= ----------------- ` I a er Address d Type of Buildi Size Lot............................Sq. feet U �-, Dwelling—N.o. of Bedrooms._.f��............... ...__.Expansion Attic ( ) garbage Grinder ( ) aq Other—Type of Building _:_' •----: No. of.-_.-_______ p --__ Showers ( ) — Cafeteria ( ) - - ersons------------------------ Q' r Other fixtures _ ------------------- WDesign Flow..............._____________________________gallons per person per day. Total daily flow.................... -_-_,__-•--•----.-_.-...gallons. W Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter.-.--_---.- --_ Depth---------------- xDisposal Trench.'No_______________•::_- Width-__--_-___-,_--_-_-- Total Length--_-_____--_--___-._ Total leaching area.-----_-_-_-..-___.-sq. ft. Seepage Pit No......:.............. Diameter..................... Depth below inlet..................... Total.leaching area------- ----------sq. ft. Z Other Distribution box ( , ) Dosing tank ( ) ~" Percolation -Test Results Performed b ____________________________________.............. _Date---___:•_-----_-__-_---..--._._-_------- Test Pit No. ---------------- per inch Depth of "Pest Pit.................... Depth to ground ,water...--_---_--_--.'_-_----- ;3; ! ,Test Pit No. 2................minutes per inch Deptbr of Test. Pit.___ ----------- Depth to ground water--.------__----__--._... O t F Description of Soil . --------------••,•-----------------------------------•------------------------ W Y '+ U Nature of Repairs or Alterations—Answer when applicable._-_--_. ___________------ _____________________________________________________________ ..�:-- Agreement: { The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ArficlepXI of the State`Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl}ance has�been issued by the:board of health. f Dat--------------- Application Approved B x .` a ate te Application Disapproved,f r the following reasons--------------------------------------.................................................-.......................... Date PermitNo......................................................... Issued... ............................ -------------------- Date rA 'THE COMMONWEALTH OF MASSACHUSETTS r' BOARD OF EALTH y OF............. .............................................................. TPrtifirtttP.of Tamphaurr THIS 1 0 &- hat theIndividu Sewage isposal yst m constructed ( ) or Repaired by "'` . « Jfinstaller at---•------t. �----- - -- - --------- - ---- ---- ---------- has been installed in accordance with the provisions of Article XI of he State Sanitary Cod as descr'bed in the application for.Disposal Works Construction Permit No.... ............ ................. dated.._:1 __ ._'�:._�'.. _..�..'�. .�--___- THE ISSUANCE OF,THIS 'CERTIFICATE SHALL NOT BE CONSTRUE® AS A G ARANTEE TZ, THE SYSTEM WILL FUNCTION•.SATISFACTORY.• DATE ----•----------•--=............................................. Inspector-----:............................................................................... THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD VVOEALTH .,, No..•�±t ----•----- FEE--- ..... r rti,aa VPrmit Permission ' her granted.."''. . ._ ;- -------------------------------------------------------•----......... I to Construct ( ) o p ' ). In t 'dual S age isposal tet;, J �I -:-----_ ---� -- at NO.-•'--� •- •-•- - '- ---�"Y--� -•--- [�'tR'�Y� "S reet as shown on the.application for Disposal Works Constfvcti6h"11P r it N ... .. . ___ Dated__' .------, ... � .___.... DATE. =- k•. . .--- I F 1 Board of Heal - FORM 1255 `R aas &,WARREN• INC.; PUBLISH'ERB, _.. •.• i t � A, Jq i s .3 7� � �/ /®� ". �� ti -� ,�..,�----. �� � ,, S-e�-��� 3 //3 J/7� ,� �\_ THE FOLLOWING IS/ARE THE BEST- IMAGES FROM POOR QUALITY ORIGINALS) I m DATA 9 A-A6TT BOY -4ri AFFAIRS SHMC SERVICE ICE x 7 0 ormawChWom wnt&96IMM rapt admat w ee Thm cm Co TM VaWWUM l9 MUE APVi ACCMMTR T4 THE e of mY XNOW Z ACGORbWG To UVWW John$&dW&n Trnx v(C.t JL 310,410M). Dennis MA 02M Nova Tms II�1S'EC1 QN ,AS P TSS T ANC!VA IL+ONLY,C iCl�;//���� � AND IS ZERO GUARAMU OF h'�P of TMS SYST M oR ANY CObO*M.NT oW THW SYSTEM DUM Moreed WOW a tw*.aectwrplo Kam&in the proper tunICUM and, StiGP�R } PA P oOh or IMMwrttnn thuty(30)degd at i#7sp ion for : John Sul/nre�t p.�V. be �, r,owrbr The er�ntt enowa�"ru eo'Ths 182 , COM-Rdd. OstffvillG MA 02655 1. PAS 6*.LOVHMW• 8M T A AR81lS• 2Ae�@d t revised' 9/2/98 Page tnttt t%mird nn PV4 Sl W Pear" COMMONWEALTH OF MASSACHUSETTS M r0 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �R DEPARTMENT OF ENVIIONMENTAL PROTECTION 'r a ONE WINTER STREET,BOSTON MA 02108 (617)292.5500 .1g99 CORE ARGEO PAIJL CELLUCCI DAVID B S Govertsor Cotntassraner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION Property address: 182 Acorn Rd. Ostenrille MA 02655 , creme of Owner John.Sullivan , Address of Owner: P.O. Box`932 Date of inspection: 2/19/1999 Dennis MA 02638 Nomeoflraspector:(PlaesePdritl PAUL B. LOTHROP " 1 am a DES approved to Section 15.340 of title 51310 CMR 1.5.000l company Name: AATTABOY EP 1 ERVICE Malting Address: P.O. A 02653 Telephone*xnber: C, 0—FE PON STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is trues accurate and complete as of the time of inspection The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage.disposal systems. The systern Passes _ CarrdrtionaUy _ Needs Fu Evel atio By the Local Approving Authority Fails hapector's Signature: Data: 2/19/1999 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)wrthrn 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 the report to the appropriate regional office of the Department ofEnvrronowntal Protection The original should be sent to'fhe system owner and copies sent to the buyer,it applicable,and the approving authority NOTES AND COMMENTS r revised 9/2/98, 1 of.7r "Ponied on RP(N(led Nov, - v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOl11 FORM PART A CERTMATiON{coirtfinued),, Property Address: 182 Acom Rd. Osterville owner: John Sullivan " Dace of uawmili n: 211911999 INSPECTION SUMMARY: A, B, C, or D A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described m 310 CMR'15 303 exist Any failure criteria not evaluated are indicated below COMMUM B. SYSTEM CONDMONALLY 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 Indicate yes°no, or not determined(Y,.N.or ND) Describe basis of determination in au 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 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 exfdtiation, or tank failure is imminent The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health n Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken,settled or uneven distribution box The system will pass inspection if(with approval of the Board of health) broiden pipets)are replaced obstruction is removed distribution box is levelled or replaced The system requrred pumping more than four times a year due to broken or obstructed pipets) The system will pass-- inspection if(with approval of the Board of Healtfil broken pipets)are replaced obstruction is removed c'`J:SEd y,c l CJ$ Pd: 'of ll i i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION(eantlnued) Property Address: 182 Acorn Rd. Oaterville Owner: John Sullivan Date of Inapmaw: 211911999 C. FURTHER EVALUATIM IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine of the system is failing to protect the „ public health,safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CUR 15.303(1)(b)THAT THE SYSTEM, IS NOT FUNCTIONING IN A MANNER WHICH]ALL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENIIABONMMT. Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh. r 2) SYSTEM WILL FAIL UNLESS THE.BOARD OF HEALTH(AND PUBLIC WATER SUPPUER„IF ANY)DETERMINES THAT THE SYST13A IS + FUNCTIONING N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and sod absorption system(SAS)and the SAS is within 100 feet of a su-face water supply or tributary to a surface water supply The system has a septic tank and sod absorption system and the SAS is within a Zone 1 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 onvate water suo*well The system has a septic tank and sod 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 equst to or less than 5 ppm Method used to determine distance _(approximation not valid). 3) OTHER S _ Y ' t revised. 9/2/98 Page 3of It 3 7 • u� 'a = a SUBSURFACE SEWAGE DISPOSAL SYSTEM!INSPECTION FORM PART A CERTIFICATION IcenWrrred) A ro; u l acorn Rd. Osterville J S Dm of btsvaedo r 2119/1999 D. SYSTE>ll1 FAILS: , You must indicate either"Yes"or"No" to each of the following I have determined that one or more of the following failure conditions exist as described in 310 CMR 16 303 The basis for this determination is identified below. The Board of Health should be contacted to detemmne what will be necessary to correct the failure Yes No Backup of sewage into faciUayer eyaterrr cerrrponent ehra Ito an overicsdeti or.dogged SA&or sess�ol. T 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 leas than 112 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pips(s) Number of times pumped Any portion of the Soil Absorption System.cesspool or privy is below the high groundwater elevation Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r Any portion of a cesspool or privy is withal a Zone 1 of a public well _ T Any portion of a cesspool or privy is within 60 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 orgaruccompounds.ammonia nitrogen and nitrate nitrogen E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above The system serves a facility with a design flow of 10,000 gpd or greater Marge System)and the system is a sign►ficant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply t the system-is-withm 200 feet 01-04 bula 14*4h awrfso&4Wnkra9•waW supply - —- - the system Is located in a nitrogen sensitive area.(Interim Wellhead Protection Area-1WPA)or a mapped Zone II of a:pubhc water supply wen) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 16.304(2) Please consult the local regional office of the Department for further information. revised 9/2/98 Nge4ofit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B CI*CKLIST PropeetV Address: 182 Acom Rd; Osferville Owner: John Sullivan Data of kopectian: 211911999 Check of the following have been done:You must indicate either"Yes`or"No"as to each of the following: Yes No X _ Pumping Information was provided by the owner,occupant,or Board of Dearth. X _ None of the system aaw#oaentrsbom&baanpumpadJw--aAJeasttwoweakaand'sbesystemhas+baeooacaiariagsomm)tow rates during that period. Large volumes of water have not been imrouuceo into the system recently or as par of this Inspection. X _ As built plans have been obtained and examined. Note if they are not available with NIA. X The facility or dwelling was inspected for signs of sewage back-up + X The system does not receive non-sanitary or industrial waste flow X _ The site was inspected for signs of breakout All system components,excluding the Sol Absorption System,have been located on,the arts. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or toes,material of construction,dimensions,depth of liquid,depth of sludge;depth of scum The site and location of the Soil Absorption System art the site has been determined based an* X Existing information.For example,Plan at 9.0 H _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.30243Hba) The facility owner Nand occupaats.if dtffataut from.owner)mere prareded with mfuonatiomon malawasi000.of SubSurface Disposal Systems. a. revised 9/2/98 Page sof11 , M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM`y ' PART C SYSTEM INFORMATION Property Address: 182 Acorn Rd Osterville 3 Owner: John Sullivan Data of brspeodw. 2/19/1999 n .r. s FLOW CONDITION Design H w:,430 _g.p.d./bedroom Number of bedrooms d gn):3 Number of bedrooms{actuall:3 1 ` Total DESIGN flow Number of current residents: 4 Garbage grinder Ives or no).No " F. Laundry iseparate system) (yes or no):No If yes,separatelupection required €, - Laundry system inspected (yes or no) Seasonal use(yes or no)IMO Water meter readings.if�llabte(last two year's usage(gpol: ��a �_�5,t7t7[i 0,/S•• !d 1�7iQdt7,t Q/Si Sump Pump(yes or no). NO q' Lost data of occupancy.,presentfy COtlliNltSNC#AL/INDUSTRWI: NA . w Type of estabushmemt. y x Design flow: gad (Based on 15 2031 " Basis of design flaw Grease trap present.(yes or no) _ s r> Industrial Waste Hoidmg Tank present.(yes or not Non-sanrtary waste discharged to the Tittle 5 system.ayes or no)__ o ° Water meter readings,if evadable Last date of occupancy. OTHER:(Describe) r Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and source of information _ go-Wool egmpa#in 1991 b System oumaed as mart of gctron:iyes of no} es, er• y R If yes,volume pumped: � wU gallons Reason for pumping ad 1anc r OF SYSTEM f - a! • s �. Septic tankldFstrnbutpon box/sod absorption system' -•�-^- Single cesspool * « 'Al' ° 4 Overflow cesspool Privy Shared system(yes or no) 1d yes,attach previous inspection records,if any)F IIA Technology etc.Attach copy of up to date operation and maintenance contract ,` a� "• Tight Tank Copy of DEp Approval �' r• Other APPRO)UMATE AGE of all components,date instaW0 krwwn)•wid source oCWarrnabon: °• 1972-Owner $swap odors detected when arriving at the site. #yes or ono)No r v a n revised 9/2/98 Pygeeef11 f 4 = SUBSURFACE SEWAGE DISPOSAL SYSTENW INSPECTION FORK n PART C SYSTEM IIfORMAT1ON(catOmedl Proper" • 182 Acorn Rd. OstervNie owtror: John SuUhran ' Data of 2119/1999 BUILDENG SEWOL X (Locate on site plant Depth below grade: 1 r Material of conslF+ction: cast iron X 40 PVC other lexpta►n) c;3es pool'cast iron Sep c Tank-PVC Distance from private water supply well or suction line + Diameter 4 Comma in`-No e0denc Of leakage►No pMAIAM SEPTIC YANK:_ 1occate on site plant Depth below grade: Material of construction.Xconcrete_metal^FFbergless _,,,_Polyethylene_other(expiam) H tank is tnetal,hst age— 1s age confirmed by Certificate of Compliance (YesfNo) Dimensions: 8r6e X 4r 1 0"X 6r 7e i- Sludge depth:_ ` Distance from top of sludge to bottom of outlet tee or baffle 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 How dimensions were determined Physical measurement Comments: - (recommendation for pumping.condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet evert,structurel-integnty, evidence of leak s,etc.) No Both NaWs no ace- o hiah w ei s Jns. ump or main en nc o ro ems GREASE TRAP: (locate on site plan) Depth below grade,_ Material-of construction _concrete_metal—Fiberglass _Polyethylene_,,,-othertexplam). 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: (recottmtendetion for pumping,condmon of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural mtegnty, evidence of leakage,etc,) revised 9/2'/98 Page 7ofit f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Owner- lod SuN2 A om Rd. Osferville Date of Inspection: 2/1911999 n 5 TIGHT OR HOLDING TANK: NA ITank must be pumped prior to,or at time of, inspection? (locate on site plan) Depth below grade Material of construction-_concrete metal Tribergless_Polyethylene—other(explain) Dimensions: - --- - Capacity: gahons Design fl(W gallons/day Alarm present Alarm level Alarm in working order.Yes Na Date of previous pumping: Comments. (condrmon of inlet tee,condition of alarm and float switches,etc.) 0181RBiumpi Box:yA loocate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distnbution is equal,evidenee of solids carryover,evidence of leakage into or.out of box,etc PUMP CHAMBER:NA (locate on site plan) Pumps in working order-(Yes or No) Alarms in working order(Yes or Nod Comments t (note condition of pump chamber,conddwn of pumps and appurtenances,etc) e revised 9/2/98 PaRexortl , • e 1. .. .. SUBSURFACE SEWAGE IMSPOSAL SYSTEM WSPECTKIN FORM PART C SYSTEM gNFORMATION fcorrtirMd) Property Address: 182 Acom Rd. Osterville owner: John Sullivan Data of brapecom: 2/19/1999 SOIL ABSORPTION SYSTEM ISAS):X (locate on she plan,if Possible,excavation not required,location may be approximated by non-intrusive methods)`- If not located,explain, Type: leaching pits,number:-I,-6'X 6-Precast leaching chambers,number._ ` leaching galleries,number._ leaching trenches,number,length. leaching fields,number.dimensions-VIU1X-12'(assumed) overflow cesspool,number; Alternative system Name of Technology: Comments: (n c p s fins of d c failur le of ondl dam ruflLo f vegata o °�eae chi p - g wah s`°�ains�0 7 elow verb o m�e rover rho>allure criteria at this time LeaUft MONormal IN and vege ffin- o si-ansor preakout-Ird acn ina►- o aboare aro ems CESSPOOLS _ (locate on 9 r plan) , Number and configuration 1 ' Depth-top of liquid to inlet invert: ^ Depth of solids layer: 1 Depth of scum layer:__,_ ' Dimensions of cesspool X Materials of construction. Indication of groundwater. A ; inflow(cesspool must be pumped as part of inspection) None Comments: mote not as of hydraulic falure,level of pending,condition ef.v otat�on etc.► Quite ' ngplace-No high watersta�ns^Pum ed form ow check and maintenances o apparen pro ems PRIVY:NA (locate an site plan) Mategals of construction Dimensions. Depth of solids. Comments. (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) { revised 9/2/98 Iav9oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION±FORM PART C SYSTEM INFORMATION(continued) Properttr Address: 182 Acorn Rd. Osterville owns.: John Sullivan Dace of Iopectiarr: 2/19/1999 SKETCH 0t SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into houses 10' x 1 2' L{Field Not to Scale 1000 Got 6 Septic 3 Tank 2.5 6' x 6' L{Pit t _. • is .. �rl 182•Acorn Rd. Gstervill 6' x 6' ,Gesspoo 4 ' Front Town Water. fi _�V1SEd 7.i t y8 l'ey; m .itb ` , SUBSURFACE SEWAGE DISPOSAL SYSTEM NISPECTION FORM PART C SYSTEM N FORMATION(oorrlinuadl Property Adarm;182 Acorn Rd. 4sterville owner John Sullivan Date of lnspecom 211911999 MRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep T SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet+ &010u) h0110,'n Oj' /-/P/r Please indicate all the methods used to determine High Groundwater Elevation _Obtained from Design Plans on record Observed Site(Abutting property,observation hole.basement sump etc l Determined from local cone tons Checked with local Board of health Checked FEMA Maps Checked pumping records _Checked local excavators,installers Used USGS Data 4. Describe how you established the High Groundwater Elevation (ftw be completed) Cape Cod Commission Water Resources Office Tech Bulletin 92-001 Plate#2 , - - r revised 9/2/98 Page liofil f ' / Commonwealth of Mossocnusetts Executive Office of ErnArorvnentCal Affa*s Protection A,Y o f , Wfi mW d t!! TOWN OLT as ., t1EAiTij Davkolhs ' SUBSURFACE SEWAGE DISPOSAL SYSTEM/INSPECTION FORM � z PART A VkUe" arnFICATION 182 Acorn Osterville MA 02655 John Sullivan Property spectio 5H4/1997 rrAddress of Owner. P.O. Box 932 Date of Inspection. Name of Inspector. PAUL B. LOTHROP (If dtfEereml Dennis, MA 02638 Company Name,Address and Telephone Number: 1-508-385-3333 AATTABOY SEPTIC SERVICE P.O. BOX 738 ORLEANS MA 02653 1-508-240-0522 CERTIFI!",ATIOt j UAiEMENT I certity that I have personalty 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 maintenance of on-site sewage disposal systems. The system: X Passes Conditionally Passes _„_ Needs Further Evaluation By the local Approving Authority Inspector's Signa Dates 5/14/1997 1500hrs. ZERO PROBLEMS The System Inspector shall submit a -bf 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 the report to the appropriate regional office of the Department of Environmental Protection. The originai should be sent to me s}•stem owner and copse: sent to the buyer, if applicable and the approving authority. I INSPECTION SUMMARY: Check A. B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR IS.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. .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.cracked, structurally unsound, shows substantial infiltration or"Itration, 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. trevised VIS/9s) t One Winter Sbam s Boston,Massachusetts 02108 • FAX(617)55&lo4g • Telophone(617)2112-4 00 Prow an Reviod d Payer IIL f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- 182 Acorn 02655 Owner John Sullivan Date of lnspeetlon: 511411997 i 83 SYSTEM CONDITIONALLY PASSES (continued) , 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 pus inspection if(with approval of the Board of Health): broken pipets)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 ClFURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: a '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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS 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 5o feet of a bordering vegetated wetland or a salt marsh. 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The sv$tern has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has aseptic tank and soil absorption system and is within a Zone t of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 pprn- Dj SYSTEM FAILS- 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 detemtine what will be necessary to corma the failure. Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due m an overloaded or clogged SAS or cesspool. • I traviaed 8l15/95) 2 i a .. L`... s .. SUBSURFACE SEWAGE DISPOSAL S INSPECTION FORM O SYSTEM PART A CERTIFICATION (continued) Property Address: 182 Acorn 02655 Owner: John Sullivan Date of Inspection: 511411997 D)SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. .,. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.' Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coiiform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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 0WPA).or a mapped Zone 11 of a public water supply well) 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. (revised 3/16/9S) 3 SLIBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST : Property Address: 182 Acorn 02655 T, owner. John Sullivan a Date of Inspection: 511411997 Check if the following have been done: = X Pumping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at r least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced '+nto'the system recently or as part of this inspection" X As built plans have been obtained and examined., Note if they are not available with WA. Done at Inspection The facility or dwelling was inspected for signs of,sewage back-up. X The system does not receive non-sanitary or industrial waste flow • X The site was inspected for signs of breakout X All system components,41cluding the Soil Absorption System, have been located on the site NAThe 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. t X The size and location of the Soil Absorption System on the site has been determined' X The facility owner(and occupants, if different fro:r:o4iner) were provided with information on the proper maintenance of Sutr:' Surface Disposal System. tre+rieed B/i5/95) 4 ; : 2. s it �', • ... t a '. ' np�. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addresst 182 Acorn 02655 Owner: John Sullivan Date of Inspection: 611411997 FLOW CONDITIONS RESIDENTIAL: Design Flaw. 330 gallons Number of bedrooms:3 Number of current residents:0 Garbage grinder(yes or no):V0_ Laundry connected to system(yes or no):TeS Seasonal use(yes or no): NO Water meter readings, if available: NA at time of inspection Last date of occupancy:Fall 96 - COMMERCIAL/INDUSTRIAL Type of establishment: NA Design flow:�ga(lons/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: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on File System pumped as part of inspection: (yes or no)eS if yes,volume pumped: 300 lions ' Reason for pumping: „I►low"check TYPE OF SYSTEM Septic tank/distribution boxtsoil absorption system Single cesspool �^ Overflow cesspool Pry Shared system(yes or no) Cif yes,Bch previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: 1972-owner Sewage odors detected when arriving at the site: (yes or no) NO (revised 8I3.5/95) , y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 182 Acorn 02655 Owner: John Sullivan Date of Inspection: 511411997 sEPTIC TANL-NA (locate on site plan) Depth below grade Material of construction:_concrete`metal _FRP cther(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thidtness Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert;structural integrity, evidence of leakage, etc.) GREASE TRAP:NA (locate on site plant Depth below grade. Material of construction: _concrete metal _FRP other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of ar•tim in bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) trevined a/1S/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION (continued) Property Address: 182 Acorn 02655 Owner. John Sullivan Date of Inspection: 5/14/1997 TIGHT OR HOLDING TANK:NA (locate on site plan) Depth below grade: Material of construction: concrete_metal_FRP--other(explain) Dimensions: Capacity: gallons Design flow: gallonstday Alarm level.- Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION Box-.AA + (locate on site plan) r Depth of liquid level above outlet invert: Comments: (note ii level and distribution is equal, w.idence of solids carryover, evidence of leakage into or out of box,'etc.) PUMP CHAMBER: NA , (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc) (revised 8/7.5/9S; * 7 t. i MA SURFACE SMACE DIWVSAiL SY$'MS INSP£C"ON F`CMVW (PART C SVSMM INFORMATION (contimmA p ��e�, 182 Acorn 02655 JOAl1 Jullivan Date of Ir+spectiont 511411997 WI1 MSOWTION SVSTEM(14%.X (locate on site plan, if possible, excavation not required,but may be apprcxinm ted by non4ntrusive methods) if not determined to be present,explain: Type: Wching pits.number:1 leaching chambers, number._ , leaching galleries,number. leaching trenches, number,length:_ ?eac hing fields,number, dimensions: overflow cesspool, number. Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc)_. M'forecast concrete- 1',j jM din&water- 1'Sludge datft-IVcrm � ZERO EMjRLEAllS;7FRQ Ujah 4f/abar C497nr CI pooiLS: X _ (locate on site plan) Number and configuration: 1 Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer 0r Dimensions of cesspool:8 - I ` Materials of construction: concift indication of groundwater: None inflow(cesspool must be pumped as part of inspection) Done 511411997 Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) Norma!"T"in Place»Z Q P&OBLEIIdS pow. NA (locate on site plan) Materials of consouction: Dintertsions Depth of sollcL Comments: boots condition of soil,signs of hydmuile failure, level of ponding t5wrdltion of vegetation.W—) ttavieod Bl1S/95i 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) piny Address: 182 Acorn 02655 Owner: John Sullivan Date of hapearor 511411997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent refer n landmarks or benchmarks locate all wells within 1W 182 Acorn Fron# N West Side Not To Scale. oOl Town Water 41 dry' 6'A6' - + /10 It C/Poo1. i; . 6'W6" "Pit DEPTH TO GROUNDWATER - Depth to paundwater: 15 feet method of determination or approximation: Cape Cod Commission Water Resources Office izvViaed 8/15/95) 9 I o ' ''. L/ Rf t C E N , AATT�►J SOS MAR SEPTIC SEAVICE . >nwwoFB 5''199I DESIGN• INSTALLATION a PUMPING•D.E.P.1NSPECTIONS• DIAGNOSIS• rA ATIO('�RIN"ftrvtE Brswttor,Chatham D•e�nl�.Es.them.11•rwlah,Opt me,W�Illl�et Truro . on RFEZ'Q�lc "C DISCLAIMER: .ON FORM THIS INSPECTION IS TRUE AND ACCURATE TO THE ,• �uu BEST:OF MY KNOWLEDGE ACCORDING TO REVISED r `� TITLE V(C.M.R. 310, 4/01/S5): vyvpi HOWEVER, THIS INSPECTION IS AS OF THIS TIME he information reported`Bei w is�true, accurate AND DATE, ONLY, ((, 'r � � �""" )� ring and experience-in the proper functiat and 71 AND IS ZERO GUARANTEE OF FUTURE PERFORMANCE OF THIS SYSTEM OR ANY COMPONENTS OF THIS SYSTEM: r SIGNED / � � within thirty (30) days of completing this. e inspector and the system owner shall submit nd the approving authprity, PAUL B. LOTHROP 3 op C / failure criteria as defined in 310 CMR 15.303. PAUL S. LOTHROP • BOX 738,OR LEANS, MA 02663 240.0522 ; patrea. ine system, upon completion of the neplacernent or repair, passes inspection. r indicate yes, no, or not determined tV, N, or NO).' Describe basis of determination in all instances. if"not determined", explain why.notl The septic tank is metal, cracked,, structurally unsound, shows substantial infiltration or exfiltration,, or tank failure is imminent. The system will pass Wpection if the.existing septic tank is replaced with a conforming septic'tank as approved by the Board of Health. trevised 8115/951 t - Cne 1Mnter Street • I94aton,,101assaohusetts 02108 • PAX(617)W&1049 e . Tilophone(817)292-SM `' ►IMAW m RaryeMd IRoa► I Y : commonwealth of Massachusetts . Executive office of Environmental Affairs Department of �.(�• ��I Environmental Prtotection •nt a TrYdy Cox Y 89atMetY.EOEJI Do d e.ftha SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM • � '} O PART A -�`-> CERTIFICATION Property Address: Address of Owner: Date of Inspection: 0a�P�, (If different) Name of Inspector: �P Compa y e Ad e o e VYA IRTIFI So t 7 1� > I certify that I have personally inspected the sewage disposal system at this address and that the information reported B I w is true, accurate and complete as of the time of inspection. The inspection was performed based'on my training and experience in the properfunction and maintenance of on-site sewage disposal systems. The system: a`-.mosses _ Conditionally Passes Needs Further Evaluation By-the Local Approving Authority _ Fails Inspector's Signature:' Date: "4 The System Inspector shall submit a copy of this insp. to_the Approving Authority within thirty (30) days of a mpleting 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 shah submit the report to the appropriate regional office of the Department.of Environmental Protection. The onginal,shouid be sent to :ne system owner and coptea sent to the buyer, if applicable and the approving,authority. INSPECT SUMMARY:' Che A, , C,or D: Aj SYSTEM SES: _ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR15.303. Any failure criteria not evaluated are indicated below: _ Bi SYSTEM CONDITIONALLY PASSES:' One or system components need to be replaced or repaired. The system, upon completion of the replacement or repair, . passes inspection. Indicate ,yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If not determined", explain why note _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration-or exfiitration, 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 e/1S/95) One Winter Street • 'Boston, Messaahusetts 02108 • W(617)MG-1048 . Tolephone(817)282 3300 40 Punted on Reyckd Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PAR7.A , aRTIFICATION (continued) Property dress: a 0 p�. f`1 toQ_v ( (D(R(es� Owner. t ' Date of I ct`1i no �r"En.v\J 81 SYSTEM CONDITIONALLY.PASSES (continued) 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 Board of Health): 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 Cl-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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH-DETERMINES THAT THE SYSTEM IS 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, 1F APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN.A MANNER THAT PROTECT'THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within,100 feet to a surface water supply or tributary i0 a surface water supply. The systeni has a septic tank.and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50,feet of a private water supply well. The system has'a septic tank and soil absorption system and, 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 fens than 5 PP.m• DI SYSTEM FAILS: 1 have determined that the system violates one or more of the following failure criteria as defined-in 310 CMR 15.303. The basis for determination is identified below. The Board of Health should be contacted to determine what will be necessary to con+eu the failure. _ 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 dogged SAS or cesspool. ( w / /9 ) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A pCERTIFICATION (continued) Property dress. Owner:. - Date of 1 ect on: 01 SYSTEM FAILS(contrnu Static liquid level in,the distribution box above outlet invert due to an overloaded or.clogged SAS or cesspool: Liquid depth in cesspool is less than 6" below invert-or available volume is less.than 1/1 day now. 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. _ . Any portion of.a 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 I of a public well. Any portion of a cesspool or privy is within"SO.feet of a private water supply well.- Any-portion of a cesspool or privy is less than 100 feet but greater than SO 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. El LARGE SYSTEM FAILS: . The following criteria apply to large systems in addition to the criteria above: The design flow of system is-10,000 gpd ovgreater (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: 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 wells 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 S.00 and.6.00. Please consult the local regional office of the Department for further information. lrevised 8/16/95) $ _ r , SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART B CHECKLIST Property Wdr 8 oac�s5 Owner. Date of I elZon: Check if the following have,been done: roping information was requested of t e owner occupant, and Board of.Health. L N o the system components have been pumped for at least two weeks and the system has been receiving normal flow rises f_%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. / facility or dwelling was inspected for signs of sewage back-up. _ e system does not receive non=sanitary or-industrial waste flow , y�te-Stt�was•inspected for signs of breakout:. system components, uding the Soil Absorption System, have been located on the site. eptic 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. he size and location of the Soil Absorption System on the site has been-determined based on existing information or approximated b no methods. e facil.it, oti+ner t nd occupants, if different.from-owner;-were provided with information on the proper maintenance of Sub- Surface Di yysem. • 1 . F • ` III ftevi�ed AI15/951" 4. i J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Ad ess: v Owner: - , Date of Insp c ion FLOW CONDITIONS HEM Design flow; a ns Number of bedrooms:' Number of cuirent residents:_ Garbage grinder(yes or no):,�� c / Laundry connected to system ( es or no): Seasonal use (yes or no): Water meter readings, if available: ' �1/•tom— � "" -1�.�3 P/ rg Last date of occupancy: l COMMERCIAUINDUSTRIAL: Type of establishment: Design how:_„_,Sallons/day Grease trap,present: (yes or no)_ Industrial Waste Holding Tank present ( es o Non-sanitary waste discharged to the itl sys em: (yes or no)_. Water meter readings, if available: ' .Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source.of information: System pumped as pan of inspection: (yes or no) 'If yes, volume pumped: Sallonc r Reason for pumping: TYPE OF SY ptic tan i-x/soil absorption system. Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspec don retards, if any) ,Other(explain) r , APPROXIMATE AGE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) {rsviisd 8/2S/451 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO TION (cotttfnued) " Property Address:. L COR4� Owner. Date of Inspection; INJ SEPTIC TANK:_ (locate on site plan) . Depth below grade:_ Material of construction: rate_,metal^,FRP­other(explain) t t Dimensions: Sludge depth: Distance from to ofu ge to bottom of outlet tee or ' baffle /.� Scum thickness: - Distance from top of scum to top of outlet tee or baffle: r �� Distance from bottom of scum.to bottom of outlet tee or baffle:- Comments: (recommendation for pumping, condition of inlet Ed outl or baft dent f liq t ri evidence f eaka , etc.) tn GREASE TRAP:_ (locate on site plan) Depth below grade: material of constructs ncre ._metal _FRP._other(explain) Dimensions: Scum thickness. ` Distance from:too of scum to top of outlet tee.or baffle: Distance from bottom ni lcum tn bottom-of outlet ter or baffle Comments; (recommendation for pumping, condition of inlet and outlet tees'or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc. (revised 0/15/95) , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C rSYSTEM INFORMATION (continued) n Property.Address: 61z 1—1 Owner: Date of In eetion• TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _,co Wcremetal:_FRP other(explain) Dimensions: Capacity: gallons Design flow: Aallons/day Alarm level Comments: .(condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution.is equal, e%idence of solids carq-off. evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments:. (note condition of,pump chamber, condition of pumps and appurtenances, etc.) (revised 8/iS/951 M , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - //''��,�pp SYSTEM INFORMATION (continued) Property Address:- Owner.' Date of In on: 'V SOIL ABSORPTION SYSTEM us) (locate on site plan, if possible; t required, but may be approximated by non-intrusive methods) If not determined to be.present, explain: Type: leaching pits, number: leaching chambers, number,. leaching galleries, number.`_ leaching trenches, number,length: t leaching fields, number, dimensions o-�,4, I'a C—Assuif%C-6) overflow cesspool, number omments• (note on �of �in3�hyd l iriailu 'level of p n corVilition of veffetatio tc CESSPOOLS: (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: Material's of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments:, (riote 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,) (revised 8/13/9S) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR14Ui►T) N (continseerl) , Property Address: �r Owner: Date of Inspectlan: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two locate all wells within 100' I pxrmanent references landmarks or benchmarks,- RD DEPTH,TO GROUNDWATER r Depth to groundwater: 4 fact methal of determination or r'xlrttatl l r -- L -- r irevi��d 6/23/9s1 � ,*�^� .'t�'i 'TOWN OF BARNSTABLE BI�IR=W 0 dinance or Regulation ARMING NOTICE . Name of Offender/Manager T- � ,��1All ' 1 Address of Offender MV/MB Reg,.I V Village/State/Zip . � Business Name am/pm, on, _19 Business Address ..Signature of Enforcing Officer Village/State/Zip' Location .of Offense l. r _ 6�.. (3 _ , Enforcing Dept/Division Offense Facts This will .serve only as a warning. At this time no legal action has been taken. It is the goal: of .Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices 'are attempts to gain voluntary compliance. Subsequent violations will result .in appropriate legal action by the Town. -:`�`^v;m�i.w•-�, i[RSr-^?r+.�rt ri sF-`(v x ly :�9 ,y.1 @x�.��' L `�` �t�r`;tlj`rtro �'� v ':fr`r 7 ��• �, }t it 4'•afi {'tx q'��x' t t�'.._„_ �f s�2 y'%i TOWN :'OF BARNSTABLE BAR-W" . Ordinance..or;Regulation 'WARNING NOTICE t , Name of Offender./Manager Address of..Offender ; .. .. t n►` I\ ! MV/.MB Re,g # �^ v Village/State/Zip 41 A m Sr' 77 Business Name , e _am/pm, on FQ 19 Business Address Signature of Enforcing Officer Village/State/Zip Location Hof '.Of fensef,, Enforcing Dept/Division Offense Facts 01 This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. TOWN OFF BARN STABLE 4'` BAR-W & _ _.-�. Ordinance- or Regulation WARNING NOTICE Name of Of fender/Manager, y, t. 7 x V,r "" Address of Offender -,., `; , , ��,; MV/MB Reg.# / ~ Village/State/Zip � . rw. i ' r" V� Business Name � ,,"� Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense 1 kfe s It ✓ Enforcing Dept/Division Offense /t k k -ft0 4t 4 , 101M Facts i This will serve only as a warning. At this .:time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance: Subsequent violations will result in appropriate legal action by the Town. ` ..2 548 659 921- Receipt for Certified Mail No Insurance Coverage Provided � A Do not use for International Mail POSTAL SEERVEICE (See Reverse) CO Sent q 0) r t Slr o. R al P. t to and ZIP Cphe O 0 Postage Go E Certified Fee O � LL Special Delivery Pee ea f I. IRestrictedlDelivetyrFee C rReturnMeceipnShowing 1 to Whom&Date Delivere IL / Return Receipt Show' Q o Date,and Address 's ass TOTAL Postage &Fees Postmark or Da .—� CO) 22 J b14 STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier(no extra charge). f 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return V) address of the article,date,detach and retain the receipt,and mail the article. r 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. O O 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, �; endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If ti return receipt is requested,check the applicable blocks in item 1 of Form 3811. 6. Save this receipt and present it if you make inquiry. 105603.93-B-0218 ai SENDER: I also wish to receive the v ■Complete items 1 and/or 2 for additional services. w ■Complete items 3,4a,and 4b. following services(for an d ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address 2 d permit. y ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N t ■The Return Receipt will show to whom the article was delivered and the date .. delivered. Consult postmaster for fee. 0 3. 'cle ddressed to: , 4a.Article Number E CL E 4b.Service Type 0 /%G '7Jo7—, ❑ Registered IN Certified N ❑ Express Mail ❑ Insured c I 0I ¢ � ❑ Retum Receipt for Merchandise ❑ COD ' I C `o J 7.Date of Deliv ry w j �� �� M 5.i0lhceive :(P'nt a e) 8.Addressee's Address(Only if requested c I w and fee is paid) s W F 0 6. ig to d e o e t) 0 v, I PS Vorm 3811, December 1994 Domestic Return Receipt 1 I First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid USPS Permit No.G-10 I •i Print your name, address, and ZIP Code in this box •f f Health Department Town of Barnstable P.O.Box 534 i, Hyannis.Massachusetts 02601 Fax(508)775-3344 I Phone(508)790-6265 - ' LEGEND N PROPOSED SEWER CONNECTION (. a _ 6 FT. FROM HOUSE i -- 47 -- EXISTING CONTOUR °od ° EXISTING 4" SCH40 PVC PIPE x aass EXISTING SPOT GRADE INV.=98.34t(VERIFY) °� a m° o � .,. t 44 PROPOSED CONTOURS P 2 Q C SEPTIC SYSTEM NO.1 -W EXISTING WATER SERVICE O �ey� y�o°BSc o /moo SEPTIC SYSTEM NO.2 -G EXISTING GAS SERVICE to c 5 �'A CESSPOOLS _ STILL FUNCTIONING ° O �J g LOC TO BE REMOVED +' -6.H.i1- OVERHEAD WIRES ,° y„' TO BE CONNECTED TO - c� KI� PROPOSED SEPTIC.SYSTEM TEST PIT x 94.81 WHEN LEACH PIT FAILS BENCHMARK 9`S y oc IP FND / -�Gy S 54'19�20 W FENC�L-<NE i S 54*19'20"'W -#y95.90 o,� 182.80' / - - 31.00' � - r- 1 � / � 0 4 1� ♦ 102 39 -{-. 10 99.00 �, / R°od ;P-2 100.75 �`� �9 N 97,90 9,6 -- - - - LOCUS MAP I` 97.63 e�p 7 �"� NOT TO SCALE T z ��2� x 102,3o \ GENERAL NOTES: I'0 98• 100.83 , PLAY 102.02 FUTURE CONNECTION GROUND -s1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL �,0 -�� + 102.85 BOARD -OF HEALTH AND THE' DESIGN ENGINEER. Cn W ►'� 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 0o f o ° ., p p }• - .. .. , AND ANY OF 3 �, P. cn ° SEPTC �68 10287 Q OCALERULES EAND ENVIRONMENTAL OEGULATIONS CODE, CEPTLASVREQUES REQUESTED BELOW:APPLICABLE o TANK _ L -310 CMR 15 405(1)(b) ��,� ° ! ��p. ` x 103.08 ' {- 3.46 i' 103:59 1) A 3' variance to the 3' maximum cover requirement for 6' "r x 99'5�5 EX/ST/NG maximum cover. S.A.S. shall be H-20 and vented. �'• . 00 3 THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR r7 _ HOUSE#1SZ� TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH SAND THE Z T.O.F.=104.4f .,DESIGN. ENGINEER. - `� 0 CELLAR FLOOR EL.=97.3f PATIO �1 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING VENT x .100.3 - - -108- - -' / FROM .THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE--CONSTRUCTION CONTINUES. 5•' ALL ELEVATIONS BASED ON2 ASSUMED .DATUM. 104.40 x- 9 61 O' .10116 103,7 �� '6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 3 / 4 x 100� 5 x 2,59 " THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF J HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. x 103.35 t 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. Cp 103 35 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. VJTILITY Pp E 9. ALL AREAS, CLEARED FOR CONSTRUCTION SHALL" BE RESTORED` AS 103,54 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 3 C\ % �P / t DIRECTED BY THE APPROVING AUTHORITIES x 100,55 10: IT SHALL BE THE 'RESPONSIBILITY OF THE. CONTRACTOR TO 'VERIFY PK SET / / R� 9s, Q ..- THE LOCATION OF, ALL UNDERGROUND UTILITIES, -PRIOR TO BEGINNING ? LOT 34 100.00 ��, j CONSTRUCTION. A N 145-01 1 OF _ WHERE RE UIRED. CONTRACTOR SHALL .REMOVE ALL "UNSUITABLE SOILS _ 11. Q T L 100 88 �o IGH `PDL ��� MAss9 ' IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 9� 17,350fS.F.. `REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). of o PETER T. 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 101.47 McENTEE INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. AACORNi o CIVIL N r 60.00 No, 351O_ 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND (� 3 IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. � N 53'5510 E op REG/STF�``� , DRIVE . x 104.78 S � ` PROPOSED SEPTIC SYSTEM UPGRADE PLAN 102.0� Gs 182 ACORN DRIVE, OSTERVILLE, MA BENCHMARK / #I ` Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 PK NAIL SET - OWNER OF RECORD EL.=100.00 102,29 JENNINGS, CHRISTOPHER J Engineering by: SC1"E 20' PST WN M. 247 13 & FITZPATRICK, NICOLE Engineering Works, Inc. 182 ACORN DRIVE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. OSTERVILLE, MA 02655 (508) 477-5313 2/1/14 P.T.M. 1 Of 1 NOTE: TO PREVENT BREAKOUT, THE PROPOSED 11.0' 7'7, FINISH GRADE SHALL NOT BE < EL:94.5 FOR A DISTANCE. OF 15' AROUND THE SHED ' PERIMETER OF THE S.A.S. %)7 SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & OUTLET AND SET TO 6" OF FINISH GRADEINSTALL RISER & COVER INSTALL RISER & COVER OVER ONE CHAMBER (MIN.) AND SET TO 6" OF GRADE SET TO 3' OF F.G. TO SERVE AS INSPECTION PORT T.O.F.=104.4t I I O I F.G. EL.=100.0t F.G. EL.=96.0 100.Ot N F.G. EL.=98.Ot F.G. EL.=97.Ot VENT L4I m 01 0 L - 7' ! ! L 8' L 17'(MAX.) IF I (n ® S=1% (MIN.) ® S=1% (MIN.) ® S=1% (MIN.) , 4'SCH40 PVC e 4'SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/8" TING 2" o s• ®O TO 1/2 DOUBLE HOUSE(#182) 14" INV.=95.00 WASHED STONE _T.INV.=96.00 48" LIQUID INV.=95.75 24 w(OR APPROVED FILTER FABRIC) 23�j�`��. CELLARO LOOR.04 -9. t LEVEL GAS BAFFLE iNV.=95.17 PROPOSED 3/4"-1 1//2"- D-BOX 4' 3' 4' DOUBLE WASHED INV.=94.00 STONE a PROPOSED SEPTIC TANK EFFECTIVE WIDTH 11' USE 5 LC-6 GALLON LEACHING CHAMBERS IN SERIES WITH SEWER CONNECTION 4' OF DOUBLE WASHED STONE-ALL SIDES AND 1' BENEATH - INV.=98.34t H-20 RATED TOP CONC. ELEV.=94.8 -BREAKOUT NOTES: INV. ELEV.=94.00 E3®E3 0 E3 EM E3 ELEV.=94.5 1) CONTRACTOR SHALL- VERIFY ALL EXISTING PIPE ®®®®®®® S.A.S. LAYOUT INVERTS, PRIOR TO INSTALLATION. 12' 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL &. BOTTOM ELEV.=92.00 TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' 5 UNITSx6'/UNIT=30' 4' _ _ _ 6" CRUSHED STONE BASE, AS SPECIFIED IN 310 4' OF NATURALLY OCCURRING 38' i F 4• KNOCKOUr CMR 15.221(2)• PERVIOUS 20• DW COVER _ MATERIAL - 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' (MIN.) ABOVE G.W. 4 CONTRACTOR SHALL INSTALL AN APPROVED GAS NO G.W. EL:=86.9 - M ' - LEACHING SYSTEM SECTION 4•.KNOCKOUT 4• KNocuour- BAFFLE ON THE OUTLET TEE. K. SEPTIC SYSTEM PROFILE L _ _ 4' KNOCKOUT - J ' N.T.S. 72" SOIL LOG PLAN VIEW DESIGN CRITERIA DATE: NOVEMBER 5, 2013 (REF. P#14,214) SOIL EVALUATOR: PETER McENTEE PE, (SE#1542) ® ® ® ® ® ® E3 I 22 I ® ® ® I NUMBER OF BEDROOMS: 4 BEDROOMS WITNESS: DONNA. MIORANDI R.S. HEALTH AGENT Elev. TP- Depth Elev. - Depth wVERT SOIL TEXTURAL CLASS: CLASS I �- TP 2 -� 12" 98.4 0.1 97:9 0,. DESIGN- PERCOLATION RATE: <2 MIN/IN - FILL a FILL 97.6 10" 96.9 12' 72" 38- DAILY FLOW: 440 GPD • A LOAMY SAND , _ A LOAMY SAND_ ,• SIDE VIEW END VIEW DESIGN FLOW: 440 GPD 10YR 4/2 ) 1OYR 4/2 GARBAGE GRINDER: N0 97.1 B 16" 96.4_ LOAMY SAND LOAMY SAND - WIGGIN LC-6, H-20 LOADING _ C/� PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY 10YR 5/8 36" 9 1 5/8 LEACHING- CHAMBER 95.4 C1 4.9 C1 10YR 36" - LEACHING AREA REQUIRED: (440 GPD) = 594.6 SF N.T.S. .74 GPD/SF MED. SAND MED. SAND 2.5Y 6/6 2.5Y 6/6 PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 5 LC-6 GALLON LEACHING CHAMBERS IN SERIES ' WITH 4' OF DOUBLE WASHED STONE-ALL SIDES 87.9 126".- 87.4 126" 182 ACORN DRIVE, OSTERVILLE, MA SIDEWALL AREA: 2 11' + 38' x 2' EFF. DEPTH = 196.0 SF C2 FINE C2 FINE Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 ( ) LOAMY SAND LOAMY SAND P BOTTOM AREA: 11' x 38' = 418.0 SF 10YR 5/4 I_.. 10YR 5/4 Engineering by: SCALE DRAWN _ JOB. NO. 87.4 132 86.9 .132". r_ N.T.S. P.T:M. 247-13 TOTAL AREA:............................................................. 614.0 SF NO GROUNDWATER OBSERVED` Engineering Works, Inc. DESIGN FLOW PROVIDED: 0.74 GPD SF 614.0 SF = 454.4 GPD PERC RATE: <2 `MIN./IN. - 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. / ( ) ' (508) 477-5313 2/1/14 P.T.M. 2 Of 2