The URL can be used to link to this page

Home My WebLink About0040 AVALON CIRCLE - Health C40 Avalon Circle terville , P 145 055 a o 0 o 0 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use 40 Avalon Circle - Osterville, MA only the tab key Property Address i to move your Claudia and Loren Chalker cursor-do not Owner's Name / use the return r key. 40 Avalon Circle Owner's Address rQ Osterville MA 02655 City/Town State Zip Code September 30, 2005 Date of Inspection: Date 2. Inspector: David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 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 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: s ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C'� S September 30, 2005 ! , x Inspector's Signature Date e ;c 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 i a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system own, r shall submifthe 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. t5-2204.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5-2204.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 t5-2204.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2204.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. I t5-2204.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection 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 IargE! 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. t5-2204.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection 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(3)(b)] t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 2 - Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 140 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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: Last date of occupancy/use: Date Other(describe): - t5-2204.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner - 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 2+years. Certificate of Compliance issued 1111102 (Board of Health records) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - _ Distance from private water supply well or suction line: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): 1 _ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 10 inches - Distance from top of sludge to bottom of outlet tee or baffle 24 inches Scum thickness 6 inch Distance from top of scum to top of outlet tee or baffle 7 inches Distance from bottom of scum to bottom of outlet tee or baffle 11 inches How were dimensions determined? Design Plan - t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time and maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 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): t5-2204.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: - Capacity: - gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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 appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2204.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form lo Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: - ® leaching galleries number: 1 - ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down. t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection 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 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.): t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. LEACHING LOCATIONS GALLERY 2 sox A B I 33 ft 25 ft 2 59 f t 52 f t SEPTIC TANK o I 6 A EXISTING DWELLING 40 W Z J K W H G 3 I AVALON CIRCLE NOT TO SCALE t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Avalon Circle Property Address Osterville MA 02655 City/Town State Zip Code Claudia and Loren Chalker September 30, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 30+feet Please indicate all methods used to determine the high groundwater elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 10/30/02 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 8.5 feet above the bottom of a test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. t5-2204.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 Outback Engineering 106 West Grove Street Middleboro, Ma 02346 (508) 946-9231 November 1, 2002 Town of Barnstable Health Dept. 200 Main Street Hyannis, Ma 02601 Subj: 40 Avalon Circle Septic System Inspection To whom it may concern: Outback Engineering has conducted the necessary inspections for the newly installed septic system for the subject property. The septic system was installed in conformance with the approved plan prepared by Outback Engineering. Very truly you , )9ames Pavlik, P.E. TOWN OF BARNSTABLE EL LOCATION O Cyr SEWAGE # VILLAGE (� �IGY+ E'_— ASSESS 'S MAP & LOT z INSTALLER'S NAME&PHONE Nn SEPTIC TANK CAPACITY !;�. `v 0 LEACHING FACILITY: (type.) _rt-e,L1I�O6 (size),J52rx f�411 NO.OF BEDROOMS BUILDER OR OWNER— PERMITDATE: c 3 6 -;— COMPLIANCE DATE: 11- ► U 2 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, o G \ 01, 33 ' I I 4 Fee o O `- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for MigogoY *p6tem Con.5truction Permit Application for a Permit to Construct( )Repair(A Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 0 4 VOM Lt e)e_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Tl Fernando M j6ha ucL �� 15- 6 Installer's N Address,and TeL lyq.;� Designer's CamC,,ev,!�Ad.�d�ess and Tel.No. /�'` Pa� t �/ �55 S Y8 C! ,1 1� �l1Q�Ll / 7 S A u Type of Building: z Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow D gallons per day. Calculated daily flow gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank T��7�l�i Type of S.A.S. 4 Description of Soil Nature ofRepairs.or terations(An r hen pplicable) T : '-LED IN STRICT 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#Title 5 of the Environmental Co a and not to place the system in operation ntil a Certifi- cate of Compliance has been issue by thi Board of Signed a Date/� , U �� Application Approved by Date /%30/0j_ Application Disapproved for the following reaso s Permit No. 9000`5- Date Issued l D_3 0 ^OJ ——————————————————————————————————————— 1 _. .. 00 _ Fee�. THE COMMONWEALTH OF MASSACHUSETTS µ Entered in computer: Yes PUBLIC HEALTH DIVISION;, TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for M'oponl *potent Conotruction.Permit Application for a Permit to Construct(,,e epair X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. o j`h V C� wale,ate• Owner's Name,Address and Tel.No. `Assessor's Map/Parcel.,. ,;,:. U.S. i� � -�-eYrtanda � �Gha�cL. .7 5= 6 Installer's 7m3Addregs,and Tel.N, Designer's Name,Ad(yess and Tel.No. *0 r- i S, R Z o I C�C�lP f t Type of Building: z Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ([ f Design Flow Q gallons per day. Calculated daily flow /- ' 7 gallons. Plan Date D° a-1 Number of sheets / Revision Date Title Size of Septic Tank alK 1 s -�7 U 0 Type of S.A.S. Description of Soil �►^-- Nature of Repairs or Alterations(Ans%er when applicable) Y1 4:, r,� T •. Date last inspected: Agreement: w` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions�f Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued`by this Board of r7jtTi Signed I "'M Date �\ Application Approved by / //1 Date, f - -' ..Application-Disapproved for the following reaso s Permit No. -;;LD6a— 5�� Date Issued 10' 3 O CIo� ——————————————————------————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ii Certificate of Compliance THIS IS TO Ch. TIFY,//thAAa_t the On- ite Sewage Disposal System Constructed( )Repaired(�Upgraded( ) Abandoned O b wri.C.. at DL V 1 1 4 ha .ben constructed in accordance with the pro)'sions o f Title 5 d' a or Dis o 1 System Construction Permit No � dated Installer y�t,l Designer The issuance of this permit shall not be construed as a guarantee that the sy em wil functiA-ad;signe(j.C Date Inspectorm.. \.J ------�— ----- /--------------------------- No. �U� J /�.- Fee 5o, �d - . . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5po!gar �pgte Construction Permit Permission is hereby ted Yp Construct( Re air )Ljpg e )Abandon( ) System located at �jY�e.- U �V and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of& pe Date: ��_3 �� Approved by V/ d TOWN OF BARNSTABLEL LOCATION C ( SEWAGE # 62-f� f l _ VILLAGE 021E(2S C— ASSESSQR ('S MAP & LOT N —O INSTALLER'S NAME&PHONE NO 11416rtie d� SEPTIC TANK CAPACITY 5.Cfl ''T c 1-0 0 c,ALL,/ LEACHING FACILITY: (type) (size) NO.OF BEDROOMS .3. BUILDER OR OWNER Awl'Q PERMITDATE: c 3 6 COMPLIANCE DATE: 1I— 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 f, o G �a 33 A) . a � t No......................... FEB ............. THE COMMONWEALTH OF MASSACHUSETTS BOARDI?F HEAL-TH .................OF..... .. .. -......... .............................. Appliration for Dhiputial Workii T-mitrurtion Famit Application is hereby made for a Permit to Construct �or Repair an Individual Sewage Disposal o yst ..... . ............. ..... ... .................................. ............. ......................... --------�A............. . ........ 1 Locati A ; za' . �... ............................. ...... ....... .. ........ .. ......... A s 0 n A S nst .......... ..... MKI........... .A res.s t... ... ........T.... . ......... UType of Building Si PeLot_.L,.)_,_jr0'-e......Sq. feet I Dwelling—No. of Bedrooms_.___.__2.............................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafetetia Otherfixtu�res -----------------*--------------------------------------------------------------------------------------------------*....*----------- Design Flow.._..._..!�V --gallons per person per day. Total daily flow------------Z.-4.0..................gallons. P4 Septic Tank—Liquid capacity/lj?�' ..gallons Length................ Width._.....__._...__ Diameter__-_____________ Depth....______..___. Disposal Trench—No. ..- Vr. ......... Width---C�.... Total Length______........ Total leaching area....................sq. f t. Seepage Pit No......../----------- Diameter...._...45� .S-Depth below inlet...1.4:r:........ Total leaching area..................sq. f t. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.....................................................t------------------- Date.................... ............ a ...... - Test Pit No. 1-----!./......minutesperinch Depth of Test Pit-----/Z------- Depth to ground water/&_ ----- Test Pit No. 2................minutes per inch Depth of Test Pit____......_.____.... Depth to ground water.-__._........__.....__. .............;�---------- .............. ---�7-;- ......4�r*......P"", ........ ------- ........... 0 ------------- W Description of Soil...P..-J......... .... . ........../............. ................ �ea U .................................................................................................................................................................................................... ----------------------------------------------------------............................................................................................................................................ 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'L-TTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of health. Signed...... ...... --------- ...... Date Application Approved By............ .............. ................................................. ........................................ 0 Date Application Disapproved for the following reasons:.............................................................................................................. .................................................................................................................................................................................................... Date Permit No...................... Issued..... .. Date . ................ No................_....... FEs.... .:.?:............. THE COMMONWEALTH OF MASSACHUSETTS •�a 4 BOARD F HE Ti-I Appliration for Dipjxoiial Workii Tomitrurtion rrmit ./ All Application is hereby made for a Permit to Construct 4-T or Repair ( ). an Individual Sewage Disposal Syst - Locati .. is ° Lot #� y O ner ► A r s nstaller r e:-- A ress Pq ».. UType of Building •'' " ¢` Si e Lot_I_,-------.-Sq. feet Dwelling—No. of Bedrooms...... ............... _.....Expansion Attic ( ) Garbage Grinder :( ) Pk Other—Type of Building ............................ No. of personal......................... Showers ( ) — Cafeteria,(4 - ) a' Other fixtures W Design Flow.........�P ? ____gallons per person per day. Total daily flow----........"�. 4 ................gallons. 1. 1:4 Septic Tank:—Liquid capac>t/~. . gallons Length .............. Widtlti---------------- Diameter______. . Depth................ Disposal;Trench NV 1 ......eI_.. Width._i" .. Total Length + Total leaching area:`:.................sq. ft ' See-pageWPit No ✓':._ -__._.. Diameter.,.....(' Depth below Inlet t � Total'leachirig area.................sq. ft. z OtheraD st>yiJ5ution box ( ) Dosing tank w/ a :Percolation Test Results ; Performed by................................i ...::------------- ............... Date........................................ minutes per inch Depth of Test Pit__._/._ _...:._. Depth`to ground water Test Pit No. 1 ...._-• •-- Test- 'it No. 2................minutes per inch Depth :of Test Pit.-.__............... Depth to grotKd water___.._................_. ... ......................... •-•-- - Description of Soil---0 ----••.._.. ......... ...... + ` --------------- W . -------------- ::::::::::::::::::::::::::::::::::::: ---------- �. �ru UNature.of Repairs or Alterations—Answer�ryyhen applicable____________ __________________________________________________________________________________ ... ; Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in'.accordance with the provisions of 5 of the-State Sanitary Code— The undersigned further agrees not t9r$lace the system in operation until a Ceftihcate of Compliance has been issued by the board of health. Ad N Signed•--i-Vii-Iii-Ii _. ..... ----41, - i Application Approved By........... '' c ---------------------- •------•-•--•-- Date Application Disapproved for the following reasons:------------•• ............... --•------•------••-----•-•---•--------•-•----•--•-•-----------------.._... ,. Date PermitNo......................................................... Issued-....................................................... Date - THE COMMONWEALTH OF MASSACHUSETTS ^`r r BO1-�RD 'OF HEALTH ` - --T-A Currtifirtt erof Tompliana T IF That t e In" *dual S.Gwage Disp al System onstructed r..Repaired ( ) by................ .G�✓ r,y w jau�er ` at-_...---- .--- y r has ben installed in accordance with the provisions of T j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. __..__..4ie .t_____.___. dated___.._ �'1A'�".*:?................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............----------------=- . ..,z Inspector.................................................................................... . 5 THE COMMONWEALTH OF MASSACHUSETTS - BOARD O HEA TH' -` � ems,,,,..--•- t� --_ ^---,. NO......... .......... EE.... .... tt;Q ,irk 1 11tr tort ' Permission is hereby granted.......... ...... ..--- to Construct or Repair ( an In vldual age D os yst at No...........;..6� �'Street as shown on the application for Disposal 'Works Construction Pq it No ............... f � i Board of Health kDATE. t �-�? ..................................... FORM 1255 HOBBS'& WARREN,, Ill PUBLISHERS � r . A THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , �- m / LI DATA 400010 Wm. E. Robinson, Jr. Septic Inspections 43 Tomahawk Drive Centerville, MA 02632 (508) 775-7986 Pager 978-622-8700 � 1.� w2 V F�C�E0 JUL 2 4 1998 •, TOWN OF BARNSTABLE HEALTH DEPT. Location Lepera 40 Avolon Cir. " Osterville Ma 02655 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART A CERTIFICATION Map Number 145 Parcel Number 057 PROPERTY ADDRESS: 40 Avalon Circle Ost. Ma Lot 40 ADDRESS OF OWNER: DATE OF INSPECTION: 7-17-98 1153 Pauline Ave.James Island NAME OF INSPECTOR: William Robinson S.Carolina ,29412 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: W. E. Robinson Septic Inspections MAILING ADDRESS: 43 Tomahawk Drive Centerville, MA 02632 TELEPHONE NUMBER: (508)775-7986 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES. NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: 7-17-98 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The:original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. 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 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: System is in good working condition. Tank should be cleaned. 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 bthe;Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) - Years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank is 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. Page 1 of 10 (revised 04/25/97) DEP on the World Wide Web:http://www.magnet.state.ma.un/d. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 40 Avolon Cir. Ost.. Ma.02655 Owner: Lepera Date of Inspection: 7-17-98 B]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). Describe observations: Broken pipe(s)are replaced Obstruction is removed Distribution box is leveled or replaced The system required pumping.more than four times a year due to broken or obstructed Pipe(s). The system will pass inspection if(with approval of the Board of Health): Broken pipe(s)are replaced Obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 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, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS As 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 the SAS is within a Zone 1 of a public water supply well. The system has aseptic tank and soil absorption system and the SAS is within 50 fleet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 Feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and,volatile organic compounds indicates that the well is free from pollution from that:facility and the presence of ammonia nitrogen and nitrate nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Avolon Cir.Ost. Ma 02655 Owner: Lepera Date of Inspection: 7-17-98 D]SYSTEM FAILS: You must indicate either"Yes" or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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 over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow 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 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 coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: You must indicate either"Yes"or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a Significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes. No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or mapped Zone II 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. - I (revised 04/25/97) Page 3 of 10 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Avolon Cir. Ost. Ma 02655 Owner: Lepera Date of Inspection: 7-17-98 Check if 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 Health. X None of the system components have been pumped for at least two weeks and the system has not been receiving normal flow rates during that period Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. 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. X All system components, including the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants, if different from-owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information. Ex. Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue; approximation of distance is unacceptable)[15.302(3)(b)] revised 04 25 97 Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 Avolon Cir.Ost.Ma 02655 Owner: Lepera Date of Inspection: 7-17-98 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no):' No Laundry connected to system es or no): Yes Seasonal use(yes or no) Yes Water meter readings, if available(last two(2)year usage(gpd): 96-38 97-47 Sump Pump.(yes or no): No COMMERCIAL/INDUSTRIAL: NONE: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no): Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A T.O.B. System pumped as part of inspection:(yes or no) No If yes, volume pumped: Gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption.system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any): I/A Technology etc. Copy of up to date contract? Other = APPROXIMATE AGE of all components, date installed(if known)and source of information.- System installed 8.10-79 ''Permit# 79-448 Sewage odors:detected when arriving at the site: (yes or no) No (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Avolon Cir.Ost. Ma 02655 Owner: Lepera Date of Inspection: 7-17-98 BUILDING SEWER: (Locate on site plan) Depth below grade: 3699 Material of construction cast iron. X 40 PVC other(explain) Distance from private water supply well or suction line 20' Diameter Comments: (condition of joints,venting, evidence of leakage, etc.) SEPTIC TANK: (Locate on site plan) Depth below grade: 1810 Material of construction X concrete metal Fiberglass Polyethylene other(explain) If tank is metal, list age Is age confirmed.by Certificate of Compliance (Yes/No) Dimensions: 8'x5'x5' 1000 GST Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or;baffle: 38" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 1" How dimensions were determined Measured 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.) Tank should be cleaned. ( maintance cleaning) GREASE TRAP: NONE; (locate on site plan). Depth below grade: Material of construction concrete _ metal Fiberglass Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or'baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Avolon Cir.Ost.'Ma.02655 Owner: Lepera Date of Inspection: 7-17-98 TIGHT OR HOLDING TANK: none (Tank must be pumped prior to, or at time, of inspection) (Locate on site plan) Depth below grade: Material of construction Concret metal Fiberglass Polyethylene other(explain) e Dimensions: Capacity: Design flow: Gallons/day Alarm level: Alarm in working order Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: _ Comments: (note if level and distribution is equal, evidence'of solids carryover, evidence of leakage into or out of box, etc,) Box is in like new condition. PUMP CHAMBER: NONE; (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition.of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Avolon Cir. Ost. Ma 02655 Owner: Lepera Date of Inspection: 7-17-98 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. Leaching pits, number: 1-LP-1000 Leaching chambers, number: Leaching galleries, number: Leaching trenches, number, length: Leaching fields, number, dimensions: Overflow cesspool, number, Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) LP is in good condition , less than half full at time of inspection. CESSPOOLS: NONE; (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(cesspool must be pumpedas part of inspection) Comments:: (note condition of soil, signs of hydraulic failure,,, level of ponding'condition of vegetation, etc.) PRIVY: NONE;: (locate on site plan)none Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page B of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Avolon Cir. Ost.Ma 02655 Owner: Lepera Date of Inspection: 7-17-98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100(locate where public water supply comes into house) REAR , PLD•- 3v v p �3.t7• 31' - fl. ,(revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Avolon Cir. Ost. Ma 02655 Owner: tepera Date of Inspection: 7-17-98 Depth to groundwater 15+ feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) Permit # 79-448 (revised 04/25/97) Page 10 of 10 I► 10, y .ate I 0 TOWN OF BARNSTABLE L OCATIOi-4 Avolow ar. SEWAGE # 79'U4 i%�ILLAGE OSI UVille- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � ��E SEPTIC TANK CAPACITY 000 GST LEACHING FACILITY: (type) 0' bd D (size)' NO.OF BEDROOMS 3 Z bn oC4 BUILDER OR J1 WP►(�p�,'nSpnl Tr+�ec1+�S l.4 J L A PERMITDATE: '1-00 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 a V L04 QEfla 8. OL �o00 451' ` O B.E• 38' o p.gox BENCH MARK: TOP OF FND. . ELE=61.0 ." _ E aJ (SAS).SHALL B (�G S .>_ , 34.25' LONG „ MANHOLE COVERS TO EXTEND TO 11.0' WIDE 2$ WITHIN 6- OF FINISH GRADE 10" DEEP p uT%Z 2X BAFFLE REWD J : +19 EL=57• 0 `Ile 11 S a 2X 2" PEASTONE TOPPING A. D.B. :I -_- --_ E X I STI Nta 1 /. "1 r '?�0 7: _ CAP ENDS GENERAL NOTES: h A� T/+rJK IO 6, TnHE 3' _ _ -_ _ _ - _�_3�4" DOUBLE WASHED — ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM ` 5�_�4� s oNE ALL AROUND SYSTEM PIPE SHALL BE EITHER C.I. OR s SCHEDULE 40 P.Y.C._ . THE BOARD OF HEALTH SHALL BE NOTIFIED 1.5 _ 31.25' .5' PRIOR TO BACKFILLING OF- SEPTIC SYSTEM. 20' MIN. w - - SEPTIC SYSTEM STRUCTURAL COMPONENTS USE;.FIVE.(5) INFILTRATORS � . SHALL BE CAPABLE OF WITHSTANDING A SOIL TEST LOG PROPOSED SEPTIC SYSTEM WRIT .o' of STONE O SIDES H-10 LOADING, UNLESS SPECIFIED OTHERWISE PERC RATE=< 2 MIN/INCH NO SCALE IS OF STONE oENDS —.SEPTIC SYSTEM UNDER DRIVEWAYS SHALL NO"STONE AT BOTTOM COMPLY WITH A H-20 LOADING. ` —THE DESIGN AND COMPONENTS OF THE SEPTIC DEPTH 0 ELEV= 60.0 . A EaAW suro Im•R 4'7. - � r , .: _ : . SYSTEM SHALL BE IN COMPLIANCE WITH THE g STATE OF MASSACHUSETTS SANITARY CODE q . Il LOIWY SAND IOYR �Ib ;'q, TITLE V. AND SHALL BE IN COMPLIANCE WITH `51.5 A. THE LOCAL BOARD OF HEALTH RULES AND REGULATIONS. M SRO 14YR �',. 12 - __Cl MEDIUM THE CONTRACTOR SHALL BE.. RESPONSIBLE FOR F G \ram LOCATION OF ALL UNDERGROUND UTILITIES AND 14e 4&00 /`. / r ►� i�J G SHALL NOTIFY DIG - SAFE PRIOR TO `�\ ��\��\�,( — CONSTRUCTION. NO GARBAGE GRINDER Z t,�O W k- o �,EO too .� DESIGN CRITERIA: . . 1. .. , r n . 3EBEDROOMS LEGEND: - .J _ � �.,��.`� `� �� - \N S� G AY 330 G.P.D. N r N� p. AT 110Y G.P.B. D EXISTING CONTOUR r - WATER SERVICE W W— 1 + _ 0 6_ F�Ay REQUIRED SEPTIC TANK:. E_x15?_ Ky. ! Ooo 6AL.-orj TEST HOLE r 1+ NONE'. .GAS SERVICE —CT�G p � N O SEPTIC TANK PROVIDED r BENCH MARK QBM DESIGN PERC RATE <2 MIN/INCH 4 � SIZE OF REQ'D (SAS) AREA = 330/0.74 = 446 S.F. AV TS SIDEWALL ffl%83)(34.25)+(2)(O.83)(11)= 75.12 S.F BOTTOM 4:25) = 376.75 S.F. N -I-,O, I.O d 155 SIZE AF LEACHING FACILITY PROVIDED: =. - I; 376.75 S.F. + 75.12 S.F.^= 451.87 S.F. 4O NOTE: 334.4.4 GPD PRIOR TO INSTALLING THE NEW (SAS) THE CONTRACTOR SHALL PUMPOUT ALL CESSPOOLS r � � / � EFFECTIVE DEPTH: 10" AND BACK FILL WITH CLEAN MEDIUM SAND ? _ s EFFECTIVE LENGTH: 34.25 IF CESSPOOLS ARE ENCOUNTERED IN THE C 10 Oob F s9 EFFECTIVE WIDTH: , 11.0' (SAS) AREA THEY SHALL BE REMOVED. Nx e, S �� JAMESA oyG� OUTBACK ENGINEERING ' PAVLIK / �► ` `' 1� : o � 106 WEST GROVE STREET ' S .� 4 8 - - o CIVIL � MIDDLEBORO, MA 02346 �-�0` 2 .o No 36488 (508) 946-9231 f 9 9FG/ E Q ' PROJECT: SEPTIC SYSTEM REPAIR FOR G I dZ C L E n AS SHOWN �W. � 3 6 v Dom- I� �2 8 � � MAP 14 S� LOT O S S �m OWNER: FE2,,lA4DO MiC11A�t� _ 3 0 40 AV A 40 1-3 Gt�c1.t r M `