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HomeMy WebLinkAbout0063 BAY STREET - Health Oo 63 Bay Street Osterville A= 117-145 1 3 0 C i J �j s � S M E;A��Dj v No. � UPC`i2134 J 0 J smead.com • Made in USA X f �a Commonwealth of Massachusetts • , : . fY Title 5 Official Inspection Form r hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments..: { :F � sr_•T,, t,' 63 Bay St Property Address P�? James Bell Owner Owner's Name y` information is required for every Osterville MA 02655 3-11-19 page. City/Town _ State Zip Code Date of Inspection =w 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. A. Inspector Information 674 /3(o&o - Shawn Mcelroy Name of Inspector ' ' ' Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth r MA: 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15,340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at thep`roperfy address listed above;the information reported below is true, accurate and complete as of the time of my inspection' and " the inspection was performed based on my training and experience in the proper function and ' maintenance of on-site sewage disposal systems.After co_nducting this inspection'I have determined that the system: ' I. ® 'Passes 2. ❑_.Conditionally Passes• I 3. ❑ Needs Further,Evaluation by.the Local Approving Authority 4. ❑ Fails 3-11-19 f . Inspector's Signature - Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and C + 1) 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: System is in good working order with no sign of failure. - 2) 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): r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 l ' ,� Commonwealth of Massachusetts ,. Title 5 Official InspectiowFor' m. . ' �,M Subsurface Sewage Disposal System Form-Not,forVoluntary Assessments . ! 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 page. City/Town t h. - State Zip Code Date of Inspection C. Inspection Summary (cont.) 4• 2) System Conditionally Passes•(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if ` pumps/alarms are repaired. ' ❑ 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): ' ,r w ❑ broken pipe(s)'are replaced ` ' " ' "EJ Y' -❑N '❑ ND (Explain below): * ' El obstructionis removed " ❑ Y ❑N ❑ ND (Explain below): ' El + distribution box is leveled or replaced`, ❑Y:, El N El ND (Explain below): r ❑ 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): 3) 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"ystem is failing to protect public health,`safety or the environment. a. 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: t t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form I'll I Subsurface Sewage Disposal System Form =Not for Voluntary Assessments } t,•�H +f', 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic,tank and soil absorption system(SAS) and the.SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: - You must indicate "Yes"or"No"to each of the following for all inspections: Yes No A ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r ,,� Commonwealth of Massachusetts ra '� Title , 5 Official. Inspection Form I�I� p %► Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 63 Bay St Property-Address . James Bell %_ Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 .. page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ;; 4)_,,System Failure Criteria Applicable to,All,Systems: (cont.), _ . Yes, No M ' t Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® 'or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow' . El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: EL. ® ;- 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 ❑ Any to a surface water supply. ❑ t ® Any portion ofa cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 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 cesspool serving a facility with a design flow of 2000 gpd- ❑ • ®: 10,000 gpd. 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 r necessary to correct the failure. 5) 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,C.4. t, . 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 Y rY 9 PP Y ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r, Title 5 Official Inspection Form' )"l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �r 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional_office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No r ❑ ® 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 flow's 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? • ® ❑ Wasthe 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)] i t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form p Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments T,:;e;>' 63 Bay St y Property Address „ .James Bell r Owner Owner's Name information is required for every Osterville . _ MA 02655 3-11-19 page. City/Town State: Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of;bedrooms (actual): 5 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: ' Number of current residents:' - •, 0 Does residence have a garbage grinder? „ ,, ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? - ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? r ,1 ❑ Yes ® No Last date of occupancy: _ , 2018 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18- Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay St Property Address James Bell ' Owner Owner's Name information is required for every Osterville MA 02655 . 3-11-19 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: f 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments.. r U r, jo, I �._,.•T,:;, 63 Bay St Property Address James Bell r Owner Owner's Name information is required for every Ostefville MA 02655 3-11-19 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) :• k. ' . 4. Type of System: f ® Septic tank,distribution box, soil absorption system ❑ Single cesspool T . ❑; ,, --Overflow 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 _ i , ❑h . Tight tank.Attach a copy of the DEP approval. ❑,` Other(describe): , . _ r•. Approximate age of all components, date installed (if known) and source of information: Tank and field 1983 with tank pump chamber unit added in 2011 ! Were sewage odors detected when arriving at the site?,. : _ El Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ® cast iron ' r® 40 PVC' ❑ other(explain): ` Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form 4. '=' I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection D. System Information Cont. 6. Septic Tank (locate on site plan): Depth below grade: Tank 1-18" / Tank 2-24" 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: Tank 1 1500 gal Tank 2 1500/500 H-20 Sludge depth: 12" on both Distance from top of sludge to bottom of outlet tee or baffle- . 20" on both Scum thickness '0 both Distance from top of scum to top of outlet tee or baffle 6" both Distance from bottom of scum to bottom of outlet tee or baffle 16" both How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert;evidence of leakage, etc.): Both tanks in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts - .� y Title 5 Official •Inspection Form '. zl, Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments . 63 Bay St Property Address James Bell Owner Owner's Name r information is required for every Osterville MA 02655 3-11-19 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I r 7. 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.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form ial Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Bay St y Property Address James Bell Owner Owner's Name information is required for every Cisterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.). h 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 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): Good condition with water at working level and no sign of back-up from field. r t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form ref Subsurface Sewage Disposal System'Form -Not forVoluntary Assessments - f" 63 Bay St Property Address James Bell Owner Owner's Name ' information is Osterville r . MA 02655 3-11-19 required for every + page. City/Town a, State Zip Code Date of Inspection D. System Information (cont.) I 10. Pump Chamber(locate on site plan): Pumps in working order: .`±, L ® Yes ❑ No* Alarms in working order: ' ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber in good condition with pump and alarm tested. h * If pumps or alarms are not in working orders stem is a conditional ass:- p P g Y P 11. Soil Absorption System (SAS) (locate on site plan, excavation not required):- -If SAS not located, explain why: Type: Elleaching pits` number: ® leaching chambers number: 5-Flodiffusers ❑ leaching galleriesnumber:g ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection. Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,> 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Cistefyille MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) : Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Flodiffuser field in good working order with no sign of back-up into d-box or surrounding stone. 12. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts - { Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not.for-Voluntary Assessments 63 Bay St _ Property Address James Bell . Owner Owner's Name information is Osterville MA 02655 3-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) � - 13. Privy (locate on site plan): - Materials of construction:' `'' 'r• '' Dimensions Depth of solids ' Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .. 4 . t , t 1 t5insp.doc•rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts 1� Title 5 Official-*Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Bay St Y Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below drawing attached separately c %d J. ` F 30 - " --5� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments 63 Bay St Property Address James Bell Owner Owner's Name information is �r required for every Osterville MA 02655 3-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: _ ❑ Check Slope r • - ❑ Surface water ❑ Check cellar ❑ Shallow wells . Estimated depth to high groundwater: 128 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: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show groundwater encountered at 128". i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ra Title 5 Official Inspection Form rl Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63 Bay St Property Address James Bell Owner Owner's Name information is Osterville MA 02655 3-11-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Information: Co inspector® P A. Ins p Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 �y Commonwealth of Massachusetts j 7 1a,=1 Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 6_3 Bay St_ Property Address " James Bell �- Owner Owner's Name , n information is _r. required for every Ostervllle MA 02655 8-2-166i page. City/Town State Zip Code Date of Ihipection 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. A. General Information 1. Inspector: Shawn Mcelroy __ Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-2-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ms•3, Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts la=� Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments Al;. a� 63 Bay St - Property Address James Bell Owner Owner's Name information is Osterville MA 02655 8-2-16 required for 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: System is in good working order with no sign of failure. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection Form r.l R' w. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments., a� 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No b> ❑ ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ;t ❑ ® 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- 101000gpd. ❑ . ® 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-3113 Title,5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ti Commonwealth of Massachusetts III f Title 5 Official Inspection Form , I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osteryille MA 02655 8-2-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue -. approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts 7 - Title 5 Official Inspection Form = rl Subsurface Sewage Disposal System Form -Not'for Voluntary Assessments 63 Bay St Property Address F... James Bell $ fti7 Owner Owner's Name information is required for every Osterville .MA 02655 8-2-16 z . page. City/Town State Zip Code -Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in My way. Please see completeness checklist at the end of the form. r A. General Information s/�W 74 . . 1. Inspector: r _ k . Shawn Mcelroy Name of Inspector Upper Cape Septic Services • ' Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this'address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: Tk ® Passes - i ❑ Conditionally Passes- r ❑ Fails ❑ .Needs Further Evalu on by the Local Approving Authority, k 8-2-16; Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. -****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17" 0 S Commonwealth"of Massachusetts :a=1 Title 5 Official Inspection. Form p X' •.��1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63 Bay St Property Address James Bell Owner%..t Owner's Name information is required for every Osterville ,t MA 02655 8-2-16 page. City/Town State Zip Code Date of Inspection c,rt ' 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ _One or more system components as described in the "Conditional Pass':section need to be replaced or repaired. The system, upon.completion of the replacement or repair, as-approved by the Board of Health, will pass. , Check the box for"yes", "no"'or"not determined"'(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a,complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Z Title 5 Official Inspection Form G XIII I r; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 63 Y St Property Address James Bell ' Owner Owner's Name information is .. required for every Osterville MA 02655 8-2-16 - page. City/Town State Zip Code Date of Inspection ' B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass,with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ,., jJ`'" ❑ 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 pipes) are replaced ❑ Y ❑ N, ❑ ND (Explain below): 7❑ obstruction is removed 4t ❑ :Ys• ❑ N' ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ •ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) ,Further fvaluation'is Required by the Board of Health: j ❑ 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:Y , r ❑ Cesspool or privy is within 50 feet of a surface water ❑• Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 t e Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection .Form ,nr 41�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � a' p. !a 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: . ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone'1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate `,Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or❑ ® t 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-3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Vill Title 5 Official Inspection . Form >> Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,. 63 Bay St l J Property Address ' James Bell Owner Owner's Name information is required for every Osterville' MA 02655 8-2-16 - ' 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. • ' P ❑ . ® 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. y For large systems, you must indicate,either"yes" or."no"to each of the following, in addition to the questions in.Section D:.' Yes p 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 nitrog en,sensitive area (Interim Wellhead Protection El ❑ 'Area— IWPA) or a mapped Zone II-of a public water supply well Iif you'have answered "yes"to any question in Section IE the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form -1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments teA' 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on.the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form :�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay St t J" Property Address L. James Bell ,e•;, Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder?:'.. ❑- Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ; '.t ❑ Yes ® No A Seasonal use? - Tfi , <.. .u;. ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): •r Detail: Sump pump? .:. El Yes ® No Last date of occupancy: €, ( 8-2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: , Design flow,(based on,310 CMR 15.203):1 a ?'Gallons per day(gpd) Basis of-design flow(seats/persons/sq.ft., etc.): Grease trap present? t. . > ° „ .f t�„t ❑ Yes ❑ No Industrial waste holding tank present?' .,° ❑ Yes ❑ No' Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposaf System-Page 7 of 17 Commonwealth of Massachusetts I+ f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,_p_ems!✓ 63 Bay St l 1' Property Address James Bell Owner Owner's Name information is Osterville MA 02655 8-2-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11 Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool +: ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 63 Bay St Property Address }.. James Bell 4, . Owner Owner's Name information is - • - required for every Cistefyille _ MA 02655 8-2-16,'' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . f Approximate age of all components, date installed (if known) and•source of information: Lach field 1983---New tank and d-box 2011 Were sewage odors detected when arriving at the site? at ❑ Yes ® No Building Sewer(locate on site plan):- , 32" Depth below grade: feet Material of construction: -' ❑ cast iron ® 40 PVC (explain):,, 0 other ` Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): t r . Depth below grade: 24"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: - 1000/500gal--2 compartment H-20 10" Sludge depth: t5im•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts laa Title 5 Official Inspection Form f, Al. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a% 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 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 22" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts ail f Title 5 Official Inspection Form ' 'f;4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments- 63 Bay St Property Address James Bell ` Owner Owner's Name information is Osterville' MA 02655 8-2-16'• required for 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.): a .:} V , 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts as Title 5 Official Inspection Form f 1.1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Jf!a 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 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 0 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.): Good condition with water at working level and no sign of back-up from field. 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.): Pump and alarm tested and in good working order. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 it • Commonwealth of Massachusetts =1 Title 5 Official Inspection Form f ' 1* Subsurface Sewage Disposal System Form Not for Voluntary Assessments�+ ;• " •i a_ss!g 63 Bay St Property Address James Bell Owner Owner's Name r, information is required for every Osterville MA 02655 8-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5-Flodiffusers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name,of technology: k Comments (note condition of soil, signs of hydraulic failure, level of ponding,fdamp soil, condition of vegetation, etc.): Flodiffuser field in good working order with no sign of back-up into d-box or surrounding stone. q: Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts t :a=1 � Title 5 Official- Inspection Form W., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay St Property Address James Bell Owner Owner's Name information is required for every Osterville MA 02655 8-2-16 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.): i Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts f Title 5 Official Inspection Fora * . ' 1-2I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 01 14, 63 Bay St , l J" Property Address James Bell Owner Owner's Name information is '= required for every Osterville MA 02655 8-2-16 °' -r page. City/Town State Zip Code Date of Inspection •` D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: - ® hand-sketch in the area below ❑ drawing attached separately Le F ­4 -�E t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �W.", Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments 63 Bay St Property Address James Bell Owner Owner's Name information is Osterville MA 02655 8-2-16 required for 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: 12 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: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database --explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I - Commonwealth of Massachusetts a=1 r Title 5 Official Inspection Form :� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay St Property Address James Bell Owner Owner's Name information is Oste►ville MA 02655 8-2-16 required for 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i v No. l Fee BOARD OF HEALTH TOWN OF BARNSTABLE 01ppricatiou jFor Yell Cou.5trurtton Permit Application is hereby made for a permit to Construct(4 Alter( ), or Repair( ) an individual well at: C-3 S-� 0 omtfv\NVl 11-I1 )g-s Location-Address Assessors Map and Parcel 5'�.rntL6 A ` 07—(.55 Owner �— Address t)uv"t�� Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well 14" '�C �oL�f/ Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Cert' cate of Complian has been issued by the Board of Health. Signed Z Date Application Approved By !/ 5 Date Application Disapproved for the following reasons: j C Date Permit No. y l Issued 7 " _r'I'� Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of M Ytauce THIS IDS TO CERTIFY,that the individual well Construc�te Altered( ), or Repaired( by y Installer at (,e�'3 BWY c��40 OT EU has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector tit No. U i I ( Fee BOARD OF HEALTH ,TOWN OF BARNSTABLE ZIpprfcatiou _for Yell Cougtructiou Permit Application is hereby made for a permit to Construct(f), Alter( ), or Repair( ) an individual well at: � --J Loc tia on-Address —r Ass ors Map and Parcel Owner S Address ,o Installer-Driller Address— Type of Building Dwelling Other-Type of Building No. of Persons Type of Well `�, ®�} ��� �( Capacity Purpose of Well ktt i%pA,pv, Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Cert' Cate of Complian a has been issued by the Board of Health. Signed ___ r' 1 Date 4 Application Approved By (� Date Application Disapproved for the following reasons: Date Permit No. {WV" I 1 'y Issued e / — — Dat BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructe , Altered( ), or Repaired( ) by Installer has been installed in accordance with the provisions of the Town of Barnstab a Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Cou5tructiou Permit No. � a v l 1 — v I a Fee S Permission is hereby granted to 7b=JQY of & ' Installer to `/ Construct JJ(��jj , Alter ), or Repair( ) an individual well at: No. CGS t )1 f 7 Street �'--- as shown on the application for a Well Construction Permit No. j 201 L4" �' ted S 6? —l�/ Date Approved By 4S i 3b"E j .4 1 TTELI w oH,�---- \ T ' HE % FLOOD ZONt LINE DIVIDINrC� z - �\ '` 30 E NE ZO FROli ZONE A 111 BASEL h— WA \ \ ON, ti TJ,a� A-THE-GROt NC 7� z 7'-'E�v i1 V��..i �UiV�IE�i SURVEY- T." �' a t I I PROP. 1000/500 GAL. O 2-COMPARTMENT H-20 MONOLITHIC SEPTIC TANK EXISTING CESSPOO" BE PUMPED a , I+ i PROP. 2"SCH. 40 PVC FORCE � AND FILLED WITH CLEAN SAND (TYP.) _ �4 ` j ' I I MAIN (SLEEVED) � i 3 C N f POND ,moo Nr � EL.=5.21± STgNE DRIVE o � - Benchmark. I , . Comer Concr. / fH 1 O o ' / L. '\ EIe* 11.33' �o o EXIST. DIFFUSERS (PER cv f N G V.D.29 AS-BUILT CARD)TO REMAIN / \ / INV.L8.2' p. I \ 2 / ^ OF2 ,;: EXIST. DISTRIBUTION \ J a" o - BOX TO BE REMOVED ' f MAP 117 �Ex_cBNr Z R-11 Ns a PARCEL 145. \. PROP. 3. -INLET DISTRIBUTION BOX O INV=15.6't PATIO. < ?3j \ 75,005 S.F.± p LANDSCAPE PROP.4"SCH. 40 PVC (SLEEVED)(T` O OFj ORCH EXIST. 1,500 GAL. SEPTIC TANK TO \ oQON� EXIsTNG ` BE UTILIZED IN THIS DESIGN 4 BEDROO M \ DWELLING .� ' T.0.F-=17.7'± \ A � SLA8=11.3'+ \ S,g43ZZ7I � \ ExIST. 3 I 1 8ED- - c� �� — ly' �aTT. M MAP 117 N� � 2 2"55'43"�V PARCEL 144 MAP 115 ss 00, � ;1 Co' �h •`� . Massachusetts Department of Environmental Protection 3 - Bureau of Resource Protection Well Completion Reports `V Well Driller Please specify work performed: Addres s at well location: New Well treed-umber Street-N 63 BAY ST Please specify well type: o s ap#: Irrigation / Assessor's Lot#. ZIP Code: Number Of Wells: 02655 City/Town: Well Location BARNSTABLE In public right-of-way: GPS t;Yes G No North: West: 41.62824 70.38918 Subdivision/Property/Description: Mailing Address: r click here if same as well location addres Property Owner: Street Number: Street Name: CO HORATIO FURTADO 63 BAY ST City/Town: State: Engineering Firm: ABINGTON MASSACHUSETTS ZIP Code: 02655 Board of health permit obtained: r Yes Ca Not Required Permit Number: Date Issued: W2014 017 5/27/2014 -� Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRIWNG METHOD Overburden Bedrock uger Choose Bedrock-- WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in drill - Extra fast or slow Loss or addition of (ft) stem drill rate fluid 0 8 Sand And Gravel Brown _ YE5 r NO r Fast r Slow Loss 0 Addition 8 20 Fine To Coarse Sand Brown 0 YES C NO r•Fast r Slow 00 Loss G Addition 20 30 ISilty Sand jBrown G YES r NO G Fast G Slow Gi Loss G Addition 30 32 Clay Brown G YES G NO G Fast G Slow G Loss G Addition 32 45 (Medium Sand Brown G YES G NC r Fast G Slow G Loss G Addition WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop in drill Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) stem drill rate fluid Staining Chips Choose Code G YES G NO G Fast G Slow G Loss G Addition Ye Ye ADDITIONAL WELL INFORMATION Developed Yes �) No Disinfected Yes !3 No Total Well Depth 45 Depth to Bedrock Fracture Surface Seal Type lNone Enhancement C,Yes CASING (� I Is Casing above aground. From To Type Thickness Diameter Driveshoe 0 42 Polyvinyl Chloride Schedule 40 ---� 4 Ke SCREEN No Scree From To Type Slot Size Diameter 42 45 Stainless Steel Well Point 0.010. 4 WATER-BEARING ZONES I DRYWEL�I From To Yield (gpm) 14 45 12 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Submersible Horsepower 3l Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Pump Intake Depth(ft) 41 Nominal Pump Capacity(gpm) 15 ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material2 Weight Water Batches Method'Of Placement (gal) Choose Material lChoose Material Choose One-- -� WELL TEST DATA Time Pumping Time To Date Method Yield(gpm) Pumped Level (ft Recover Recovery (ft ` (HH:MM) BGS) (HH:MM) BGS)_ 5/30/2014 Constant Rate Pump 12 1:36 21 0:01 14 WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate(gpm) 5/30/2014 14 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. F PATRICK Supervising Driller DESMON Driller DESMOND Monitoring 1M].istration# 877 Signature PATRICK, DESMOND WELL Firm DRILLING INC. Rig Permit# 024 Date Job Complete 6/4/2014 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. CERTIFICATE OF ANALYSIS Page: 1 'of 1 Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 6/4/2014 Sally Desmond Desmond Well Drilling Order No.: G1480119• P O Box 2783 • Orleans,. MA 02653 Laboratory 1D#: 1480119-01 Description: 6water-Drinkin Wat Sample#: Sample Location 63 Bay St. Osterville, MA Collected: 06/02/2014 Collected by: Customer -' Received: 06/02/2014 Routine M ITEM RESULT UNITS RL MCL METHOD# TESTED .Nitrate as Nitrogen • 6,6 mg/L 0.10 10 EPA 300.0 6/2/2014 Iron 0•79 mg/L 0.10 0.3 EPA 200.8 6/3/2014 Manganese -0.050 mg/L 0.025 EPA200.8 6/3/2014 pH 6.3 PH AT 25C NA' 6.5-8.5 SM 4500-H-13: 6/3/2014 Sodium 27 mg/L 2.5 20 EPA200.8 6/3/2014 Total Conform Absent P/A 0 0 SM 9223 6/2/2014 Conductance 340 umohs/cm 2.0 SM 2510E 6/3/2014 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician: The water may present aesthetic problems(taste, odor,staining)due to Iron. Attached please find the laboratory certified parameter list. Approved By: _ (Lab Director) t ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 No. e�b`` J THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH OFrilsable- tso APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (V/ Abandon ( ) - ❑Complete System '1Q Individual Components to�i L3av 5�cee� Oske_Wi11r_ Audre.y Ca Farle j Location IOwner's Name H4� k i l 309 yii ilslde AW-1 westf zAck &q y en t, PMap/Parcel# Address arce,l i �5 Lot# Telephone# �C Eineerl i 1 tl)t_ 1� Install s ame Designer's Name 6- 1 2b5y Cccn`o"fy E. watc.6m,NA az63 , ; Add,,,, �dg 3ff5� Address 1 ,508- 273-03 77 Telephone# Telephone# Type of Building: 15t,n5te- F`zw"Ir awe.ltfn�s Lot Size 7.5,100.5- Sq.feet Dwelling—No.of Bedrooms f6jc(s) f0or-A 4 Garbage Grinder ( ) Other—Type of Building .No.of persons Showers ( ), Cafeteria ( ) Other fixtures 4Y only h li oseaeoi pk-im CM 1-o 5 VN eW, iWO/5e al• tartki ► e � - (no inc eQ of "ow ) Design Flow(min.required) gpd Calculated design flow ` gpd Design flow provided ' gpd Plan: Date Mai it . Z 0l l Number of sheets Revision Date Title fr'ayoseJ s' 'is sj sVqwl uegade Description of Soil(s) See- attache eIqn Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS SnSpa« a anew 10001,500 S4QOn 2- caLqe0rA%4e-0 fnonali-lhiC H-26 k041C %120,MP 60"Yiloec, ne-j 3 i'nlci J-look -� associoa e_cl e4c, eietT C,%-mecA ko extsVnR _-g1QSe_ clWos41 sv, 6m (m Clcceetse_ of Blow) The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signe Date l Inspectto 1( FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 °.^' .... ♦ �"31; e`2Ff"..-Tr�,rs.cea�• .:tu�ja...',�»....-+My[.,"'7y}. u» T.y r +Ct'1 �' , -,.,�.�,.:e.,-r`''�:.`..,r Y.,,. t. r 1 �!' ---,"_. .. [}tt,A(( ! r J n,,".F`. ,,.�1z.r ii�' ',,� 'S ..may..- �.�.w.y,, '1h•.. 1�.-y,,....tr'''. f t �� 3•'�� + is ,f ', iJ 'Al\y )j 1 No. /l Jv/ THE COMMONWEALTH OF MASSACHUSETTS FEE v .- - �' 1BOARD OF HEALTH _ OF CtjortnSEalo�2 .APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT .Applicati n'for a Permit to Construct ( ) Repair ( ) Upgrade (V Abandon ( ) - 0 Complete System MIndividual Components 4'A 60V ,Stree.'f os�ecyikko NA AUdcey C. Foclev y�'k,,N ' Location � g Owner's Name ' Map 301 $llslde ALC: wesiEtLAA. N1 V696 r Map/Parcel# Address aice�- y-5 1� 9. « j t#Lot Telephone# •` # s' SC Er�ic►eectrs5 t Tit c. Installer's ame i Designer's Name v*Y 1 I Z 85 y cconbut y Ni�inWCV! E, wo(c�nowt,H N o2 53 K Address Address 1510j?� q :5 ,22 5of3- 273-0377 l Telepho ye#" 't 1 Telephone# _ 409 ,A�w�`1yy wcll�tn�5 Lot Size �✓{t ��� Sq.feet Type of Building g- � 61 ' �'.. Garbage Grinder ( ) Dwellin —' �'No.of B1dero oms `Et�e.�5� �-o}c�� •�` Other—Type,of Building r..! No.of persons Showers ( ), Cafeteria ( ) Otherfixtures_ 1 A' I IY rt�g Y_xtstin5 bascvoe.Ai osu�n Vvi% to PJttSiivl� SAS yiA "op. 1000/.600 g4i tank (00 incte4 OF Elow) Design Flow(min`required)--f�.1-r .gpd Calculated design flow gpd Design flow provided ' gpd Plan:,Date hQy 07 Z o(1 "Number of sheets �� f t) Revision Date Title Pfaposeg 5co}Ie Sys}cwl UQgfode Description of Soil(s) See al{achecl plate Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Yn SIaU a thew )0001500 541W) z- C0meorittnk0 Monalr-Ihe. N•z0 ��nK %�t�r+P c4t6ftv►1�e� new 3 tv►le� �-�ocrX t e�ssoeicFed eyC. Qi�t�� k Ccgnec( ko extsltO5 _<Ak4jGee_ dtuosci s.cicdt► Cno ioc(ea5e- m- Flag) r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. . ,�. Signed ,/ l/ Date l614 2,P/t • Inspect s 4 ' FORM 1 - APPLICATION FOR DSCP e , DEP APPROVED FORM 5/96 t " }Lk �-,o,rain as a ra ru as:w v..�u s.�.r�u�+u�.s�..-..-.. t—r. mr r u�`—a—r—v————— ¢,; No. l �'"�� THE COMMONWEALTH OF MASSACHUSETTS FEE . �0 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) r by: ►'n at CO 17) � . �S� i2glv - has"been installed in accoAialce with the rovisions of 310/CMR 5.00 (Title 5) and the approved design plans/as-built ­i plans relating to application No. //` dated h/0_7//I Approved Design Flow .15-5® (gpd) Installer V �- M Designer: Y Inspecto - fflDate The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. / FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96" No. + } THE COMMONWEALTH OF MASSACHUSETTS FEE .0 r BOARD OF HEALTH I DISPOSAL SYSTEM CONSTRUCTION PERMIT . Permission is hereby granted t99}Construct ( ) Repair (1 ) Upgrade (/�) Aban on ( ) an individual sewage disposal system at t 1 <1� 6,4-l1 y//c?f as described /r � / d f in the application for Disposal System Construction Permit No. r �i( dated 6 1 0'7! 1 r Provided: Construction shall be completed within three years of the date of hi s--permits J1 al conditions must be met. Dated Board of Health I 6 FORM 2 - DSCP DEP'APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARRENTm PUBLISHERS-4BOSTONA 07/28/2011 20:42 5082730367 #0.356 P. 001./001 Town of Barnstable Regulatory Services Thomas F.Geiler,Director UMSTABLE, Public Health Division j 631 e� Thomas McKean,Director 6D Mp't • 200 Main Street, Hyannis,MA 02601' Office: 508-862-4644 Fax. 508-790-6304' Date: g-o t. t I Sewage Permit# I� Z °" Assessor's Map/Parcel W7 I i yS Installer&Designer Certification Form i Designer: SC Installer: Address: ?b5y Address: �� �l�l�(-77:�' --- ¢c,�� Y On // M Tcfi r was issued a permit to install a (date) (installer) y. n septic system at �� e)� Sk(ex, based on a design draw :by (address) 'G En��tOee;tag nC', dated (designer) certify that the septic system referenced above was installed'substantially"according to the design,,which may include minor'.approved changes such as lateral relocation of the -= distribution box and/or septic tank. Stripout (if required) was inspected and'the soils rn were found satisfactory. t co { 1 certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but iJacco, ce with State..&Local Regulations. Plan revision or certified s-built by desigw. Stripout(if required)was inspected and the soils' we furls �y.YM 4F i JohN Ch uRvN��L (Installer's Signature) J iL • <ra y ' esigner's ignatur 7ALTH p Here) ; PLEASE RETURN TO BARNSTABLE PUBLIC DIVISION, CERTIFICATE„ OF COMPLIANCE- WILL NOT BE ISS>C1ED YINTII. BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAotTice formsldesignercenifieation fonn,doc Town Of Barnstable , Permit Number ,Derutment of Public Works BnaNsz►s E _ 230 South Street,Hyannis MA 02601 http://www.tbwn.bamstable.ma.US- Office:Office: 508,862-4090 Fax:-508-862-4711 ROAD OPENING/TRENCHYPERMIT Pursuant to G.L.c.82A§1 and 520 CMR 7.00 et seq.(as amended) Section A Name of Applicant Phone Fax "IV115IR Mailing Address Email Address Name of Excavator (if different from Applicant) Phone Fax Mailing Address Email Address l section B N — Name of Prope Owner Mailing Address 2 07��o 6 3 A79&r // // ❑ Public W ❑ Private Way Property A dress Map/P rcel, rivate Property Does this excavation meet the definition of a"Trench"per 520 CMR 7.00? J Yes ❑ No - If NO; go to Section D A trench is defined as a subsurface excavation greater than 3 in depth, that is 1 S'or less between soil walls as measured from the bottom. Section C we `'✓CG500�q; G,/L '684577172(06 2TIA All <5/Z�iZ �d'1�T0 I?9b� 709/�s.61 ,0 5/2P>z ' 1-t�� �yP /wiz Excavators Insurance Certificate# Policy Expiration Date yd141.0 ®aA A- - 509='?5-iG zD Name and Contact Information of Insurer: DigSafe # � 17�1 C�C iVtC�OGV�f,L s 3131i9WM /2AX )CD IN&Y 7-75" l 121 Name and address of Competent Person(as defined by 520 CMR 7.02) Name of the Person performing the excavation of the Trench 1 it �I1 0 W n 6gllglaU/,� Massachusetts Hoisting License # License Grade Expiration Date Section D Description,location and purpose of proposed road opening or trench. Include a description of what is to he laid in proposed road opening or trench(eg;pipes/cable lines etc..). Please use additional sheet if more space is needed. f By signing this form,the applicant,owner,and excavator all acknowledge and certify that they are.familiar•with,or,before commencement of the work,will become familiar with, all laws and regulations applicable to work proposed, including OSHA regulations,G.L.C. 82A,520 CMR 7.00 et seq., and any applicable Town of Barnstable ordinances, by-laws and regulations and they covenant and agree that all work done under the permit issued for such work will comply therewith in all respects and with the conditions set forth below. The undersigned owner authorizes the applicant to apply for the permit and the excavator to undertake such work on the property of the owner, and also,forth," luration of construction,authorizes persons duly appointed by the Town of Barnstable to enter upon the property to monitor and inspect the work for conformity with ne conditions attached hereto and the laws and regulations governing such work. The undersigned applicant,owner and excavator agree jointly and severally to reimburse the Town of Barnstable for any and all costs and expenses incurred by the' Town of Barnstable in connection with this permit and the work conducted thereunder, including but not limited to enforcing the requirements of state law and conditions of this permit,inspections made to assure compliance therewith,and measures taken by the Town of Barnstable to protect the public where the applicant owner or excavator has failed to comply therewith including police details and other remedial measures deemed necessary by the Town of Barnstable. The undersigned applicant,owner and excavator agree jointly and severally to defend, indemnify,and hold harmless the Town of Barnstable and all of its agents and employees from any and all liability,causes or action,costs,and expenses resulting from or arising out of any injury,death,loss,or damage to any person or property during the work conducted under this permit. The Department of Public Works must be notified at least 24 hours in.advance of scheduled trench compaction,and/or repaving. Cutting of pavement is prohibited at all times unless prior approval is given by this,permit application.Newly paved roads have a five(5)year moratorium for cutting of pavement and permits will not be granted unless the need for cutting is proven to be a necessity for emergency repairs. THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION THIS PERMIT EXPIRES 90 DAYS FROM DATE OF ISSUE t f DATE: APPLICANT LICANT SIMNATURE y DATE: EXCAVATOR SIGNATURE (IF DIFFERENT) For Town of Barnstable use--Do not write in this section PERMIT APPROVED BY HIGHWAY DIVISION Date: Fee: PERMITTING AUTHORITY-DPW Dater ]pate Paid: CONDITIONS OF APPROVAL Check 4 Client#: 17112 2PKMC0 DATE(MMIDDIYYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 0610312011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIF-,E HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dowling&O'Neil Insurance PA/C N"o"E 0. Ext 508 775-1620 FAX No): 5087781218 E-MA Agency -ADDRESS: 973 lyannough Rd., PO Box 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 t. INSURER A:Travelers Insurance Company. INSURED INSURER B:Associated Employers Insurance PKM Contractors,Inc. ` INSURERC: P.O.Box 775 INSURER D: East Dennis, MA 02641 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: ' - I REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRR ADDL SUB POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MMIDD A GENERAL_ LIABILITY 1680571 D2662TIA11 510412011 05/04/201 EACH OCCURRENCE $1 000 000 X'COMMERCIAL GENERAL LIABILITY PREMISESEBEOBE ante $300 U00 CLAIMS-MADE a OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 + GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OP AGG $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ POLICY PEt° LOC COMBINED SINGLE LIMIT 1 OOO,OOO A AUTOMOBILE LIABILITY BA1796A70911 SEL 5/04/2011 05/04/201 Ea accident $ BODILY INJURY(Per person) $ M TO NED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident $ AUTOS X AUTOS ELLA LIAB OCCUR EACH OCCURRENCE $ S LIAB CLAIMS-MADE AGGREGATE $ RETENTION$ WC STATU- OTH- COMPENSATION WCC5008068012011 3/27/2011 03/27/201 X. Y I E OYERS'LIABILITY E.L.EACH ACCIDENT $50O OOO IETOR/PARTNER/EXECUTIVE YIN N i OFFICER/MEMBER EXCLUDED? NIA E.L.DISEASE--EA EMPLOYEE $500 000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below e DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived, (e'itended the coverage provided:by the policy provisions. •� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF,, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD LS1 #S822021M82201 _ T01N1�Old BA�LNSTABLE � -- - LOCA'�'i0Nj 3C / ..-SEW, AGIE# VEIrLA _ DD►15T�.LL 'S NAIVIE PIONE NO ,�W c��►crrx. c T. L �IING 1�,t4C1I±i,ITY .ice) Kapp W !�[lI1Lt1P1�QR aWPT]GfR. . cowwr.Il4NCL� Sttpmratsori +�Pmnae lee NtaxlmumAd�uiWC U'n�f WA' terTable�atha attomo X cbin�k ilil�+ PlvaSv1i+taY Sully Wc�l said i,%, tin���liry`.�f mny:�rsils eiitst att slta::ae wlQ4 Wo€eat dP Uai lei fs�illt3').: Pest r 0�t tet�and and�La.I.w t hol,ty gray welland�exist ulttu»'�UQ fi:et'pf eo�iins I'ac�cy ,f r: Fee l S T4�'VV T O f T 'X AM SEWAGE .oCATIo SSESSOR'S 1vrA� z:0x �.. �cA �L ,��s rr pcz`tl~ El�`I C QA.pA?C�CY E ACM d PACILYT"1C: (type) P)BRMITDkM ,._ 5npr�Cio��3a�;eAn�G I��tv��era;txae� 1Vlaximuml��justcsd GCpuYedwatet'�'�blata tl�c BdttonidL60hin RIrilicy l lv�t :�JVatc� Supl►ly'V`141'wil�.caczhjre� 1cai,�ty Of. vicl9s cxfs$ "�r38 F�.cl i^c. UVet� rJ and 1:cAGtg9tt i~SCIAt¢y any wctland5 exisE / iyitfaiii 300 fe. leaaliins 4`uci � S��, : 4. p a 0 0 - F A So ' 5-E - 30, o-M- Co ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay Street M Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �jH OF MqS on the computer, use only the tab o� cy 1. Inspector: r �� key to move your o JOHN L cursor-do not John L. Churchill Jr. P.E., P.L.S.use CHURCHILLJR. N key.the return Name of Inspector N0.41807 JC Engineering Inc. A ,y Company Name SST S � 2854 Cranberry Highway TA AZE Company Address East Wareham MA 02538 City/Town State Zip Code (508)273-0377 PE#41807 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31.0 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F4per Evaluafo th Local Approving Authority June 21, 2011 Inspe s Signature Date T system inspector shall submit a copy of this inspection report to the Approving Authority(Board ealth 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:Subsurface Sewage Disposal System•Page 1 oP17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .' 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 Cityfrown 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: Inspection conducted for only the existing septic system installed in 1985. This report is not for the existing cesspool, which is dedicated to the existing basement plumbing only. Homeowner is proposing to eliminate existing cesspool and redirect basement plumbing to the septic system installed in 1985. 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. El Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley,Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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, t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 'M 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection 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 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: ft D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page: Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection ❑ ® 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 Y2 day flow 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M •' 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 CitylTown State Zip Code Date of Inspection ❑ ❑ 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. C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ 1Z Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑. Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] (Sins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 gpd D. System Information Description: 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 readin s, if available last 2 ears usage d 674 gpd (2010) 9 ( Y 9 (gpd)): 452 gpd (2009) Detail: Water use includes an extensive irrigation system for the property. Sump pump? ❑ Yes ® No Last date of occupancy: June 2011 Date Commercial/industrial Flow Conditions: t5ins+09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System •Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay Street M Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill.Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 Cityrrown State Zip Code Date of Inspection 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: 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 El Single cesspool t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Bay Street Property Address Audrey Churchill Farley &Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. 'Osterville MA 02655 June 14, 2011 CitylTown State Zip Code Date of Inspection ❑ 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): ID. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed in 1985 based on septic as-built card on record with the local Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: approximately 2 feet P g feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on si te plan): Depth below grade: eeto top of tank t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 Cityrrown State Zip Code Date of Inspection 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 Approximately 5.TW x 10.5'L Dimensions: (i.e. 1,500 gallons) 1., Sludge depth: D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 5.5" Distance from bottom of scum to bottom of outlet tee or baffle 17.5" How were dimensions determined? Field 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.): Recommend pumping once a year. Liquid level up to invert out pipe. No evidence of leakage. Tees in good condition. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay Street M Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection 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 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 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey.Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA . 02655 June 14, 2011 Cityrrown State Zip Code Date of Inspection 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 D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 inches 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 appeared level. .Top of d-box to existing grade=22 inches. No riser installed. Recommend a riser to be installed over the d-box to bring to within 6 inches of existing grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection 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: D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Four(4) ❑ 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection FormSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay Street M Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 City/Town State Zip Code Date of Inspection No evidence of failure present at time 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 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ 8 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Bay Street M Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is pwrier's Name required for.every page. Osterville MA 02655 June 14, 2011 CitylTown State Zip Code Date of Inspection Comments (note condition of soil, signs of.hydraulic failure, level of ponding, condition of vegetation, etc.): D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \jai• 63 Bay Street _ Property Address Owner Audrey Churchill Farley & Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Personal Residence Trust information is Owner's Name required for every page. Os/Town le MA 02655 June.14, 2011 City/Tow State Zip Code Date of Inspection 0 STONE DRIVE EXISTING CESSPOOL(FOR O BASEMENT)TO BE O ABANDONED&FLOW TO BE S.A.S. DIRECTED INTO EXIST.SAS �(3 CP D.B. (1 O � i S.T. / HC-1 PATIO SWING TIE MEASUREMENTS.. DESCRIPTION HC-1 HC-2 PORCH HC-2 SEPTIC COVER IN(1) 15.3' 46.6' #fi3 EXISTING SEPTIC COVER OUT(2) 23.5' 48.9' 4BEDROOM DWELLING DISTRIBUTION BOX(3) 36.7' 55.5' EXIST.1 r BED.COTT. D. SystemInformation (conf.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: > 10.7 feet b. .s. feet Please indicate all methods used to determine the high ground water elevation: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Bay Street Property Address Audrey Churchill Farley&Terrance M. Farley as Trustees of the Audrey Churchill Farley Qualified Owner Personal Residence Trust information is Owner's Name required for every page. Osterville MA 02655 June 14, 2011 Cityfrown State Zip Code Date of Inspection ® Obtained from system design plans on record If checked, date of design plan reviewed: November 5, 1984 (last revised 4-12-85) Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Obtained from an observation hole/perc test conducted on the property on April 2, 1985 as shown on the Proposed Site Plan plan dated November 5, 1984 (last revised 4-12-85). Also, observed the water level of an existing 5,000 s.f. pond located approximately 160 feet away from the SAS to be approximately the same elevation as the high groundwater elevation found in the aforementioned observation hole/perc test. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 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 V No.... s. ...._t2 Fim$..............`..-D..._ THE COMMONWEALTH OF MASSACHUSETTS, BOARD OF HEALTH, Appliratiun for Disposal Works Cfnn,�#rnrtiun 1hrutit Application is hereby made for a Permit to Construct Im or Repair (2() an Individual Sewage Disposal System at:: ------------ ----- cation-Address or Lot NQ. jLC O w r �Adr ss I. ........................... -•-••-••..... ..af ................... ZZ Installer " Type of Building , Sig .----.Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ` " Garb; Grinder ( ) Other—Type of Building No. of persons:........................... .M t� yP g ---------------------------- P �Y ., ) — Cafeteria ( ) W Other fixtur ` WDesign Flow.................. .. ...................gallons per person per day. Total daily flow . �� ......... .._....gall"is: WSeptic Tank—Liquid cap Length................ Width............ DDepth., x Disposal Trench—No. ..... ............. Width..... ......... Total Length..._...... Ta. '� area.__. ..... ft. Seepage Pit No--------------------- Diameter.__..................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed osing tank Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch . Depth of Test Pit.................... Depth to ground water........................ .......................................................................................... 0 Description of Soil ................................�----�----•---. .�`Hjl 1 ----------------------------•-•--------...........---•--•.. x U -•------------------------•----------------•-------•-•••••----------------- -•------•---._..__...----•-••........... W -----••••-•------------------------------•---•-••--•--------•-------------:- U Nature of Repairs or Alterations—Answer when applicable_ ............................... ... ._._.. ? _''. ._.....I.... ..... ..................... Agreement: The undersigned agrees to install the aforedes ed Individua ewage Disposal System in accordance with the provisions of IIIL- 5 of the State Sanitary Co —The unde ]g d further agrees not to place the system in operation until a Certificate of Compliance has bee iss ed by the a of hea h. _ Signe ...... _. ....... ............... .. ....... Date Application Approved By.................................. Date Application Disapproved for the following reasons:-------•-------------------------------------•------•--------------------------.........._......-----.......... ............................................•---•--^-......----•---•---........---------•-•--•--•----......-•-------......-----•--....---••---......----------------•---•------...Date•---••-•---•. SPermit No.... � ' .......... �2.............•---------•-•--------•--. Issued....................................................... Date I` No...._ " Fps........................... :�_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........���..?�i�_m{TAOL ._... ApplirFa#iou for Disposal Works Ta nstrurtivit rumit Application is hereby made for a Permit to Construct Ow. or Repair (A) an Individual Sewage Disposal System at: QS t DW I LL t: .............. -... ._... ............. ................................................... ----------••----------•-•--•-•-•-•-----•--••----...._......--------•---........................... i I Location-Address r Ct� P A� .... ..................... ..........7---- T �.-'C-o r Lo.t....9.•'.� •----�.'..".t?..�..__ Addrei t tttZo(ag)zr ? 0 vieOwnc.) (K G Uf,Gt .............................. .............................................................•-•-------------------•------------ ..� ...............----..... .. ....... Installer Address Type of Building � Size Lot...........:................Sq. feet U Dwelling—No. of Bedrooms...................:........................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of BuildingNo. of persons............................ Showers — Cafeteria aOther fixtures . ..............••---•-••-•••-•----•-•••--•-- --•-••••••----•-•••--••••----•••......--•--••--•--.....( ).............----•-........... d W Design Flow...................... t ................gallons per person per day. Total daily flow........... 5...................gallons. 9 Septic Tank—Liquid cap ity..j 2p.gallons Length................ Width............... Diameter................ Depth................ xDisposal Trench—No. .... ............ Width........ :........ Total Length.................... Total leaching area.......''7 6....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-•--•••---•••-•---------••----•--•-••-••-•........--•-----••-••-•--•......--•---------------•••............................................................ O Description of Soil...........!....._.'T t... 0 `� � °� V -------------------------------------------- •---..---- ----••---------------------•---------•----------....--•---------•-••••••-•-•••--••--.... ......------------------....---------------------•-----------....------------..........-•-...... UNature of Repairs or Alterations—Answer when applicable... `?:TA-t-'__---- .-__ �_��!.....a,��.......5.................... t{S?J3. 55Ot15 Va -4 4t(1 '�"'['t>A ----------------------------•-.............---.............---------------------------------------------------•-----------...••--•--•--•-•--••- Agreement: The undersigned agrees to install the aforedesc fibbed Individual4&wage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary CodXe—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been/issued b board,of health. y& _ Signed. ........... -- .... /rJ�IS�rUS jDate............. Application Approved By...........................! ..... ................. ................................. Date Application Disapproved for the following reasons-------------------------------------------------------------------------..................................... ---•-•--•-•--••-•••••-"-••--•••................•--....••---••---.......•---•-•----•••••---•----•--••••--•-•----•••-••--•-•--•-----••-••-•-••--......_.......................--..__Date Permit No.... .-•---•.............. ...--•••••-•- '��... .......... =•..•-• Issued-------------•-----•--------------------........---.-- .. Date THE COMMONWEALTWOF MASSACHUSETTS BOARD OF HEALTH ��...................................... ..........................................OF......... .... .. . .... TrrtifirFa#r of TompliFanu THIS IS TO-CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired . . at------------------------------�.�� -_. has been installed in accordance with the provisions of TITIE of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. _ e3................. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR E® AS A GUARA THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.----•-----•--•--.........1- !... _..-.. '5....._.. Inspector. Q i(la Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH fr�-7�Z ..........................................OF......�.�1�� T.. ,� E...................................... No.. FE ................. Disposal Morks Toasts ion rrmit Permission is hereby granted.......��'.. —'.:.. ......�'.-I tqt C_ ....... to Constru t ) or Re a�ir an Individual Sewage Disposal System at No.. ..... t"1L - i- 1...�...!.1A �----------•-------•-- �1-�•k� ..)..................... rY • Street �_�.� as shown on the application for Disposal Works Construction Permit No.s�.S"_•1 ...- D ted... ............ ........... *j • ......................... .._ .......................�.1_ v ._.._.....__•__ ........ .....•------. Board of Health DATE..... (-/-------��--s�.•--......---•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS BAXTER & NYE, INC. , . Registered Land Surveyors and Civil gngineers 7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering November 26 , 1985 Town of Barnstable Board of Health 367 Main Street Hyannis , MA 026'01 RE: Farley Residence 63 Bay Street,. Osterville Site Plan dated September 16 , 1985 Dear Board: In accordance with your request I have inspected the installed septic system at .63 Bay Street . Based upon visual inspection, the system has been installed in accordance with th.e Site Plan dated September 16 , 1985 . I trust that this meets your present needs .. Very truly yours, Peter Sullivan, P . E. Baxter • & Nye, Inc. _ PS/fm7 PEETER SULLIVAN -4 3 1 :; No.29733. "j� �sSfOA'At MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS --. LOCATION SEWAGE PERMIT NO. 4 � ' ST C�Si�1rA1iLL� VILLAGE '05(new(LLe A INSTALLER'S NAME ADDRESS g. ovg- B U I L D E R OR OWN ER f -pa2QAlcz- FA-ew 11 2,;; � ST- OSTLn'w l cz DATE PERMIT ISSUED , D DAT E COMPLIANCE ISSUED ' ,} rts a To 0 13- -To 3o X G ' - To of r4cvs";-�-S8' UALL So 65" -ro 1 PVCzJb S be bo' V A Y TOP OF FIND. = 17.7'± ADJUST TO REQ'D GRADE w1MIN.2 OR MAX.4 PROVIDE H-20 CONCRETE RISER FINISH GRADE OVER D-BOX= 15.8'± ' - ' BRICK COURSES OR EQUIVALENT DIMENSION F.G.OVER WITH FRAME&COVER OVER INLET FINISH GRADE OVER CHAMBERS = 15.0 16.4 , GENERAL NOTES F.G. @ FND. = 11.3'± WITH REINFORCED CONCRETE COLLARS. TANK EL.= 12.4'± AND OUTLET COVERS REMOVABLE WATER-TIGHT RISER SLOPE @ 2% MIN. OVER SYSTEM TO WITHIN 6"OF FINISHED GRADE 4"SCHEDULE 40 PVC MIN SLOPE 1% 3/4"TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE 1• UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION SLAB 24"MIN.ACCESS COVER(TYP.3) 9"MIN. 5"DIA. OUTLET(S) (SLEEVED) 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE 36'MAX. ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. PROP. 4" EL.9.42' _ f _ ----- " -�-- - -a�-_------ 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD SCH.40 PVC **MATCH EL.OF EXIST.INV.IN OF HEALTH AND THE DESIGN ENGINEER. 2"DROP MIN. 2"PVC SCH.40 FORCE NOTE: CONTRACTOR TO VERIFY TYPE, DIMENSIONS & ELEVATIONS OF SAS& REPORT TO ENGINEER IF DIFFERENT MIN.SLOPE�t% 6 3 3"DROP MAX. 3" 9" MAIN(CLASS 150) 9"�MIN. ** f 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL - -- -- -- TO DISTRIBUTION BOX 36 MAX. 12.40 BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. /*8.2'± 4. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 14" 4"SCH.40 PVC - ---- - 7.75 5. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. PROVIDE WATER-TIGHT SEAL 2"PVC TEE OUT TO SAS o O �o O 6. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO (TYP @ INV. IN&OUT) 0 000 oo BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR 48" o00 o o INSPECTION. SYSTEM IS NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING '_ GW @ EL.5.2'# 1• 12" MIN. 6" oo APPROVAL FROM BOARD OF HEALTH AND DESIGN ENGINEER. 8.00' **12.70' 12.53' 2 o000 C) 0 0 0 0000 7. ELEVATIONS BASED ON N.G.V.D. 29 DATUM OF 11.33' ESTABLISHED ON A CORNER 0 0 o OF A CONCRETE PAD AS SHOWN ON PLAN. 32.8'TO HSE. 1000 GAL. ,. 0 0 0 0 0 o o 0 0 8. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION 6 CRUSHED STONE o OVER MECHANICALLY 4' THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE " **MATCH EL.OF EXIST.D-BOX COMPACTED BASE 8.5' (TYP) .-I (TYP.) AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY EL.3.46 6 CRUSHED STONE 4.0' ( 4.0' OVER MECHANICALLY 3 --- 42.0' - 4.9' DISCREPANCIES TO THE DESIGN ENGINEER. =22" BELLTER INLET DISTRIBUTION BOX MODEL#A1801-4x22 GAS BAFFLE COMPACTED BASE TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV, 5.2'± POND EL. *** A 12.9' _ 9• ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE BASE. FIRST TWO FEET OF OUTLET 10.40 (TO BE VERIFIED) STRUCTURES SHALL BE MADE WATERTIGHT. PROP. 1000/500 GALLON TWO COMPARTMENT H-20 MONOLITHIC SEPTIC TANK PIPES TO BE LAID LEVEL. " G.W. EL.=5'#PER TOWN OF BARNSTABLE 10. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR NOTE: FOUR (4) DIFFUSERS 5'MIN. 1992 GROUNDWATER CONTOURS MAP ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH SEPTIC TANK SHALL BE LENGTH 10'-2.5" WIDTH 6'-0.5" DEPTH 5'-11 .5" DIMENSIONS PER WIGGINS CROSS SECTION VIEW WATERPROOF AND WATERTIGHT. PROP. SEPTIC TANK PROFILE PRECAST(508-564-6776) PROP. DISTRIBUTION BOX DETAIL TYPICAL DIFFUSER PROFILE EXISTING DIFFUSER DETAILS DIFFUSER END VIEW ALLSEPINATIO SYSTE FROM M APPROPRIATE ALL WIT AUTHORITY. 11. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS *CONTRACTOR TO VERIFY EXIST. EL. PRIOR TO NOT TO SCALE NOT TO SCALE LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE ANY WORK& NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NEMA 4 JUNCTION BOX CORROSION RESISTANT& INSTALL 1-1/4" PVC TO HOUSE. JOINTS TO BE MADE WATERTIGHT. BUOYANCY CALCULATIONS SWING TIES TEST PIT DATA THEY SHALL WITHSTAND H-20 LOADING. LIQUID-TIGHT CABLE CONNECTORS SUPPORTED WIRE PUMP AND FLOATS TO SIMPLEX CONTROL PANEL No. 1-CC2 • � 12. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. - rJ _.._ . r . • r INSPECTOR: Unknown CONNECTORS SUPPORTED BY 1-1/4"PVC CONDUIT, NEMA-1 MFG. HOOVER INSTRUMENTS. DESCRIPTION HC1 HC2 r >� r ' f° ;f PROPOSED 1000/500 GAL. 2-COMPART. H-20 MONO. SEPTIC TANK: 13. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN JOINTS TO BE MADE WATERTIGHT HOISTING CABLE 7 x 19 STAINLESS STEEL / 1 r3, HIGH GROUNDWATER EL.=5.2# SEPTIC COVER IN (1) 36.0 40.7 . r • EVALUATOR: Baxter& Nye, Inc. SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. 1/8" DIA. / 1,760 LB. STRENGTH TOP OF TANK EL.=9.42' r'< 1 1 • N/A , . I t C.S.E. APPROVAL DATE: 2"BALL VALVE w/UNIONS SCH.80 PVC BOTTOM OF TANK EL.=3.46' SEPTIC COVER OUT(2) 41.2' 41.T f`" ;� .• 14. PROPOSED PROJECT IS LOCATED WITHIN: WATER DISPLACED = 5.2'-3.46' x 10.21'x 6.04'= 107.3 C.F. ti ~'ZONE 2 "F r DATE: April 2, 1985 - GEORGE FISHER CO. MODEL NO. 560 ( ) � - r, , . • � . • • ° ASSESSOR'S MAP 117 PARCEL 145 r 5" WEIGHT OF DISPLACED WATER= 107.3 C.F.x 62.4 LB/C.F. = 6,696 LBS. 6• 3" 2"SCH.40 TO D-BOX WEIGHT OF 1,000/500 GAL. 2-COMPART. H-20 MONO. SEPTIC TANK= 14,500 LBS. •�•, ; '�. . OWNER OF RECORD: AUDREY C. FARLEY SOIL COVER ABOVE TANK=(12.4'-9.42')x 10.21'x 6.04'= 183.8 C.F. O _'ir• ' 47 f• ' rw w r ��, ELEV TOP= 16.20 10• SCH. 40 TEE w/CLEAN-OUT CAP WEIGHT OF SOIL ABOVE TANK= 183.8 C.F. x 120 LB/C.F. = 22,053 LBS. (1 2) • . • . . ;� ADDRESS: 309 HILLSIDE AVENUE ALARM ON - ELEV WATER= 5.20 5'-11.5 U 36,553 LBS. (i.e. 14,500+22,053)> 6,696 LBS.; THEREFORE ACCEPTABLE j'a • •" , " • . _ WESTFIELD, NJ 07090 4'-6.5• \. UMP ON 1/4"WEEP HOLE IN DISCHARGE PIPE r • N• PERC RATE _ O 1 PUMP N 2"BALL CHECK VALVE SCH.80 PVC 100 r'Y .. . _ ', DEPTH OF PERC= FEMA FLOOD ZONE C, B, &A11 (EL.11) 1000 GAL. P.S.I. FLOWMATIC MODEL No. 208S 8 . .��• . ■ ; .`r i, i, j TEXTURAL CLASS: COMMUNITY PANEL# 250001 0015 C 1/4"WEEP HOLE IN DISCHARGE PIPE ' CONTROL FLOATS Lo M C-1 r� k10 rR • • .• . `M a..i " Pond Elevation 15. DEED REFERENCE: L.C.C. 179109 1: PUMP ON/OFF 120 ACTIVATION O #63 ,,1, • ••. •'� -- - - -- - -___. 16. PLAN REFERENCE: 1.) L.C. PLAN#25910-B 2"SCH.40 PVC DISCHARGE PIPE EXISTING ` ° 0" 16.20' 2.) L.C. PLAN#14421-G 2: ALARM ACTIVATION , t _...€.�.,._ •• � � ` � _ w � BARNES SE411 PUMP 0.4 H.P. 115 V 1750 DWELLING ` �+'br • 15.20' 17. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY FOR PUMP MUST BE EQUIPPED WITH A HIGH LEVEL f` • 12" RPM, 2" DISCHARGE PASSING 2"SOLIDS ` • • SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY FOR USES OF ALARM LOCATED IN THE BUILDING SERVED C-2 � •• � ����`' sore : „��•;• LOCUS • • WHICH IS POWERED BY A CIRCUIT SEPARATE AND CAPABLE OF PUMPING 45 GPM AT 10 . . • • • , FROM THE CIRCUIT TO THE PUMP. OF TDH OR APPROVED EQUAL • * , � � ,'�, r�'� •� • THIS PLAN OTHER THAN ITS INTENDED PURPOSE. • ' ` • , ;• ,.?' ',�, ; •� • ' 18. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. PROP. 1000/500 GAL. H-20 MONO. SEPTIC TANK DETAIL ° ' � "• ' • • • •• •r . , jar • 1.�1! . � * •• � r • / • k1 � Alt `; ;��f ,� � r:� •• • : •` • �• e APPROX. FLOOD ZONE LINE DIGITIZED �e�/ ! liell • , �� I- 'F: , •: * • • FROM FEMA MAP PANEL#250001 0016 D o�' tiG • b ll r r • , r _ Medium- Fine Sand (effective date: July 2, 1992)---, an ,�fs • 11 0� , :r '�:eck - / 'Parker �N84 2.06 - _� _ EDGE OF PAVEMENT_ i / ! BAY STREET �� °44 30"W 90.76' - )-- _ _ ____� _ _ , (33'WIDE LAYOUT LOCUS PLAN 128 4" Water Encountered _ 5.50' LEGEND y'�61b N84°44'30"W �.� _ -- �.�. I. v - � 114.00 I S84044-30"E - - - SCALE: 1"= 1000' _ r ___. \% \ \ S84° 30 E rREELINE may ' �'�-�� Test pit data taken from Site Plan of ' > EXISTING CONTOUR m � FLOOD ZONE LINE DIVIDING z' % - - � \Q ,�• \ ? Land dated Nov. 5, 1984 (last revised 50 PROPOSED SPOT GRADES LONE B FROM CONE Al BASED o --NT/ �. A `� , DESIGN DATA (EXISTING) 4-12-85) prepared by Baxter& Nye, Inc. N ON ACTUAL ON-THE-GROUND 50 PROPOSED CONTOUR z Q� z FIELD INSTRUMENT SURVEY-, p NUMBER OF BEDROOMS (EXIST.) 5 (HOUSE&COTTAGE) E/T/L' EXISTING UNDERGROUND UTILITIES Z J ` y / ' , � a � o PROP. 1000/500 GAL. DESIGN FLOW 110 GAUDAY/BEDROOM - C� `^ 2-COMPARTMENT H-20 TOTAL DESIGN FLOW 550 GAUDAY ❑/H/W EXISTING OVERHEAD UTILITIES MONOLITHIC SEPTIC TANK p >> '� ' DESIGN FLOW x 200 % = 1,500 GAUDAY W W EXISTING WATER LINE EXISTING CESSPOOL TO BE PUMPED PROP. 2" SCH. 40 PVC FORCE USE EXISTING 1,500 GALLON SEPTIC TANK AND FILLED WITH CLEAN SAND (TYP.)_ I ' / MAIN (SLEEVED) GAS - EXISTING GAS LINE EXISTING 4 - 500 GAL. DIFFUSERS EXISTING WALL SIDEWALL CAPACITY TEST PIT LOCATION POND � �� I / (LENGTH +WIDTH)(2)(2.0' HIGH) (0.74 GPD/S.F.)=GAUDAY - / 'I " o (42.0'+12.9')(2)(2')(0.74 GPD/S.F.)= 162.5 GAL/DAY O O O EXISTING 1500 GALLON SEPTIC TANK EL.-5.2# / 6 m \ Benchmark ST NE DRIVE o BOTTOM CAPACITY /,• Comer Concr. % o � a , ( ( LENGTH x WIDTH ) (0.74 GPD/S.F.) = GAL/DAY O O O PROPOSED 1000/500 GAL. H-20 MONO SEPTIC TANK Elev. = 11.33' to EXIST. DIFFUSERS PER N.G.V.D. 29 ; AS-BUILT CARD)TO REMAIN (42.0'x 12.9')(0.74 GPD/S.F.)- 400.9 GAUDAY INv.18.2'± �� t TOTALS: 0 PROPOSED 3-INLET DISTRIBUTION BOX EXIST. DISTRIBUTION PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE Gp I BOX TO BE REMOVED TOTAL NUMBER OF DIFFUSERS 4 Q o �o 0 o TOTAL LEACHING AREA 761.4 SQ. FT. FM-FND- PROP. 2"SOLID SCHEDULE 40 PVC FORCE MAIN M co TOTAL LEACHING CAPACITY 563.4 GAL./DAY MAP 117 \ y EX.CBN qL r$' \ �O EXISTING DIFFUSER �s o PARCEL 145 .� \ DESIGN DATA (PROPOSED) r INV.=15.6'± pgT10 �, PROP. 3-INLET DISTRIBUTION BOX 75,005 S.F.# O ; �• REV. DATE BY APP D. DESCRIPTION rs9 \ PROP. 4"SCH. 40 PVC(SLEEVED)(TYP OF 2) BASEMENT TOILET, SHOWER, &WASHING MACHINE INSIDE EXIST. HOUSE O!OFF \ ORCH ~N`' APE USE PROPOSED 1,000/500 GAL.2-COMPARTMENT MONO. SEPTIC TANK PROPOSED SEPTIC SYSTEM UPGRADE EXIST. 1,500 GAL. SEPTIC TANK TO I #63 BE UTILIZED IN THIS DESIGN PREPARED FOR: 4BEDR oM AUDREY C. FARLEY a 1�. DWELLING T.O.F.=17.7'± \ N7 0 �.� � SLAB=11.3'± \ 25S'g3„� w DOSING & STORAGE REQUIREMENTS LOCATED AT -Y 54co s s' EBEDT. �? 63 BAY STREET - Corr. M M MAP 117 ANTICIPATED FLOW: 100 GPD OSTERVILLE, MA 02655 '� Ln N�2o r " _ DOSING REQUIRED: 1 CYCLE/DAY a 9g 043"I,� o PARCEL 144 100 GPD/ 1 = 100.0 GALS/CYCLE RESERVED FOR BOARD OF HEALTH USE SCALE: 1 INCH = 30 FT. DATE: MAY 11, 2011 MAP 115 0 15 30 60 120 FEET MISCELLANEOUS NOTES: UF PARCEL 22 _. DISTANCE REQUIRED BETWEEN PUMP \, ��q`s ON AND PUMP OFF FLOATS: o` �O H �? PREPARED BY: N7 J. � JOHN L. sa' JC ENGINEERING INC. 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF 30'�,� 100.0 GAL/CYCLE = 125 GAUFT = 0.80 FTlCYCLE �� CHURCHi�L JR. ,,, EACH SEPTIC SYSTEM COMPONENT INSTALLED. 8�36' (USE 0.85'TO PROVIDE FOR BACKFLOW) N CIVIL 2854 CRANBERRY HIGHWAY _ EAST WAREHAM 2.) PORTION OF PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2& � STORAGE REQUIRED ABOVE WORKING LEVEL: 100.0 GAL. �,. �0.� �: , MA 02538 SITE PLAN GROUNDWATER PROTECTION OVERLAY DISTRICT. ENTIRE PROPERTY IS STORAGE PROVIDED ABOVE WORKING LEVEL: 250.0 GAL. 508.273.0377 LOCATED WITHIN THE ESTUARINE WATERSHED. SCALE: 1" =30' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No. 1980