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HomeMy WebLinkAbout0126 BAY STREET - Health 5 6 Bay Street Osteiville A= 117-019 SMEAO No.2453LGN UPC 12134 smead.com . Made In USA '�iCr � � � � � � � � � � � � � � .� � �, � �, � % � a � � �� � � � � o V1 '�' G � � � r � � � . � �� s leasco t UL o has a.. • [D o o Th u)ho IS, 11 6GU GI�cS ed . t Nu F _5 f 1 g t 4 L • A x l � r ' TOWN OFBARNSTABLE LOCATION SEWAGE# © f 9 W 0 VILLAGE ASSESSOR'S MAP&PARCEL(�� �—C7!�► < INSTALLER'S NAME&PHONE NO. S LyA% M ErC_ 'K V"SEPTIC TANK CAPACITY LEACHING FACILITY: (type).° Q 01C i Q (size) NO,.,OF BEDROOMS 4 OWNER PERMIT DATE L'`��I'q Vt i COMPLIANCE DATE: Separation Distance Betwedn the: d Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Lu �v -0 CV iL 4 c � ?1' C y�c t No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplifation for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(t f Upgrade( ) Abandon( ) ❑Complete System EQ4'dividual Components Location Address or Lot No. �'� �o (� y OS�J wner's Name,Address,and Tel.No. Assessor's Map/Parcel 11 OLD i e fir, ( n Installer's Name,Address and Te.No. Designer's Name,Address and Tel.No. sc oia ��� k 2 w ti y�.rr 3 ,., (Z J �� oa /a.S,, 60L Type of Building: I Dwelling No.of Bedrooms /1/ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ly rr gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) C C, lA e V-�. ©(b WK Z>Q> ACV Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board ofHealth. Signed Date Application Approved byan:�Kf Date 2 Application Disapproved by Date for the following reasons Permit No. a-o tq 9 CV Date Issued �6 p 0-0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes �/' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Misposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair(vf Upgrade( ) Abandon( ) ❑Complete System �dividual Components Location Address or Lot No. \11(G (3�,y p� U�/N ner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. cca�\ \k a 0,J yam.r r-+,J t/ J w( nrn, C. /a fi4 1.11 Type o Building: v Dwelling No.of Bedrooms Y I Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) r' Other Fixtures Design Flow(min.required) gpd Design flow provided Al gpd s ` Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. _Description of Soil F• Nature of Repairs,or Alterations(Answer when applicable) Q p{—* 6 J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. { Signed ? Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by S r ,Z rC,r\V at �r f'� � ('?�_ �_� r has been constructed in accordance P _ with the provisions of Title 5 and the for Disposal System Construction Permit No. �O4�- d dated Installer 3 r FiA 4� ��6 � Designer i #bedrooms Approved desi - ow Al and The issuance of s pe it shall not be construed as a guarantee that the system wil functio designed. Date C, Inspector • r v ----------------------------------------------------- ----------------------------------------- No. ;"l I —��v Fee T THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(X Upgrade( ) Abandon( ) System located at c—N and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co leted within three years of the date of this permit Date��` L(— Approved by �- Commonwealth of Massachusetts 1 e 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 126 Bay Street Property Address Eileen Morgan .° Owner Owners Name/ �/ `4 required is Cisterville Ma 02655 6/10/2019 S ? .required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 6z* /39(ALl T—sri the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the.return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code ---" r 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property 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 conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority ,I 4. ❑ Fails 6/10/2019 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 ` " c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. r 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 126 Bay St Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a single leach trench. The system was found to be in proper working condition at the time of inspection. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 il I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owners Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): f, ❑ 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): ❑ 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): 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 system 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 'v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 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 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form , 10 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow I ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 water supply 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 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 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. Cityrrown 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 afl inspections: 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)] l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 1 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 ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑• No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �r 126 Bay Street V Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No 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: P 9 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: 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. . 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): Approximate age of all components, date installed(if known)and source of information: system installed 1990 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 126 Bay Street Property Address Eileen Morgan Owner Owners Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other ex lain 9 (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 gallons I Sludge depth: g^ Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I � 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information for every tion is required Osterville Ma 02655 6/10/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. . Tight or Holding Tank(cont.) 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.): Distribution box was replaced for inspection, permit#2019-200 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 25'x2'x4' ❑ 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 _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 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.): leach trench was video inspected from d-box and was found dry with no signs of past overloading. 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 ra Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts N . •{ � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 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 � 3 o a z Al 3° (3 ( 110 AZ. 2S 132 2 A3 z3 �33 2N t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tea Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour map. f Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay Street Property Address Eileen Morgan Owner Owner's Name information is required for every Osterville Ma 02655 6/10/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osteryille Ma. 02655 3/8/2011 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the �5&(, computer, use 1. Inspector: only the tab key to move your Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landscape Const. Company Name 564 Old Siage Rd. Company Address Centerville • Ma. 02632 �d0n City/Town State Zip Code 508-778-0249 S1437 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 3/11/2011 a�1 r~-- Inspector's 4Signature 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. _ 1 , t5ins•09108 Title 5 Official Inspection Form:Subsurface pecti Sewage D ppsal System•Page 1 of 17 c ° Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 .3/8/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® [have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are. indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is 'structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y E] N ❑ ND(Explain below): t5ins•0§108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Cityrrown 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): El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Citylrown 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 1.00 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a.public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm; provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El M Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 n Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ -E 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. El E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ M Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd, For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 3 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name requir required is Osterville Ma. 02655 3/8/2011 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? El Have large volumes of water been introduced to the system recently or as part of ® this inspection? E 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? M ❑ Were all system components, excluding the SAS, located on site? E ❑ 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)] 0. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 gallon septic tank with PVC inlet tee. outlet tee was concrete baffle, D-Box and leach trench as per plan at B.O.H. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes E No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes Z No Seasonal use? E Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail 2010/ 10,000 gallons, 2009/26,000 gallons Sump pump? ❑ Yes ® No 010 Last date of occupancy: Date Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? 0 Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑.Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 6/2010 Date Other(describe below): General Information Pumping Records: Source of information: 12/19/09 Ace as per owner Was system pumped as part of the inspection? ❑ Yes Z 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 ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 ,4 _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1990 Records at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24" below top of foundation feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10 ft from public water line feet Comments(on condition of joints; venting, evidence of leakage, etc.): One other old building sewer not in use 5 ft below top of foundation on right side cellar wall Septic Tank(locate on site plan): Depth below grade: 6 inchesfeet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No . Dimensions: 1000 gallon Sludge depth: all water t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Titles Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Citylrown 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 all water Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? stick tank Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): not needed as of this date 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•69/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 Bay St. Property Address Louisa Guzzetti Owner Owners Name information is required for Osterville Ma. 02655 3/8/2011 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.): All good Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM , '126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Cityrrown 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 _liquid level below invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): level , no evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: 0 Yes L] No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: leaching trench as per repair permit at B.O.H. t5ins•b9/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments �^M 126 Bay St. Property Address Louisa Guzzetti Owner Owners Name information is required for Osterville Ma: 02655 3/8/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers number: leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 25x2z4 ❑ 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.): all good Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 126 Bay St. , Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)' Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 5 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Z Check cellar ® Shallow wells Estimated depth to high ground water: 10 ft 2 inches 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: n Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand Auger to ground water approx 7 ft of separation from bottom of leach trench Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 126 Bay St. Property Address Louisa Guzzetti Owner Owner's Name information is required for Osterville Ma. 02655 3/8/2011 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 New Page 1 file:///C:/Docmnen s%20and%20Sedings/Owner/Desltop/Septic%o20R w j , 3110 j J i C 101 000 TOWN OF BARNSTABLE LOCATION SEWAGB A - 2,2�t— _ VILLAGE ASSESSOR'S MAP&LOT 1/ / 9 D ' yM ddo INSTALLER'S NAME ie PHONE NU. up SEPTIC TANK CAPACITY LEACHING FACILITY:(tVpe} (size) NO OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ' BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED-. VARIANCE GRANTED: Yes No 1h&—h t ; I 1 , _f.�J`, ia yyI t. Ir Fa Sf i9,- • ' >' of': ' p r lip ' f s')W F - cy, l 1 oft 3/10/2011 11:01 N I z CD CD CD A J Ci CD d A N O i a N O C v COD d CD W �V O � (D .-+ N d-maw,hLs o8 sv�ele�-�' sGze �+e�� o � to �e a6k- TOWN OF BARNSTABLE LOCATION �1 SEWAGE ® � VILLAGE ASSESSOR'S MAP 6T LOT ' � �� N INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /•D LEACHING FACILITY:(type) � � (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER r BUILDER OR OWNER DATE PERMIT ISSUED: DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No / 4 t `' wv ItL 'h its _ A 3 i:.'3'a Fr,,•y \ `pia 'l" "�t �i+ � `'\. `R4 4��P�lx11 pma y{ vie lASSESSORS MAP NO: C� PARCEL N0: Fim.... .-..._....._..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH f TOWN OF BARNSTABLE Apphration for 11iiivatial Works Tonstrnr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at N "• ---.1 -------------------------------------- ................ _.. :---------------------- Location-Address or Lot No. ......••••.. . ...................wne......._.............................•..... ..................--`......... . . caner dress a .. ........ -- .................................................. .........S9 ....� ...... f nstaller Address Ue of Building Size Lot----------------------------Sq. feet Dwelling,—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 'PLI� Other—T e of BuildingNo. of persons............................ Showers — Cafeteria P4 Other fixtures ............................................. 9� W Design Flow............................................gallons per person per day. Total daily flow_._..................•..._................__gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width.:.............. Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (TA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... a O Description of Soil..Azl:�-_ 'f _._. . ' x U -------•--•--•-------------•--..---------------•----••-----------------------------•-•--.......------------------------------•----------•---••-...--------------= W --••---------•-------------------•--------•----•------------------------------------------------------•------- -----------r-- ------ V Nature of Repairs or Alterations—Answer when applicable_- = -=................... ............ -----............ ----•--•---••--•-----------............. ------•--•-•--•............ .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian has bee issued -the boar of health. Signed .... /�/�� -... ----1�. ..... . ....... .. . ......................... ................ire................. Application Approved By ------------------- ems.-..--------------------------- ----.............................. Date Application Disapproved for the followin easons: ..........................................................::. ---------------------------------------------------------------------------------------------------------------------------------------------------------------•-- ------------------------------ .... ........................................ Permit No. --- r f, �,.0 Issued -- [e Dare ` 1106 f No...&... ..t s F:ms....._50......... THE COMMONWEALTH OF MASSACHUSETTS - ` BOARD{ OF HEALTH i TOWN OF BARNSTABLE 'r4m - r F Appliration for Disposal Works Tonstrnrtiun Upermit Application is hereby In de for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ......l ................................................ ...................... Location-Address .........or Lot No. / ner ) /� dress Installer Address U. T , e of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) P14 Other—Type of Building .......................... No. of persons............._'............ Showers ( ) — Cafeteria ( ) QI Other fixtures ..........................---..;,;------......•-----.......--=----- ---- d W Design Flow...........................................--gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_............. Depth................ x Disposal Trench—No..................... Width......1............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...............1L... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ) - Dosing tank ( ) '-' Percolation Test Results Performed-by.....'---------------- a ---------------•-------+-----------•----•---...-.... Date-�,;---------•----•----------•-------., Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....-.--_-.--.-..--.--.- 44 -Test Pit No. 2................minutes per inch ' Depth of Test Pit.................... Depth to ground water--_--.-_--____-----. x ......... ....... •--- ODescription of Soil--- fives---- is - ----- _ ..............I................................................................................................. U --------------- .•------- ------------ •------------------------------------------------- --------- -------------------------------------------------------------- --------------- ------------------------- -----•-----•----------------------------------------------------------------------------------••.-------•------•--------------------•-------•----..-----=............................................ U Nature of Repairs or Alterations—Answer when applicable_- .............. .....--_.-..------------------- --_----..---. ------------------------------------------------•----------•------------•------•---------...•-•....-----...•-----. Agreement: v The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board,.of-health. ' _.Signed ------------------------ ........................................ .... _. . ' Date ..-Ks Application Approved BY -----------------, —�.. ---- . -- ----- '�' ............................. --- - �' .....�--------------------------------- Date Application Disapproved for the followin -reasons: .. `. ', C Date Permit No. ----- ......... Issued ............. . .h -. Dates THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE C�Pr#tftc�x#e Df C�um�XtttnrE THIS IS TOCER(IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) b ........... ..............................................................---------------------------------------------- -------.....................................................Y--------------------- ---------- . Installer QQn at 1 � �� ------- ?�... .. . U`S,�- � ^'t -------------.................... - -------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...... ..- �...Y ......... dated._)........................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST ,UED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ......... ....................................-------- Inspector ... .�.. -�' -------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ QQ TOWN OF BARNSTABLE Disposal Works Tun#rur#inn Permit Permission is hereby granted.............. r? ...... a:gin... to Construct ( ) or Repair (�) an I dividual Sewage Disposal System at No. l .- ......... .. �T ... .- - . ------------------ ...................-•-•.......-.-------.-.-••---•-............. r Street as shown on the application for Disposal Works Construction Permit No.Aa ...... Dated.......................................... .4 . _ .... .................................. Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS