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LOCATION 2� SEWAGE PERMIT NO.
VILLAGE
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I NSTA LLER'S . NAME L ADDRESS `
JOHN A. AAL•TO BAOKHOE SERVI'sE "
1 Fn Wpinr,t-StYQpt
West Barnstable; Mass.'026553
NB U I L D E R OR OWNER
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DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Bates St.
Property Address
Ed Murphy
Owner . Owner's Name
information is required for Osteryille Ma. 02655 4/8/2010
'
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector: �C
only the tab key �/
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
reran City/Town State Zip Code
(508)428-4028 S14454
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 iDEP 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
CAI
4/8/2010
Insp ctor's Signatur Date cor
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•09/08 Title 5 Official Inspection Form:Subs. ce Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every 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:
The septic system is in proper working order at the present time.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 20 Bates St.
M
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at.a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•09108 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
20 Bates St.
M
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every 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
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Csterville Ma. 02655 4/8/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs.of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® 0 Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of-Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon tank,D-Box and leaching pit.
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 0 No
Water meter readings, if available last 2 ears usage NA
9 ( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/8/2010
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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Bates St.
M
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osteryille Ma. 02655 4/8/2010
every 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 19"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon
Sludge depth:
3"
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every 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 29..
Scum thickness
V.
Distance from top of scum to top of outlet tee or baffle
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.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of leakage.Tank appears
structurally sound.NOTE:Part of tank is in driveway.Tank is not H-20 loading.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every 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:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Bates St.
�M
Property Address
Ed Murphy
Owner Owner's Name.
information is required for Osterville Ma. 02655 4/8/2010
II
every 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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
Pump.Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is Osterville Ma. 02655 4/8/2010
required for
every page. Cbty/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-6'x10'
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line
observed 6' 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
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09108 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 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 15.3'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Re
port, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
i
Imo, 4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Bates St.
Property Address
Ed Murphy
Owner Owner's Name
information is required for Osterville Ma. 02655 4/8/2010
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r DATE : 10/24/02
PROPERTY ADDRESS : 20 Bat.es Street
Osterville,Mass. �// ��
-- 02655'-_--
--- -------- e7_1
On the above date, I inspected the septic system at the above address.
This system consists of the following: R(ECEI /E®
1 . 1 -1000 gallon septic tank.
2. 1 -1 000 gallon precast leaching. pit. ) 6 'X1 0' ) ICT 3 1 2002
3. 1 -Distribution box.
Based on my inspection, I certify the following condltions; TOWN OFBARNSTABLE
HEALTH DEPT.
4 . This is a title five septic system. ( 78 Code) ,
-The septic system is in proper working order at the present time.?
6 . Pumped the septic tank at time of inspection.
7. Waste water is 59" below the invert pipe of the leaching pit.
8. House has three bedrooms with 'ah office upstairs.
SIGNATU R
Name :_ J7 ._ P Ma.comber_Jr ,
Company :2ose'ph _omfber 8 son , Inc ,
Addr'ess :__BQx_� ------------. /
Mi _Q22-632-,P<6
Phone :__508- 775_ 333E
THIS CERTIFICATION DOES ,N T CONSTITUTE :`A GUARANTY OR WARRANTY
JOSEPH,P, MACOMBERiznm, INC.
Tanks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632.0066
775.3338 775.6412
-\ COMNION' EALTH OF N4 SACHUSETTS
EXECUTI��' OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 20 Bates Street
Osterville.Mass_
Owner's N'ame:Ri c-harr3 mr-c
,j nnj,q
Owner's Address: Same
Date of Inspection:1D /24/O2
Name of Inspector: (please print) Joseph P• Macomber Jr.
Company Name: J. P. Macomber & Sons Inc
Mailing address: Box 66
C'Pnt'Prvi 1 1 P Ma D2632
Telephone Number: 508-775-3338
CERTIFICATION STATEfvIEN'T
I certif, that I have personally inspected the sewage disposal system at this address and that the information reported
below is rme. accurate and complete as of the time_'of the inspection. The inspection was performed based on my
.raining 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
Needs Funher Evaluation by the Local Approving Authority
Fails
Inspector's Sigoature: (�£ Date:
The system inspector sh II mit a copy of this inspection report to the Approving.Authoriry(Board of Health or
DEP) within 30 days of completing Mis inspection. If the system is a shared system or has a design now 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 sys;tefn owner and copies sent to the buyer, if applicable, and the approving
authority.
Votes and Comments,
Additional', room upstairs. Used �as office
r~•`• This repon only describes conditions at the'tinie`of inspection and under the conditions of use at that/
acne. 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 6/1 S/2000 page I
Page 2 of 1 1
is
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Bates Street
Osterville,Mass.
Owner: Richard McGinniss -
Date of Inspection:10 12 4/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
stem Passes
-132 have not foun�any formation hich indicates that any of the failure criteria described in 310 CMR
15.303 or m 310 exist. Any failure criteria not evaluated are indicated below.
Comments:
Tha cani-i r S�S1 Pm ; c ; n �rp�et- working—order--
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 „ye
s, no or not „determined Y N Y ND in the( ) for the following stateme
nts*.,If
explain. g not determined please ,
,00 The septic tank is metal and over 20 years old* or the septic tarik(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: .
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:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Bates Street
Osterville,Mass.
Owner: Richard Mcctinnis
Date of Inspection: 101 4102
C. Further Evaluation is Required by the Board of Health:.
O 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: .
A Cesspool or privy is within 50 feet of a surface water
V Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
a .
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-Lank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
,0 The system has a septic tank and SAS and the SAS`is within a Zone l 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 b 50 feet or more from.a.
private water supple well Method used to determine distance
This system passes if the well water analysis,performed at a DEP certified laboratory, for col iform
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:
3
R
Page 4 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address20 Bates Street
Oster•villeoMass:
Owner: Ri rharr3 Mori nni
Date of Inspection: 1 n 12 d 10 2
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
I/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
7 clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool r
_ .
_ [quid depth in cesspool is less than 6"below invert or available volume is less than h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
2f times pumped�.
� ,A y 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.
11 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. 1 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.
n
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no"to each of the following'
(The following criteria apply to large systems in addition to the criteria above)
yes now
/ the system is within 400 feet of a 'surface drinking'water supply
V the system is within 110 feet of a tributary to a surface drinking water supply
the system is located in anitrogen '[iv ysensitive area(interim Wellhead ProtectionArea—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.
4
i
Page S of :
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST•
Properry Address:20 BdtPG StrAeio `
a-S-S-
0wner: S
Detc of laspectioo: 1 01�4 /n�
Check if the following have been done You must indicate"yes" or"no" as.to each of the following:
Yes ',o/
✓ Pumptrig information was provided by the owner, occupant, or Board of Health
Were ant of the system components pumped out in the previous two weeks
_ Has the system received normal no in the previous two week period ?
4/Havc large volumes of water been inrroduced to the system recently or as pan of this inspection
were as built plans of the system obtained and examined? (if they were not available note as NI-A,)
Was the facility or dwelling inspected for signs of sewage back up?
was the site inspccied for signs of break out '
l Were all system components' cludirtg the SAS, located on site ?,
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition.
e.r the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum '
Was the faciliry owner (and occupants if differen(•f om 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
Y<s no
Existing information. For example, a plan at the Board of Health.
Determined in the fielflif•any of the failure criteria related to Pan C is at issue approximation of distance
;s unacceptable) (310 CMR 15.302(3)(b))
S
i
Page 6 of
OFFICIAL INSPECTION FORM'- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Add ress:20 Bates reet
QgtPrVl 1 1P M.asq
Owner: Ri rharri Mari nnis
Date of Inspection: 2410
FLOW CONDITIONS
RESIDENTIAL - �=
Number of bedrooms(desi
gn'gn, c— 'Number of bedrooms(actual)
DESIGN! flow based on 3I0 C 15.203 (for example: 1 10 gpd x of bedrooms) '✓��?�-!u ��`-eAl
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system_(,ves or no):.Q [if yes separate inspection required]
Laundry system inspected ( es or no):
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage(gpd)): 2000-1 74, 000 gallons=476. 72 GPD
Sump pump(yes or no): AUa 2001 -1 60, 000 gallons-418. 36 GPD
Last date of occupancy:
COMM
•
Type of establishment.
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industriai waste holding tank present(yes or no):AA
Non-sanitary waste discharged to the Title 5 s stem (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): 4A
GENERAL INFORMATION
Pumping Records
Source of information: Pumped at timef ffl
ion
Was system pumped as pan of the inspection (yes or no)
If yes, volume pumped: /ZtV gallons •- How was quantity pumped determined?AA991/zW
Reason for pumping:He avy scum & solids lavers were present.
T
OF SYSTEM
eptic tank, distribution box, soil absorption system
,6A Single cesspool
Vo Overflow cesspool
/L 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)
j Tight tank �Attach a copy of the DEP approval
Other(describe):
Ap roximate aee f all cgCnponents, date inst Ile if know ) and source of information:
r�Were sewage odors detected when arriving at the site (yes or no):-I(b
6
I
Page 7 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C, '
SYSTEM INFORMATION (continued) .
Property Address:20 Bates Street
Osterville,Mass_
Owner:Richard McGinnis
Date of Inspection: 1 n/24.1 Q2
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of consrmccion:4,?e cast iron Z40 PVC10 other(explain): 16&4
Distance from private water supply well or suction line:
Comments (on condition of joint , venting, evidence of leakage, etc.):
Joints appear tight-No evidence of 1 �akge Thesystem is
vented throZlocate
gh the house vents.
SEPTIC TANK: on site plan) /l?OQ�
Depth below grade: /P?
Material of construction: _zconcrete.(�metal f fiberglass,, (P olyethylene
,�Lother(explain) AdA
If tank is metal list age:XV0 Is age confirmed by a Certificate of Compliance (yes or no)W,.b (attach a copy of
certificate) s
Dimensions: �d'� !P''4 c�?
Sludge depth:
Distance from top of sludge to bosom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: a
Distance from bonom of scum to bottom of outlet tee or baffle:
How;were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, struct0al integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
,Ptimp the c;Pnf-i r tank annual 1 ( nArhage rli Gz�ca1 i S =rPSPnt, I
'Tn1 Ai- R niit 1 Pf- fees arP i n nl Grp The rank iS GtrLlCtt_1ra11-N;—sfnund
and shows no evidence of leakage.
GREASE TRAP (locate on site plan)
Depth below grade:
Material of construct ion:',A�concrete4#meta fcbergWsi polyethylene,4GJ 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 (on pumping recommendations, inlet and outlet tee or baffle condition,struciuralintegrity, liquid levels,
as related to outlet invert, evidence of leakage„ etc.)`
GrPaSP t-ran i s not prPc;Pnt
7
I .
Page 8 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address: 20 Bates Street
Owner: Richard McGinnis
Date of Inspection:10/2 4/0 2
TIGHT or HOLDING TANIGdI�-t(tank must be-pumped at time of inspection)(]ocate on site plan)
Depth below grade: AO
Material of construction: 41A concrete metafQ44. fiberglass ±4�olyethylene 41A other(explain):
Dimensions:
Capacity: N gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: 6_ Alarm in working order(yes or no): 12�
Date of last pumping; _AM
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: •C/$
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.):
Dictrihtitinn hex has onp latp-ral .No evidence of solids
cl rry near No aV i rlPnoP cif 1 PakaqP i nt-ro or out of the box
PUMP CHAMBER4lt (locate on site plan) '
Pumps in working order(yes or no): 21,4
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Pump chamber i c n t n-rPSPnt-
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Bates Street
Osterville.Mass. "
Owner: Richard McGinnis
Date of inspection: 1o1 24 02
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate oa site plan, excavation not required)
1 -1000 gallon precast leaching pit. ( 6 ' X9 ' )
If SAS no; located explain why:
— te_d; See;=page 10
Type
,� leaching pits, number: /d r37
leaching chambers, number: 4
tV leaching galleries,number:
7U leaching trenches, number, length:
O (�
- leaching fields, number, dimensions:-0
,10 overflow cesspool, number.D_ ,� / _\
�( innovative/altemative system Type/name of technology —/ 1/yB C_ �' J
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to boney fine sand No signs of hydraulic failure
_nr pnndjnCj_ Rnils are dry Vegetation is norma as a wa
presently 59" below the invert pipe.
CESSPOOLS�rlCi(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 laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):IfI19A
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present
PRIYY,,,�,,L(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.):
Privy is not present
I
9
it
➢{dr f0o/II
OFFIC!,`i INSPECTION FOF _
NOT FOR VOLUNTARY ASSFSSME.N-S
SU8SURf^CC SEW^CE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INPOR/vtATION (cominvco
)
a'cpern . 001(11
pp20 Bates Street
O�, �Ri chardsMcrinni`s`Mom=
om or ln,p,c,,00' =4 02
S"'CTCH OP SCWACC DISPO-�,�C SYSTCM
P'o'�oi � ����cn of �nr ,,..,Ir o;fpolrl Iyllrm.ln(Iv41n� Ilrl 10 II Ic{11 Wn f1v
to<ric rrr o ptrTn{nanl r(fcrcncc ien
pvbli( Hllcr Iv I Clnl c
PP Y <nlcrLinr -0vilofnl
{
co
' z
i
i
f 2�
LOCATION SEWAGE PERMIT N0.
VILLAGE
I.NSTA LLER'S NAI -I i ADDRESS
JOH.N A. ALTO PACKHOE SERVICE .
l Fn V1latn,-Q street
n West Barnstable; Mass.025 3
R U 1 L D E R OR OWN ER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
A
' -ro"oA d
GAR
(Aa ✓
AYw,AA)w
\\ ^4/2
\ \yam'
I
a
Page 1 I of I I
r,
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Bates Street
Osterville,Mass.
Owner:Richard McGinnis
Date of Inspection: 10/24 02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
YES Obtained from system design plans on record if checked, date of design plan reviewed: 10124162
YES Observed site(abutting property/observation hole within 150 feet of SAS)
YRS Checked with local Board of Health-explain: Obtained as bulit card.
y_S Checked with local excavators, installers-(attach documentation)
YF.S Accessed USGS database-exp lain: http; /f town-ha nstable.ma.us.-
You must describe how you established the high ground water elevation:
Ised: Gahy & Miller Model. 12/16/ 4 Ground water elevations above
sea level _
Ised: USGS nhcarvation wall data ,7nnP 19A2
Ised: USGS ttin 92-000-1 Plate #2 AnniiAl ranCieG of ground
• water elevations. January 1992
Leaching C
Pit ¢/ }
Groundwater:: I-eet Below Bottom of Pit High Groundwater r Adjustment 1.8 ft per Fri
mpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
11
.....-.-..-nl-r--+--.r-..-+r-..•R rTT rrrn.ri-...-nr.:-.�*-T•a.r:-rr-s�-'i+,r.Wit:.*.s-o:T.T.ro-1<
1 TOWN OF Barnstable WARD OF HEALTH - - -
SUNSURFAU SF,NACE DISPOSAL SYSTEM INSPECTION FORM - PART D CEIITIFICA i TIUN
T. T .. —�.,1'.^�TT1.T..�T1-R:T'TIT'RTTTTTITT'r1'.r—•.'1r1tTR"i TT1TNI-TIITTTGTIT Ri^PRTIiT1('.P7CT1
rmin''mrnTirs-*TT+r+Tn:•�trr.- r � � AA
TYPE OR PRINT CLEARLY—
PROPERTY INSPECTED
STREET ADDRESS 20 Bates .Street Osterville Mass.
ASSESSORS MAP , BLOCK ANU PARCEL # 140-58 —j .
OWNER ' s NAME Richard McGinnis
PAR7' U - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME Joseph P. Macomber &'"ion Inc
COMPANY ADDRESS Box 66 CentervilYe Mass 02632
5 t r e 9 t - Town or City Stat. iIP
COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true , ' accurate , and
omplete as of the time of , inspection . Tile inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
With my training and experience in the proper function and maintenance of site sewage disposal systems .
Check one :
System' PASSED ,'
The inspection which I have- conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section o•f
this form .
System FAILED*
The inspection which "'I hFiv:"can�'a c t e d has found that the system fails to
Protect the public health and the environment in accordance with- Title 5 , 310 CMR 15130.3 , Tand as specifically noted on PART- C FAILURE
CRITERIA of this inspection form ,
Inspector Signatur Date
F
....-..�-.�T..�_T�-..-.
ne copy of this c rt.ifica``tion must be provided to the OWNER , the BUYER
( where applicable ) and the I30AFiD OF It EAL7'II ,
* It the inspection FAILED , the owner or operator shall upgrade eyatem
within one year or the date of the inspection , unless allowed or required
otherwise as provided in 3.10 ChIR 15 . 305 ,
partd , doc
.-t
6
No...... .......... S �i Fms... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
iV` ---11.4......:...........OF .? it.pp..�> .... :..
Allp iration for Bispaa al Works T11notrurtivat rumit
Application is hereby made for a Permit to Construct or Repair, ( ) an Individual Sewage Disposal
System at: `
' � 'loCciatlio�n-Address -or Lot No.
....-•................__................ /....--n---.�...........�,,,,,,,,1,------------- --....-•----.---•-f---_--...................... •-------------.....------............--...............
_....... . ... ................ . .��L.l. •---:�ML_TT'c... ......... R i -r A 6 dress.......
d
Installer Address q
Type of Buil in
U yP g , ` Size Lot...�.�k xao_S . feet
Dwelling—No. of Bedrooms.....3...................................Expansion Attic (M� Garbage Grinder (14)3
a`L Other—Type of Building No. of persons............................ Showers
g -----•-------•-•--•----- P ( ) — Cafeteria ( )
dOther�tures ----.....................-............................................................................................................................
W Design Flow........ ...............................gallons per person per day. Total daily flow........�3-0....................gallons.
WSeptic Tank—Liquid capacity.lCM..gallons Length.,E�.":nG.._ Width.Q_.-LQ". Diameter-----'-----•Depth_.5"-e y
xDisposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......�L.......... Diameter..... .......... Depth below inlet......C,e.......... Total leaching area.` od_..sq. ft.
z Other Distribution box (Y�os Dosin4,t.,ank (U�
aPercolation Test Results Performed �t �... EX.' ..i�k`�_ ... Date...' !g1,.8...
Test Pit No. 1...AZ-..minutes per inch Depth-'of Test Pit....A.Z-........ Depth to ground water--..4'�a.��.A!c
� .. P gT Nf,Vm>
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
o Description of Soil..Q� __Z,Q�- --- � z '�
U _--��'----
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'ML.11 5 of the State Sanitary Code—The u dersigned further agrees not to place the system in
operation until a Certificate of ompliance has be i ued by e board of health.
_
Sig d. .• •-- .. ���' .
r to
Application Approved By..--:---- ..............----. . --.....
� ( ....... ..... ........ 6•-- .�
Date
Application Disapproved for the followin asons:................................................................................................................
--••-•-•--•......................•--------•-----.....---------------------.....----...-•-•-•-----•---------------------...........---------•-•---......................................................
Date
Permit No..... ..�O---r--� .7�----------------- Issued.....................................................
Date
r
ram'.,,✓-
.
No................-....... Fss.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applira#ion for Uiopooal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct � or Repair ( ) an Individual Sewage Disposal
System at: ,
-- - •--•---•-•_.. .................•---
Lo cation-Address or
- or Lot No.
._...._.._�--•--•--• ---------+ ---------- ••----....--•--•• --•-•-------•-•-•----•-------------..........---------
a —{f:5.. •--�jlll•17rti� ^-. L f.i.. .:..L./ ddress..........................................
Installers �ddress
d Type of Buil ing Size Lot___l }. 5 ?Sq. feet
U Dwelling—No. of Bedrooms____.�__________________________________Expansion Attic ( Garbage Grinder ffi)C>
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----------------------------------------------------------•-•----•-----------•--------•---•---•---•--... -------------.....••------•_-.._......••--
W Design Flow_________�v.__....___................._......gallons per person per day. Total daily flow........... .�s0..............______gallons.
_"
W �Septic Tank—Liquid capacity_���gallons Length_� _ � Width--!.'-.I Width_ _ 1_` �?��_ Diameter.__..._._ '. De pth__��:`�{-x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......... Diameter.....�';).......... Depth below inlet____........... Total leaching area. - .�a_.sq, ft.
Z Other Distribution box (110-Ts Dosin nk ("o
Percolation Test Results Performed by.___._ .._ �____ Date... �_____._._..
aTest Pit No. I.__ ' :-.minutes per inch Depth of Test P -------?_____..... Depth to ground water-� 1. =- ttX�t.a ice.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of ,qiI__ _ _ G? __..__- E-13..%•1`:----•---.G'-" � 6�1 C�'� '��__`�r)-, � L—k_�` 1�1� � --
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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 TITLE 5 of the State Sanitary Code—The un ersigned further agrees not to place the system in
operation until a Ce 'ficate ofgompliance has be issued by t-e board of health.
Signbd.. ----�---•-- f����.�! �------•----------------•- -•-;----------_....----...�..._
Date
Application Approved B
Date
Application Disapproved for the f ollowing•rasons:----------------------------------------------------------------------------•--------------.._._-----........._
----•----------------•-----------------------------------•--•----•--------•------•--•._..__._..._..._•--•.._..•-•--•-••-••-•••-••-••-•••-------•----.................... ...............................
Date
PermitNo..........................-.............................. Issued_.......................................................
M: 3
Date
THE COMMONWEALTH OF MASSACHUSETTS
-------�` BOARD OF HEALTH
....... ..................OF............ ......................................
Trriifiratr of Tomplianrr
THISIS�"7 0 CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-S c . \ -
c Installer _
..
---------------------•--•--------------•-••-•----••---•-••-
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s des ribed in the
application for Disposal Works Construction Permit No.__�_ _R
-------- dated-.� dated_.-.
_..��.;�-- ---�- --�-�---`-...................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. d
DATE.............. ... l -- g �...._........ Inspector -�^'�
THE COMMONWEALTH OF MASSACHUSETTS
�-- BOARD_.OF HEALTH
< ..............5�t. . OF..---.-._....................................................................
No.... ............. l9 FEE......:2............
Ropooal Works Tonstrudion ami#
Permission is hereby granted.............. _�._��____ � '___.
} ---.-•--- --__-- U
to Construct ( �� or Repair ( ) an Individual Sewage Disposal Syste
at No.... •••-•.41---�••---•--• ` ' `' e........0"� ' b•1 If
Street
as shown on the application for Disposal Works Construction Permit No._ G_:_.?_5_� Date _______�� _. '_�__ ..fie.--••-•
---•••------ • ....
.......----•----._._... and of Health
DATE--------------- ---- ---------------•-----•-----
FORM 1255 HABS & WARREN, INC., PUBLISHERS - 'Nk
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` - DEMOLITION NOTES: GENERAL NOTES: ELECTRICAL NOTES: aaJ�O
1.All debris to be disposed of in G.C.provided,on-site dumpsters. 1.It shall be the responsibility for all sub-contractors tohave examined 1.G.C.to verify all existing and new outlets,tv jacks,phone jacks,
and reviewed the complete set of working drawings and/or specifications thermostats etc.to ensure proper location and quantity. Designer to verify / Q C�QC40
2.Demolition contractor shall be responsible for-contacting Dig Safe prior to and to provide all labor and material for their respective area of work for a heights and locations of the same. P
start of work. complete and finished installation in compliance with the intent of the ` 6 Jq
~
drawings and/or specifications,whether or not,shall be in compliance 2.G.C.to verify proper placement for phones,FAX machines,modems an
3.Demolition contractor shall verify that all utilities have been properly with all building codes and ordinances which are applicable to the audio equipment. All wiring for phone,audio and cable will be installed and m'
disconnected. project supplied by Audio company if applicable. C a f!n
2.Sub-contractors shall cooperate with each other and with the G.C.to 3.Electrical Contractor to verify all new and existing loads and inspect any o
provide materials and labor that are necessary in each others work at the existing equipment so that the final electrical work meets all current codes.
proper times so that the construction schedule is not affected:These Refer to electrical plans for further information.
interfacings shall be the responsibility of the sub-contractor whose work
is affected as such. -4.All appliances and fixtures shall be U.L.approved.
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SCOPE OF WORK 5.Provide GFI outlets,where required code, Verify ocations with designer. Z
3.All.work shall be performed by qualified contractors in strict h id b Vif l J
1.Renovation as per plan accordance with Manufacturer's specifications. .
6. Install smoke detectors as per code.
4.Product
Manufacturers indicated in schedule and/or plans were
selected based on quality,style,size,color etc.and are not intended to 7.Refer to designer for switch and outlet types. Colors to be determined.
_ be used as substitutes and are subject to Designer's approval in writing
prior to product purchase and installation. 8.Refer to electrical plan for fixture types and specifications.
5.The sub-contractors shall be held responsible for the removal and 9.Electrical contractor shall label all panels with type-written directories.
disposal of materials and items commonly referred to as"debris"or
determined by the Designer to be refuse. ` 10.All electrical and communication outlets to be at 16"vertically mounted. F
All light switches to be at 42"unless otherwise noted. F
6.All materials,colors,fixtures and finishes are to be selected by the w
Designer unless otherwise noted. 11.Contractor shall guarantee all material and workmanship free of defects
from a period of not less than one year from the date of acceptance.
7.Written dimensions govern. The contractor shall not scale the plan.
12.Correction of any defects shall be completed without additional charge and
8.Framing contractor to furnish all anchorage for crown moldings, shall include replacement or repair of any other phase of the installation which Co <
baseboards,wall units as required by millwork/cabinet contractors,etc, - may have been damaged there by. 0
N
9.The Designer shall not be responsible for any deviations from these 13.All work shall be performed by a licensed electrical contractor in a first
drawings as dated on this sheet or approved addendums to this seta" class-workman like manner. The completed system shall be fully operative u L
and accepted by Engineer/Architect/Designer. � 4-1
10.All lumber in contact with concrete shall be pressure treated. " O
14.It is not the intent of these plans to show every minor detail of construction. o N
11.All contractors are required to have insurance for protection against The contractor is expected to furnish and install all items for a complete CY N
public liability and property damage for the duration of the work. electrical system and provide all'requirements necessary for equipment to be N ate+
C placed in proper working order. o fo
12.The painting contractor shall finish all walls(new and existing)with oil G � N
base primer where wall paper is to be applied. All trim elements and 15.Please confirm exact locations of all equipment with Designer. a a
interior doors shall be finished with semi-gloss oil based paint.
OV@CVO@W 13.All work shall be performed by licensed contractors in a first class c
workman like manner and make the completed systems fully operative. PLUMBING NOTES:
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1.Plumbing work shall conform to all City,County,Health Department and ,0
Building Code requirements. Refer to Designer for additional information. V)
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2.Furnish all labor,materials and equipment required for the completion In (n o
o� erheaters,plumbing fixtures and other
systems as indicated. p g
f soil,waste,vent,domestic water � c c o
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3.Plumbing fixtures,trim,accessories and colors shall be selected by the 3 E "
Owner or Designer. Verify with Designer. "
4.Verify all dimensions with the designer prior to fabrication or installation FAE
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FE-i, CO, INC. REFERENCE: ASS
MAP 140 PARCEL 058
ENGINEERING - LAND SURVEYING
.i SCALE `. 1"=20' DATE 5/13/10
P.O.BOX 1.66 ORLEANS, MA.02653
(508) .255-8141;;' WWW.FELCOENGINEERING.CQM% REVISIONS SHEET No. 1 OF 1 JOB No. 10056
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