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HomeMy WebLinkAbout0070 BAYBERRY WAY - Health 70i3AYBERRY WAY , OSTERVILLE A = 114 072 i I i ll�aoz� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments AJ, 70 Bayberry Way (Main House) , Property Address 70 Bayberry Way LLC ` Owner Owner's Name , information is X.- required for every Osterville ✓ MA 02655 4-5-18 r� page. City/Town State Zip Code Date of Inspection �i 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:Whenfilling out rms A. General Information p, 2 on the comoputer, `�`oI"OF'MyS use only the tab 1. Inspector: key to move your O �` cursor-do not JamesD,Sears �? JAMES use the return k Name of Inspector = ; ey. Capewide Enterprises =* R; Company Name s'.,A S!....... N i INS 153 Commercial Street rllrn u u Holt Company Address Mashpee MA 02649 CitVY I own State Zip Code 508-477-8877 S1623 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 4-6-18 pector'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 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 underthe 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurfaoa Savage Disposal System•Page 1 o1 17 V's I. a5ed xed dH Z 2Z 81.0Z 80 JdV Commonwealth of Massachusetts r Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. Cityrrowrl State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and two pits, 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): tsins.doc-rev.6n6 Title 5 Official hspection Form:SuMnlace Sewage Disposal SysMm•Page 2 of 17 Z a5ed xe:1 dH 6 I•ZZ 81.0Z 20 JdV c Commonwealth of Massachusetts Title 5 official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Ostervllle MA 02655 4-5-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health); ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc rev.6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 £ a5ed xed dH £2E 8 60Z 90 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments —' 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-1 B per. 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 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 sept c 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 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 is less than 6° below invert or available volume is less than 1/z day flow P, 15ins.doo•rev.6116 TfNe 6Official Inspection Form:Subsurface Savage Disposal System-Pape a of 17 t7 a5ed xed dH £6ZZ 9602 90 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bayberry Way (Main House) u� Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cons) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either".yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5inS.doe•ray.6116 Title 6 official Inspection Form;Subsurface Sewage Disposal System•Page of 17 5 a5ed xed dH E 6:ZZ 9 MZ 90 jdV c o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments u 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Cistervi lie MA 02655 4-5-18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as NIA) ® ❑ 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.doc-rev.6116 Title 5 Official Inspection Form Suhsurfaee Sewage Disposal System-Page 6 of 17 9 a5ed xed dH £I.:ZZ 8 60Z 80 Jd`d u Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville NIA 02655 4-5-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Tank D Box and two pits. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)); 2016-42,000Gals2017-47,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 a5ed Xed dH £L:ZZ 8 60Z 90 AV Commonwealth of Massachusetts Title 5 official Inspection Form kq�w Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes EI 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page a of 17 g a5ed xed dH b6:ZZ 860Z 90 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank and pit 1983- Permit#83- 16. 1987 Relocate tank and add pit,permit#87 -69. 4-2018 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20 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.)' Pipeing is 4" PVC SCH -40, Septic Tank (locate on site plan): t o.. Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 1 151ns.doc-rev.6116 Title 5Otlicial Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 6 abed XeJ dH V 1,ZZ 860E 80 JdV Commonwealth of Massachusetts 1p Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bayberry Way (Main House) W—F� Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on purnping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 10" below grade. In and outlet tee's. No sign of leakage or overloading. 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 I506.doc•rev.5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 0l, abed xed dH b 62Z 8 60Z 90 JdV Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l� u 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC' Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade. Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Capacity: gallons I 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 l5inc.doc-rev.W16 T&5 Official Impaction Form:Subsurface Sewage Disposal System-Page 11 or I? �6 a5ed xed dH 922 860Z 80 Jdy c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 70_Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. Citylrown 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.): D Box is 16"xl6-16 below grade w/two line's out. Box is new 4-2018 w/cover at 6" below tirade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: wns.doc-rev.6/16 Title 5 Official Inspecdon Form:Subsurface Sewrge Disposal System-Page 12 of 17 Z a5ed xed dH S 6:ZZ ME 90 Jd'd Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _V 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching ga,1eries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. precast pit's. Pit#1 Older pit. Pit and cover at 2' below grade dry. Pit#2 Newer pit. Pit and cover at 15" below grade dry. Pit#2 Wall's are clean like new. Flow going to pit#1. 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 l5ins.doc•rev.6116 T tle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f 6 abed xeJ dH 9 2� 8 60Z 90 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC_ Owner owner's Name information is required for every Osterville MA 02655 4-5-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) 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..): f5lns.doc•rev.6116 Title 5 Official Inspect on Form.Subsurface Sewage Disposal System•Page 14 of 17 t7 6 abed xed dH 9 2E 81.0Z 80 Jd`d Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '-MV 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owners Name information is required for every Osterville MA 02665 4-5-18 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) 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 i 134 =,2 --j -uz 3 /3 3-34' °O 4 15ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 15 of 17 5 abed xed dH 91,ZZ 860Z 20 Jdy Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Z�'�� 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owners Name information is required for every Osterville MA 02655 4-5-18 paw. City/rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t igh ground water: 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: G.W.on file w! B.O.H. 18'+to G.K. Bottom of pit#1 at 10' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5ns.doe•rev.6116 Title S Ofridal Inspection Form Subsurface Sewage Disposal System•Page to cf 17 g 6 a5ed XeJ dH 9 2Z ME 90 Jd'd r e Commonwealth of Massachusetts p Title 5 official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bayberry Way (Main House) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 4-5-18 page. CityfTown 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 15ins,Mc•rev.6M6 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 17 of 17 L l• a5ed xed dH 91,?e ME 80 JdV Commonwealth of Massachusetts Title 5 official Inspection Form < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bayberry Way (Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is Osterville ✓ MA 02655 3-20-18 required for every page, CityfTown State Zip Code Date of Inspection ` fa.ot 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: out A General Information Sf* ag03 on the computter, `\`���� tH OFI use only the tab �y� •'••• ••.9�+ '� 1. Inspector: y key to move your � O G _� JAMES cursor-do not m use the return James D.Sears a�; key. Name of Inspector m :u, Capewide Enterprises 4:1 Company Name VI 46s�R�tFL. ` 153 Commercial Street 'r�i�rr�pSt iNStP����p,` Company Address gem Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 ' 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: Z Passes ❑ Conditionally Passes ❑ Faits ❑ Needs Further'Evaluation by the Local Approving Authority 3-21-18 spector'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 tpe 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. I5ins.doc•rev.606 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 I-PI?d V S 9 l, a5ed xeJ dH W 2 '8 X0 2 JeW f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 70 Bayberry Way (Cottage System) - Property Address 70 Bayberry Way LLC Owner Owners Name information is Osterville MA 02655 3-20-18 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. H-20 Tank D Box and two chamber's 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): { 15ins.cloc-rev.6116 Tits 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 2 of 17 6 6 abed xed dH £Z:2 9 60Z 2 -JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bayberry Way (Cottage System) Property Address 70 Bayberry Way LLC Owner Owners Name information is required for every OSteNille MA 02655 3-20-1 B page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Heahh approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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): • 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): 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. I. System will pass unless Board of Health determines in accordance with 310'CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5 ns.dae rev.6116 Tille 5 Official Inspection Form Subsurface Sewage Disposal System-Page 3 of 17 OZ a5ed xeJ dH EZ:2 9 WE 2 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bayberry Way (Cottage System) Property Address 70 Bayberry Way LLC Owner Owners Name information is required for every Osterville MA 02655 3-20-18 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 1 DO 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 Al inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in ism= is less than 6" below invert or available volume is less than %day flow k ►Nr; t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page a of 17 6Z a5ed xed dH bZ:2 8 60Z 2 JeW LL VMMOYIIOVQ vw�oyc vaNuaar uyaaeur ruurt�IVUI IVI vuiuntely r�ssaatimenis 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 3-20-18 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.- E] ® 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- 10,000g pd. ® 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.doc•rev.W S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ZZ a5ed xeJ dH t Z:I,Z ME 2 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every OSteNille MA 02655 3-20-18 page. CltyrTown 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): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc rev.6/16 Title 5 Official Inspsaion Form:Subsurface Sewage Disposal System•Page 6 of 17 £Z a6ed xej dH 2:2 860Z 2 Jew Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 70 Bayberry Way (Cottage System) Property Address 70,Bayberry Way LLC Owner Owner's Name Information is required for every Osterville MA 02655 3-20-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Tank D Box and two chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA ( y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialfindustrial Flow Conditions: Type of Establishment , Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank'present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6H 6 Title 5 Offidel Inspection form:Subsurface Sewage Disposal System-Page 7 of 17 bZ a5ed xed dH SZ:2 960Z 2 JeW Commonwealth of Massachusetts oa Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owners Name information is required for every OSteNllle MA 02655 3-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t t5 ns.doc•rev.6I16 Title 5 official inspection Form:SuosuRace Sewage Uspo681 System•Page 8 of 17 5Z a5ed xed dH 9Z:2 ME 2 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form pJ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is OStervllle required for everyMA 02655 3-20-18 page. City/Town state Zip Code Date of inspection- D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999-Permit #99-509. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . Depth below grader 19" 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.): Pi ein is 4" PVC SCH -40, Septic Tank(locate on site plan): Depth below grade: 9 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: 1500 Gal. Precast H-20 Sludge depth: • 1 15ins.doc-raw.6/18 Title 5 official inspecticn Form:Subsurface sewage Disposal system•Page 9 of v v ^ 9Z a5ed xed dH R42 91,02 2 JeW P vutuaunas.a oawdWe Lollsptmui aystem rorm-Not Tor voluntary Assessments 70 Bayberry.Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owners Name information is required for every OSteNille MA 02655 3-20-18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 81, Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Plan-Tape _Sludge Judge 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 at working level in stone drive. Steel cover on inlet In and outlet tee's No sign of overloading. 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.doc-rev.6116 TIUe 5 Official Inspection Form:Subsurface Sewage Disposal system•page 10 of 17 LE abed xed dH 92:2 860E 6Z JeW Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments .Vi ,91 70 Bayberry Way (Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 3-20-18 page. City/Town State Zip Code Date or Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ N0 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 ftui.doc-rev.6116 Title 5 Official lnspsaion Form:Subsurface Sewage Disposal System•Page 11 of 17 gZ a5ed XeJ dH L2:2 21,02 2 JeW f Commonwealth of Massachusetts Uy Title 5 official Inspection Form /a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 70 Bayberry Way(Cottage System) Property Address — 70 Bayberry Way LLC Owner Owners Name Infonnation is OSteNllle required for every MA 02655 page. City/Town 3-20-18 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,): D Box is 30"x30"-23"below grade w/steel cover at grade. Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 oftal Inspectlon Form:Subsuface Sews a of 6 sposel system•Pape 12 of 17 6E a5ed xed dH LE:2 9 X0 2 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is Osterville AAA 02655 3-20-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovabve/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is two 500 Gal dry well chambers.Ck D Box and camera out to chamber's clean and dry. No sign of over loading or holding water. 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 t5lns.doa•rev.6116 Title 5 Midst Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 0£ abed xed dH LE:2 9 60F 2 JeW Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information is required for even Osterville MA 02655 3-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soli, 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.): 151ns.doc•rev.6116 Title 5 office!Inspection Form:Subsurface Sewage Disposal System-Pop 14 of 17 6£ a5ed xe:1 dH W 2 8 60Z 2 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bayberry Way (Cottage System) Property Address — 70 Bayberry Way LLC Owner Owner's Name information is required for every Osterville MA 02655 3-20-18 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 A i r P - 3` , „ 7/4 N/C- /v G 13-3= N3=6 Gns.dcc•rev.6116 - Title 5 OKiclal Inspection Form:Suhsurfime S"e Disppsal System•Pape 15 of 17 Z£ a5ed xed dH W 2 9 60Z 2 AW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Maposal System Form -Not for Voluntary Assessments 70 Bayberry Way(Cottage System) Property Address 70 Bayberry Way LLC Owner Owner's Name information Is Ostervllle MA 02655 3-20-18 requiredd For every cityrrown per, State Zip Code Date of tnspectlon D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth t high ground water: 124 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: 1-6-81 Date ❑ Observed site(abutting propertylobservation 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: T.H.on Design plain 1-6-81 12' no G.W,. Bottom of leaching around 4'-6"below grade. Bottom of leaching at 7'-6"above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. I5ins.doe-rev.6116 Tide 5 Official Inspection Form:Subsurface Se";a Disposal System-Page 16 of 17 ££ a5ed xeJ dH 22:1,2 ME 2 JeW i Commonwealth of Massachusetts Title 5 Official Inspection Fora a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 70 Bayberry Way(Cottage System) LJ Property Address 70 Bayberry Way LLC Owner Owners Name required Is re d for every Osterville MA 02655 3-20-18 require 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 t5ina.doo•rev.6r16 Titie 5 Official Inspection Form:Subsurface Sewage Disposm system•Page 17 of 17 b£ a5ed YPJ dH 8E:6E ME 6E JeW No. ' "� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Bispo8al *pstem Construction[ Permit Application for a Permit to Construct( ) Repair G� Upgrade( ) Abandon( ) ❑Complete System 9 Individual Components Location Address or Lot No. '70 CfEy '��y W/4y Owner's Name,Address,and Tel.No. Assessor's Ma /Parcel KEN T'RcAL_ Co. P ®S ill uvow ST Nln/' C wD AAwo-s Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. (2APGWCtbE t A 1A Type of Building: � Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided N 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) 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 Healt Signed Date 3 ` C$ Application Approved by Date Ll —3`" Application Disapproved by Date for the following reasons Permit No. a-61� b r Date Issued p� l 4 No. (� oM Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: +� PUBLIC HEALTH DIVISION - TOVVN OF BARNSTABLE, MASSACHUSETTS Yes application for 3Disposal 6pstem Construction 3permit Application for a Permit to Construct Repair(IV Upgrade( ) Abandon( ) ❑Complete System jV Individual Components e Location Address or Lot No.�'70 �j�1� �� (�,j/�� Owner's Name,Address,and Tel.No. .:- KEt-1TRaAc.- Co, Assessor'sMap/Parcel + 16 7 n, S-r ?1/lrr✓ C-44AJO ;VP(05, BIZ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: ' Dwelling No.of Bedrooms /f° Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) lV A- gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title x Size of Septic Tank Type of S.A.S. Description of Soil } Nature of Repairs or Alterations(Answer when applicable) �, �_. 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._ F Signed a. _. Date , (� - i Application Approved by n�(,Q), 13• 9- Date i -1 O Application Disapproved by Date for the following reasons Permit No. Date Issued c 01 g 4 x THE COMMONWEALTH OF MASSACHUSETTS t � Y� BARNSTABLE,MASSACHUSETTS Certificate of Compriante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) 1 Abandoned( )byt� l�� EtcJ1"CY_1�� e�"' "y .-at. ri__�- lJ. J.t AV fjs r has been constructed in accordance - - --- ... c� �{ with the provisions of Title 5 and p-the for Disposal System Construction Permit No. dated L/4 Installer 99 1?� G eU _ A _<,cT' Designer A , #bedrooms y Approved design flow , gpd The issuance of this permit shall not be construed as a guarantee that the system will function°as designed:, Date L_-J ! / y Inspector t`1 ►b__e�-._ ` :•,---- ---------- ------------------ --------- -------------------------- - - - 6 & 7 ! No � Fee THE COMMONWEALTH OF MASSACHUSETTS - �jbx . PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal *pstem Construction J)ermit Permission is hereby granted to Construct( `,) Repair(x) Upgrade( ) Abandon( ) System located at ](� - akk kJ A- acid 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 mpleted within three years of the date of this permit. Date `-i --�"t Approved by 1 .fL.,.G{.- IF), COMMONWEALTH OF MASSACHUSETTS . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �6 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. 70 Bayberry Way main house Osterville.MA 02655 �/ Owner's Name: Kimberly Whittemore Trust �K Owner's Address: N Date of Inspection: _ June 11, 2008 I Ll Name of Inspector: (Please Print) James M. Ford C Company Name: James M.Ford o, . - >. Mailing Address: P.O.Box 49 Osterville,MA' 02655-0049 Telephone Number: (508)862-9400 N r- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage.disposal system at this address_and that the information reported below is true,accurate and complete as of the time.of the inspection. The inspection was,performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I.am a DEP approved system inspector pursuant.to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N s Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: . July 11, 2008 The system inspector shall sub it 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. ;1 Notes and Coimnents ****This report only describes conditions,at the time.of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions.of use. Title 5 Insp&tion.Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry Way main house Osterville.MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or,not detennined(Y,N,ND)in the for the following statements. If"not detennined",please explain: The septic tank is metal and over 20 years.old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it.is structurally sound,not leaking and if a Certificate of Compliance . indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or . obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection.if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced , obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry Way main house Osterville.MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 C. Further Evaluation is Required by{the Board of Health: Conditions exist which require further evaluation by the Board of Health in orderto 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 CNM 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 ' 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 7.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 1.00 feet but 50 feet or more from a private water supply well**. Method used.to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory; for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppin,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forth. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION.FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry.Way main house Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: . June 11, 2008 D. System Failure Criteria applicable to all systems: You must indicate either"yes."or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded.or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less.than '/z day flow ✓ 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 I of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool.or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.]. No (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 310 CMR 15303,therefore the system fails. The system owner should contact the Board of Health to detennine what will be necessary to correct the failure. E. Large System: Y To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: . (The following criteria apply to large systems in addition to the criteria above) Yes 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 bitrogen 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 que.stiori in Section E the system is considered a significant threat,or answered "yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system.owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 70 Bayberry Wav main house Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11: 2008 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J. 5 . e Page 6 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 70 Bayberry Way main house Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no).: Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown Was system pumped as part of the in (yes or no). No If yes,volume pumped: gallons--How was quantity pumped determined? " Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records;if any) Innovative/Alternative technology: Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate.age of all components,date installed(if known)and source of information: unknown Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bayberry Way main house . Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from.private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 9" Material of construction: ✓ concrete metal fiberglass__polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10" How were dimensions determined: Measuring stick Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage: GREASE TRAP: None (locate on site plan) F Depth below grade: Material of construction: _concrete — metal _fiberglass _polyethylene _other (explain): Dimensions: - Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert;evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bayberry Way plain house Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Commments(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.): The D-box was normal PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Conmments(note condition of pump chamber,condition of pumps and appurtenances,etc.): r 8 I - Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bavberry Way inain house Osterville, MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 2- 6'x6' 1000 gal wlY tone per plans— leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions; overflow cesspool,number: Innovative/alternative system Type/name of technology:. Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of,vegetation, etc.): The leach Pits had 1'ofwater on the bottom There did not appear to be any signs offailure.A camera was used for the inspection CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of'vegetation,etc.): . PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: CoiYtments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): y 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Ba berry Wav:main house Osterville.MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11,2008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Fromm xa O � 13 . S 3 . s yi si 10. Page l l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Bayberry Way main house Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 18'+1- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours myps the mays were showing approximately 18'+1-to groundwater at this site This report has been prepared only for the:septic system and components described herein. This septic system has been inspected and.passed as of the date of inspection. This report is not a.warranty or guarantee that the system will function properly in the future: There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system;,the inspection, this report andlor any components of the septic system which have not . been located and inspected. 11 114E Town of Barnstable Qp Tp� ,P` o Regulatory Services 114"SrABM Thomas F. Geiler,Director • 4' i639• ,0 Public Health Division ArED��a Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Y Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of.. bedrooms listed within this report. The actual number of bedrooms approved at a particular, property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact. the certified Septic System Inspector who conducted the inspection. WSEPTIC\Disclaimer Private Septic Ins pectionsvDOC I . - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 70 Bayberry Way cottage system Osterville.MA 02655 Owner's Name: . Kimberly Whittemore Trust Owner's Address: Date of Inspection:_ June 11, M08 I I .v Name of Inspector:(Please Print) James M. Ford co Company Name: James M. Ford r�r� r 2- Mailing Address: P..O.Box 49 Osterville,MA 02655-0049' _ N) Telephone Number: (508)862-9400 c`': o X CERTIFICATION STATEMENT C '' I certify that I have personally inspected the;sewage disposal system at this address and that the i formatidn)repoled , below is true,accurate and complete as of the time.of the inspection. The inspection was perforn,ed based�on my-- r\t training and experience in the proper function and maintenance of on site sewage disposal systei s:' I am.a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes Conditionally Passes :NeecJ4 Further Evaluation by the Local Approving Authority Fail Inspector's Signature:., .4 ku%l Date:. July 11, 2008 The system inspector shall sub 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. ;. Notes and Conunenis ""This..report only describes conditions at the time.of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in"the future under-the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry Way cottage system Osterville. M.4 . Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 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 J 10 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years;old is available. ND explain: 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): brokenpipe(s).are replaced obstruction is removed f distribution box is leveled or replaced } ND explain: .The system required pumping more than 4 times a year due.to broken or obstructed pipe(s). The system will pass inspection if,(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry Way cottage system Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 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:within50 feet of a bordering vegetated wetland or a salt marsh i; 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 aseptic 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 aseptic tank.and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed.at a DEP certified laboratory., for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 �'. Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry Way cottage system Osterville MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11 2008 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ -Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or.surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS.or cesspool J. ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less.than 1/2day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any.portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is'free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails: The system owner'should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with'a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) i 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 lI of a public water'supply well F 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 failedunder Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION'FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 70 Bayberry Way cottage system Osterville. MA Owner's Fume: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 i 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: Yes No ✓ _ Existing information.,For'example,a plan at the Board of Health. ✓ _ Determined in the field(if,any of the failure criteria related to Part C is at issue approximation of distance' is unacceptable) [310 CMR 15.302(3)(b)]. - 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: 70 Bayberry Way cottage system Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11. 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: . Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _ spd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): - Industrial waste holding tank present(yes or'no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown Was system pumped as part of the inspection(yes or-no): No If yes,volume pumped: _gallons--How,was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool `Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract.(to be obtained from system owner) Tight Tank Attach a copy of the,DEP approval Other(describe); . Approximate age of all components,date installed(if known)and source of information: Installed on 1211749-per as-built Were sewage odors detected when arriving at the site(yes or no): No 6 f t Page 7 of 11 ,i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bayberry Way cottags stem Osterville, AM Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 BUILDING SEWER(locate on site plan) ' Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private'water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc:): SEPTIC TANK: (locate on site plan) Depth below grade: 9" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. H-20 Sludge depth: 2„ Distance from top of sludge to bottom of outlet.tee or<baffle: 30" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): . Tees were 2resent. The liquid level was even with the outlet invert. There did not appear to be aw signs of leakage. Steel cover was too Irrade. GREASE. TRAP: None. (locate on site plan) Depth below grade: Material of construction: concrete "_metal fiberglass -_polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee.or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bayberry We cottage system Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was normal and steel cover was too grade. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): - 8 • Page 9 of 11 _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bavberry Way cottage system Osterville. M,4 Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) . If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-leach chambers 12'x25'per plans 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.): _ The chambers were dry and clean There did not appear to be anv signs of failure. A camera was used for the inspection CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.): PRIVY: None (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.): ' 9 Page 10 of 11 OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address: 70 Bayberry Way_cottage system Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11,2008 SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3 a3 y3 10 , Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Bayberry WE cottage system Osterville. MA Owner's Name: Kimberly Whittemore Trust Date of Inspection: June 11, 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 18'. feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: . You must describe how you established the high ground water elevation: Usiniz Barnstable topographic and water contours maps, the snaps were showing approximately 18'+1-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection..This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of.the septic system which have not been located and inspected.' 11 �I • ' Town of Barnstable �p tHE Tp� ,P` o Regulatory Services BARNnABLE, Thomas F. Geiler,Director 9Q M. f6 9. �0� viOTEp .�a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by-, receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. : QASEP"I IMisclaimer Private Septic Inspections.DOC TOWN OF BARNSTABLE LOCATION �16 1�10 �arr C%/ �J. SEWAGE# VILLAGE ASS SSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �.SW ��•a-Q LEACHING FACILITY:(type) a- ��n+�Lrl (size) NO. OF BEDROOMS 3 .OWNER k-,.,&.r11 GA,thM 0rC. Tr•UtT PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY 3 Far .� W 0 a 1 � � � 1 � W � � p � � `� W � r JZ� } t' � lr TOWN OF BARNSTABLE LOCATION -�Q & rl, SEWAGE# VILLAGE 0 ST ryil -ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SOU LEACHING FACILITY:(type) a. /01P SA P,71 (size) 3 STQnA NO. OF BEDROOMS y 4- OWNER. IGn��e.r�y (,.I�� UDC /rUsT PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY T-A SiOcc?/A�i J . 4� O oz r �C w 9L) - � No. 9 Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Zigozar *p6tem Conotruction Vertu Application for a Permit to Construct( L41repair( )Upgrade( )Abandon( ) ?*—Omplete System ❑Individual Components Location Address or Lot No. 7 O 9,%76.e r,, (� j Owner's Name,Address and Tel.No`� L1 Z y 8- Assessor's Map/Parcel // 0 Z_ �� yr/� 77 U Installer's Name,Address,and Tel.No. c2 9 5-:'76 D z Designer's Name,Address and Tel.No. Ra 6t-q_fi s P QAT-Y 1-1 S v►Pr ( P-D jol M r 03� /hq ® 36 Type of Building: Dwelling No.of Bedrooms Lot Size A d �-sgrfC� Garbage Grinder Other Type of Building No.of Persons Showers( , ) Cafeteria( ) Other Fixtures Design Flow 3 .3 d gallons per day. Calculated daily flow TI 6 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /. T-0 Type of S.A.S. Description of Soil 5.e-- ,P( Ptt JO—9 1 Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issag this Bo#of Health. Signed Date Application Approved by e Date ��7 Application Disapproved for the following reasons Permit No. Date Issued ---- _ -�y I 1 \ 250 Q4 - ------------------------------------- I _ •. \ ' i' _.' ...T.SEPTIC fiT3TiaM' 1 TU MAIN. �V .......\ w - ORIVi M� ag PSI 4 .. (0' GK15T,GARAGi �/ MIN D�Box TO BG .,� 7` IG RCMOOtLGD 0 PROP, 2 BEDROOM i __- `___. i (/ Lot Areo I \ I p PLAN VIEW Scale- I"=501 T.H_, P-99 EL.23.0 LOAM ,AbA QF OuA i SUBSOIL Z 5 P SULLIVA.F1 NO.297SS CFO 1U CIVIL MEiJM SAND ��� ,. j 4.� �a ..........L to yl C9 z! NO GROUND WATER PERG• RATE: LESS i THAN 'Z MIN INCH . DATE I�l,/�1 SITE PLAN PROPOSED iSEPTIC SYSTEM AT 70 -BAYBERRY WAY OSTERVILL.E,MASS. FOR EDWARD GONZ�LES SCALE:AS SHOWN ! DATE: AUG. 16,1999 SULLIVAN ENGINEERING INC. SHEET I Of 9 OSTERVILLE MA 1 ra0H I, No. Fee `�— "` Entered in computer: _L! r � THE COMMONWEALT�`'`�F MASSACHUSETTS ` v Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Miq."al *pMem Congtruction Permit " lication for a Permit to Construct( L4epair(, )Upgrade( )Abandon( ) omplete System . O Individual Components �r Location Address or Lot No. 70 i90-76-e r,, �/pwl Owner's Name,Address and Tel No(� L Z b7„Q / 1 �WA�v` 6"f_ 2a 1 Y Assessor's MaOarcel / O 2 65.�,` j/ ^' V }S 1 Installer's Name,Address,and Tel.No. cvv�j, ,'�`^6 $(� Designer's Name,Address and Tel.No. (J v Ro huct S AVARY iz tq S ulrto AD p1 o-ox /hey o 3b: : l. F Type of Building: Dwelling No.of Bedrooms Lot Size / d '' Garbage Grinder Other Typ-.of Building No. of Persons Showers( ) Cafeteria( ) ` Other Fixtures 41 f Design Flow gallons per day. Calculated daily flow 3'y 6 gallons. Plan Date V—4 7 Number of sheets Revision Date Title 4 Size of Septic Tank O Type of S.A.S. Z � y,5 C Peel" Description of kSoil tir-. n Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been is a this Bo of Health. Signed Date Application Approved by C. Date kr—17 Application Disapproved for the following reasons Permit No. Date Issued r' --- --------------------�--------�---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance , THIS IS TO ^ }Z th t th O sit w e i osa1,S stem Constructed( Repaired( )Upgraded( )` Abandoned( )by at O has b en constructed in accor nce with the pr isions of Title:5 and the f Disposal ystem Construction Permit No. dated Y— ' Installer �o b _� A VAR Designer The issuance of this p�er�i/�rit/ al o 'ed as a guarantee that the s st �11 function as� sign Date t�._L� �1 Inspector S� I k,- �)L- -------------------------- No. v�✓Fee / I '�r / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migw6al *p tem Conotruction Permit Permission is hereby granted to Construct( `''�kepai'r( )Upgrade( )Abando ( ) System located at 7d 90L7A4-L��&-/ 0­7 - cRT— SAV4Ryr and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. �.a Date: Approved by c. FG.22.5 See Note 5 FG.22.0 ri 20.5 19.5 2 .3 1500 Gallon 201 Top El.20.5 Septic Tank 19 9 Sot.E1.17.5 19.7 Bedding as 6.5� Per Title 5 10 10.5'. 10, . 10" 12' Bottom of Test Hole El.I I. No Ground Water DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Not to Scale NOTES —Finish Grade L Water Supply ForThis Lot is Municipal Water. • Filter - 2 Location of Utilities Shown on This Plan Am Approx. to Fabric �"Compacted Fill At Least 72 Hours Prior to Any Excavation For This Project The ControetorSholl Make The Required Motif ication to Dig Safe(1-800-322-4844) FRI er I/8-1/2 Pea Stone 3,The Contractor is Required to Secure Appropriate Permits From Town Agencies For Construction Defined byThis Plan. a. Leaching u r 4 Install Risers as Requiredto Within 12 of a Chamb 3/4 -1 I/2 Finished Grade. Double Washed 5.All Structures Buried Four Feet or More orSubject' Stone to Vehicular Traffic lobe H-20 Loading. I L_ 4-10' I 6 Septic System to be Installed in Accordance With 12-� 310 CMR 15.00 Latest Revision And The Townof Barnstable Board of Health Regulations 7. All Piping to beSch 40 PVC. CROSS SECTION V CHAMBER ..;NOT TO SCALE. DESIGN DATA Use Minimum Daily Flow(Proposed 2 Bedrooms) With no Garbage Grinder Daily Flow= 330 GPD Sepfic Tank:330 GPD x 200%=660 GPD Use 1500 Gallon Septic Tank LEACHING AREA 330 GPD/0.74=446"SF Required Sidewall=2(12'+25!)2=148 S.F. Bottom Area=12'x25' = 300 SE 448 SF Total Provided LEACHING CHAMBER DESIGN ` OF All Pipes to be Schedule 40.Use ')?„ 2-500 Gal.Leaching Chambers Ina �, dx 2e Washed Stone Field as Shown O PI:T� `d SULLI1,Am tq: CIVIL �a ;STEM . a AL EDWARD GONZALES 70 BAYBERRY WAY AUG. 16, 1999` OSTERVILLE,MASS. SULLIVAN ENGINEERING INC. SHEET 2 Of 2 OSTERVILLE MASS. 9P0Uco p------ I ENT Y BEDROOM ' CLO. � CORRIDOR I ' 13'-4" El F-I Ell 1---.El 0 BAT Z0UNEXISTING GARAGE cLo. O BEDROOM RENDVATICN FCR: +: MR AND MRS EDWARD GONZALEZ BAYBERRY WAY OSTERVILLE, MA. 1ST FLOOR PLAN a DRANK BY: SCALE: DATE: DRAWING 3/16"=1'-0" 8/4/99 A-1 s b Gfl EXISTING FAMILY ROOM BATH F• GN. MEDIA ROOM CLO. CLO. BOOKCASES RENOVATION FOR: MR AND MRS EDWARD GONZALEZ BAYBERRY WAY OSTERVILLE, MA. 2M FLOOR PLAN 2ND FLOOR PLAN DRAWN BY: ScniE: DATE: MAWNG 13/16'1=11-011 8/4/99 A-2 F JI FRONT ELEVATION RENOVATION FOR: . MR AND MRS EDWARD GONZALEZ BAYBERRY WAY OSTERVILLE, MA. FROM ELEVATION DRAWq BY: T3/16"=11-0.LE: DATE: DRAWING 8/4/99 A-3 i 1?'-0„ NEW SITTING 14'-0" ROOM EXISTING GUEST i SUITE I 30"C.O. i i I I RENOVATION FOR: MR AND MRS EDWARD GONZALEZ BAYBERRY WAY ' OSTERVILLE, MA. I FLOOR PLAN-SITTING ROOM y DRAWN BY: SCALE: DATE: DRAWING P.E.C. 1 i4"=1 -011 8/4/99 A-1 TOWN OF BARNSTABLE LOCA-i LON TI o • d+- 2 i'r`1l \LA SEWAGE # ASSESSOR'S MAP &LOT ' INSTALLER'S NAME&PHONE NO S M A M Y P-Ptjl SEPTIC TANK CAPACITY S 00 A ' 1 1 A- O?2 LEACHING FACILITY: (type)- S 0 0 X 02 (size)_ t�0 ?G a NO.OF BEDROOMS BUILDER OR OW G-DWA PERMITDATE: ?. tJ I ) 7OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. : 5 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) b Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of eachin facili ) - �'7 Feet Furnished by_ A (�� � � � �0'il.� ►�L O 7� 0 TOWN OF B STABLE R/ / -- LOCATION /h,�� VILLAGE /�, � - SEWAGE # INSTALLER'S N ASSESSOR'S MAP LOT AME&PHONE NO. SEMC TANK CAPACITY,/,6— LEACHINGL y� FACILITY: (iyPe)��/O� ` NO. OF BEDROOMS iy / (size)_ dam BUILDER OR OWNER ' 'y PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Mum Adjusted Groundwater Table and Bottom of Leaching F Private Water Supply Well and Leaching Facilityg Facility on site or within 200 feet of leaching facility) (If any wells exist Feet Edge of Wetland and Le cNng Facility - within 300 fe. of I l (�any tlands exist Feet Furnished b �fi)AX acility)f ✓/ Feet WSJ �ronfi co �0 boyberc7.r �.vcty �,�. . , d- 1 ASSESSO -S MAP N0'* l�PARCEL 17pZ - 10 CA ION SEWAGE PERMIT NQ. L- �� VILLAGE INSTALLER'S NAME i ADDRESS_ R U I L D E R R WN ram ` DA T E P E R M I ISSUE D DATE COMPLIANCE ISSUED 3- 1 - 57 Af �i� LOCATION SEWAGE P: RIMIT NO. VILLAGE INS_�T, A LLER'S NAME i ADDRESS' ® UILDE R OR OWN ER �.. j. DATE PERMIT ISSUED ATE COMPLIANCE ISSUED 5 JAL- t 7 i I r: . _ Ij it_ DATE: 6/10/99 PROPERTY ADDRESS:_______________________ ----70 Bayber� Way____--- Osterville, Ma. ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: f ® 1 . 1 -1500 gallon tank 2. 2-1000 gallon leaching pit 3. 1 - Distribution box Based on my Inspection, I certify the following conditions: 4. This is a title five septic system (.78_. code) 5 . rThe ' s'eptic system is in -proper-working_order- '.. at the present time . > 6. -Both` of theachings pits are dry . 7 . #1 p.it is 2 ' below grade . #2 pit is 30" below grade . 8 . Septic tank is 13" below grade . SIGNATURE:1 Name:_,l_F_L Macomber Jr----_--_ Company: Josej2h_P. Maco.mber_& Son , Inc . Address: Box 66 -------------------- Centerville , Ma. 02632-0066 -------------------- Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ` �ECE�EO �r LOS. H P. MACOMBER & SON, INC. �I J U N 6 Tanks-Cesspools-Leachflelds 1999 Pumped & Installed t Town Sewer Connections SyB(E DEPL ox 66 Centerville, MA 02632-0066 775-3338 775-6412 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COX Secrecy ARGEO PAUL CELLUCCI DAVT.TD B. STRL' Governor Co:rrss:c c, SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION P*ovem Ad&—: 70 Bayberry Way Narno of Owr,a,Jane Rattigan Ttee Oterville Addrau of Ownee: same Data of 4spection: s .� //p Name of inspector:AUAU 9joseph P. Macomber Jr. I am a DEP approved system Inspector purtuartt to Section 15.340 of True 5 (310 CMR 15.000) company Nanw: Joseph P. Macomber & Son, Inc, MaTuiq Address: Box 66, Centervi 11 P, Ma _ 02632-0066 T eiaplwne Number: 5 0 8-7 7 5_1118 CERTIFICATION STATEMENT I certity that I have personally Inspected the sewage disposal system at We address and that the Information reported below is true, accurate and complete as of the time of Irtapection. The Inspection was performed based on my uaining and experience in the proper Punction and maintenance of on-sits sewage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails inspector's Signature: Date: The System Inspect shell submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)wichin thirty (30) days or 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 Mail submit the report to the appropriate regional office of the Department ot�Environmerual Protection. The original should De sent to Vve system owner•and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS 2evised 9/2/98 Page I of 11 �� PrinNd on Recycled Papu SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Bayberry Way, Osterville Owner: Jane Rattigan Tte'e Date of Inspection: 6/1 0/9 9 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: 44 One or more system components as described In the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no,or not determined(Y, N, or NO). Describe basis of determination In all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was installed within twenty (20) years prior to the date of the Inspection; or the septic tank, whether or not metal, Is cracked,structurally unsound, shows substantial inTiltradon or exfiltration, or tank failure is imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. 140 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipes)are replaced obstruction is removed distribution box is levelled or replaced . - The system required pumphig-more than-four-times a yeardue to broken or obstructed pipe(s). The system wilt-very— Inspection if(with approval of the Board of Health): - broken pipe(s) are"replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (conti x ) Peop�"—: 70 .Bayberry Way, Osterville 0WT.W' Jane Rattigan' Ttee Dom.01 kuPocd"u 6/10/99 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 falling to protect the public health, safety and the environment. 1) SYSTEU WILL PASS UNLESS BOARD OF HEALTH DETERM)NES INACCORDANCE WITH 310 CI.iR 16.3-03 (1)(b) THAT THE SYS IS NOT FUNCTIONING W A W_kNNER W1-JC1l.y&1PRQ1ECT THE PUBUC UEALMAND SAFETY AND THE DNK18OKUENT. • Cesspool or privy Is within 60 feetof surface water ZV Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH"D PUBLIC WATER SUPPLIER, IF ANY)DErUWLNES THAT THE SYSTE7 FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a sepdc tank and&oil absorption system(SAS) and the SAS Is within 100 lest of & surface water supply tributary to a surface water supply. The ay&tsm has a &optic tank and soli absorption system and the SAS Is within a Zone I of a puNIc water supply weu. The system has a sepdc tank and toll absorption system and the SAS 1& wlthln 60 feet of a private water supply wall. The system has & &sptic tank and toll absorption ay&tsm and the SAS Is less than 100 fast but 60 feet or more from & private water supply well,unless a wall water an&Jyals for collform bacteria and volaUls organic compounds indicates vu wall Is flat from pollution from that facility and the prej nce of emmonis nitrogen and nJusts nivogen Is tQuaJ to or Iasi than 6 ppm. Method used to determine distance _ (approxJmadon not valid).- 3) OTHER lV revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropeMAddresa: 70 Bayberry WaY, Osterville Owner: JaNE Rattigan Ttee Date of Irupection: 6/1 0/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or "No' to each of the following: -(2, I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of•"Wage irrtoiaci{ity-or•vystem component*due¢o an overloaded orc)egged-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 diistri ution box above outlet Invert due to an overloaded or clogged SAS or cesspool. r� Liquid depth In.easspocl�fs less �IoJr Invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. - Any portion of a cesspool or privy is within 100 feet of 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 lass than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or 'No" to each of the following: The following criteria apply to large systems In addition to the criteria above: / The System serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes Nq the system is within 400 feet of a surface drinking water supply the system•is-within 200 feat of-a-t4butery40a suff&Q"#;nkk*9 4ter•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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforlrtation. revised 9/2/98 Page 4or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ProcortYAaaress: 70 Bayberry Way, Osterville Ownef: Jane Rattigan Ttee Date of Inspection. 6/1 0/9 9 Check if the following have been done: You must Indicate either'Yes' or 'No' as to each of the following: Yes No •—s;`/ Pumping information was provided by the owner, occupant, or Board of Health. -None of the system compoaants.ka►ra:baen paswgmW4or~atleast two-weeks and the rystem hasbaaaasceiuisaq MO&MaJ tto�- rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage back-up. 4 The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components,4WIlluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of baffle or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C Is at Issue, approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owner.(and.oc�pantt If differaai frost.oucner),acetapruxided.wi2h infnrmatioaon �f SubSurface Disposal Systems. revised 9/2/98 Paagesorn i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 70 Bayberry Way, Osterville Owner: Jane Rattigan Ttee Date of kupection: 6/1 0/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: JfQ g.p.d./bedroom. -r—�,[ Number of bedrooms(design)' Number of bedrooms(actual): '�''�ti V Total DESIGN flow Number of current resl ants: Garbage grinder(yes or no): Laundry(separate system) ( es or too If yes,sepamte 1upection.required 4g Laundry system Inspected or no) /_ " 1� Seasonal use(yes or no): 10���00 Water motor readings,It avall le(last two year's usage(gpd): f�,Ll Q�(fN1S Sump Pump(yes or no)y�&P, Last date of occupancy• c COMMERCIAUINDUSTRIAL: � X5 Type of establishment: All Design flow: A d ( Based on 16.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)ho Non-sanitary waste discharged to the Title 6 system:(yes or no) J Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of in ection:(yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) l/A Technology t Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other F WMA AGE a co po anSyT date Irtsta_Ifed4if keno n)-and source.o{4"formation ��7� O/� ``�'t�pp✓Qp� fZ Sewage odors detected when arriving at the site:(yes or no)z� revised 9/2/98 P2ge6ofII ' JUN-07-1999 11:19 KINLIN-GROUSR PROPERTIES P.02/OS a c*���� 3 S�r� �S t' r c�2 .�.f,a �.�. c..AJ �r.1d�11..3i (.tic ?� •G,. , �.,�...:•. fc SULL11ANNo �If �s F.k � 11'� 1 � � �.�,TiAchl� 10t�.J�-E�`� 1°• .o�+o F/.r,Tt^;? ~SSIONAEErG. 3,p�wa�., J��.�,a, 452.•bF LK-�c.:r( �SZ � •Z. S - �13U Cyr'✓ �vo-rrt,�r•� el�c��.P� � 13 S r C' '1� '� ,S�LB 1"-.�� l7,4T�' '•JA f..1'ZL.,1987 '.... I�.C77. Z li ' .S'�tf�.t/..y�.2Edr�t/.,s•�ad�.p.N�JT" ec US'.c�'!� ' 7b.�-s"nQBL/.r.4/ .Loy--.C�i✓�� JUN-07-1999 11:20 KINLIN-GROVER PROPERTIES P.04i06 ",-C-1 Pcp"L r'rT u stir laaa�a� l3 sro�t� �orra.� •i l t 3 SF ,. vr...Zc.,o"T tow: P.dTC' 't"lW Z 1 jj IA '' •���.- �• 1 .. V! ,. `�•�.�"1 ••_ram. . . �,':..*.. i .....M .. �� _ .._._. .. ;4;4 WA y ik so 97 .�••Ufa. �:.,.:,._.: • ..���:.r:f�'`'`, ! .' . . t . �•; '•^• r.. I. � : • •,' �------ ;' C 7bUK i:, f! tPIT J Ciz .T1 Sri, �� .oT Pt_A .j I Z, c 10 5c •- - �.-__ L�C7r.ri•T ItJ 1..1 0ti"{-ZV l t..t..a c ecr,FY •P"AY T1•W- aV�1b A"�'l O t.l . s�•rbw Ptr a 4,1 Qa.;=mm G.xj Cc F-- c�Eo► C-PJAPA-%f w►r�t 1'tiarr. isttiEt.iue►� :.. � �. rD S►" -BAcK Z940'eA•MV-Wrl;i Oft TNII+ �T��•l.9xi tD r �C4T� WITt4I N KE It uo7 Sss o.0 Au :'0CoTCJZ'V' 1.4�db. Sc�tZvE`�Oer JUN-07-1999 11:20 KINLIN-GROUER PROPERTIES P.03i06 - JKc�-< ?.�Z Y7c�.� .4356or 1 • _ �Jd ;. J 0 ' 0 V ...., , ,,,• ro For ��_� I v 1 , r-s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cortunued) PtogoMAd&"s; 70 Bayberry Way, Osterville Owner; Jane Rattigan Ttee Date of trupoction: 6/1 0/9 9 BUILDING SEWER: (Locate on site plan) Depth below grader Material of construction:_cast Iron X0 PVC_other(explain) Distance hopprlvato water supply wall or suction line �S Diameter Comments: (condition of Joints,venting, evidence of faakage,-etc.) Joints appear fight No Qlridg-&ee ef stem SEPTIC TANK: (locate on site plan) Depth below grade:f / Material of construction: _concrete m &I _,Fiberglass _Polyethylene_other(explain) If tank Is Instal,list ag • Js.age.confirmad by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth?� _. Distance from top o sludge to bottom of outlet tee ortatfte: Scum thickness: .ee/ Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to botto of outlet as baffler How()menslons were determined: Comments: (recommendation for pumping,condition of Inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert• structure"nte9th evidence of leakage, etc.) Pump tank annually . Garbage rl; sj nca 1 is n,-eson t , Inlet & outlet to invert GREASE TRAP: e (locate on site plan) Depth below grads: Material of construcu nr✓Aconcretw�Ametak&Fiberglass4:?!Polyethylen&other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tea or batfls:,,,dUA— Distance from bottom of s um to bottom of outlet tee or baffle: JW Date of last pumping: Comments: (recommandatlon for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet Invert. structural integnt evidence of leakage, etc.) --Grease trap is nnt prpqpnf revised 9/2/98 Page 7of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropaMAddress: 70 Bayberry Way, Osterville Owner: Jane Rattigan Ttee Date of Inspection: 6/1 0/9 9 TIGHT OR HOLDING TANK;Ij"Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grada:.Alo Material of cons truction:VAconcrete+ametal4j&Fibergi 83sapolyethylane4&other(explain) AIA Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm I orking order:Yes/& NoLVA Date of previous pumping: Comments: (condition of Inlet tea, condition of alarm and float switches, etc.) iQ t or holding tanks arp not prasenr . DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet Invert:__ Comments: (no-to-If level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — — Distribution hnx has tun iaterals .--Reth flews are equ- ' NO e-j d QPGQ A f se}i leakage PUMP CHAMBER:A&)e (locate on site plan) Pumps in working order:(Yes or No)) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) llMD t hamhar i e notprOSeiit . revised 9/2/98 Pa*eeaofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corrtinued) PropemAddra": 70 Bayberry Way, Osterville Own": Jane Rattigan. Ttee oats of Irupection: 6/1 0/9 9 SOIL ABSORPTION SYSTEM(SAS)A-4w02'01 �— "- (locate on site plan,If possible; excavation not required,location may be approximated by non intrusive methods) If not located, explain: Type: a leaching pits,number._de p leaching chambers,number:�4 leaching galleries,number:V leaching trenches,number,length: leaching fields,number, dime slons: overflow cesspool, number: Alternative system: ,/_ Name of Technology: (•�j4 Comments: (tote condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to medium fine Sandi Nhg; Rns_n£ hydr-al,l}e a- CESSPOOLS:_ (locate on site plan) Number and configuration: D Depth-top of liquid to Inlet invert:, / Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of Inspection) esspoo s are not Present Comments: (note condition of soil, signs of hydraulic failura,Jevel of po"ng,condition of-vegetation, etc.) Cesspools are not present PRIVY:—41i✓e, (locate on site plan) A Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,revel of ponding, condition of vegetation;etc.) Privy revised 9/2/98 . Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR>.LAT10N (co'�) Nop-MAddl—: 70 Baybarry Way, Osterville °r"`" Jane Rattigan Ttee 0". of tnj°.`'4 ': 6/1 0/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEU: Includs Uss to atlsast two psrmanent tslusnce landmarks or banchmarks louts all walls within 100' (locate whirs public waist supply comas Into house) Centerville , Osterville Marstons Mills Water Company 428-6691 i r Coo»fi . CIO DI i� i 1 Q \/! LA ��V , '70 Leroy D'3+ . revised 9/2/98 Fall 10of II r v , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Bayberry Way, Osterville Owner: Jane Rattigan Ttee Data of"Pection: 6/1 0/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Va Feet } Please Indicate all the methods used to determine High Groundwater Elevation: —Z<btained from Design Plans on record 4bserved.Site(Abutting property, bservation hole,basement aump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _//Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/ IgV Jr� revised 9/2/98 Page 11of11 r 1.•....,'•.��i,,,.--�•r-,.,..-.n.•,.,...,.�..,.,..1,..r�,.-.,.....,.....,...,.,...�,....T,.n.,, ..-,.-.�-.-..ate,.=-,...-... TOWN OFBARNSTABLE LXJARD OF HEALTH + � ti- T^-. • •-T ^_3UIlSUIIFACF 9F.UGr; DISPOSAL SYSTEM Ill�9I'�F,CTION FORM - PART D^T CEII�PI FI CST l()N r•11 -• -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 70 Bayberry Way, Osterville ASSESSORS MAP , BLOCK AND PARCEL # OWNERRIs NAME Jane Rattigan Ttee PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber- Jr. COMPANY NAME Joseph P. Macomber & Son, Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066 Street Town or CSty Stag tjp COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check,one ; If System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined 'in 310 CMR 15 - 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. 'System FAILED* The inspection which I have conducted has found that the system fails to protect the iaublic health and the environment in accordance with 'Title 5 , 110 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . i Q Inspector Signature e Date One copy of this ce • ification must be provided to the OWNER, the BUYER ( Where applioable ) and the DOARD OF IMAL7'1I: If the inspection FAILED, the owner or"'o orator shall up grade pgrado ' tho eyotem within one year of the date of the inspection, unless allowed or required otherwise as provided) in 3.10 CMR 16 . 306 . partd . doc TOWN OF BARNSTABLE ' L{KAYiON '7 C? &:y 1--e t_ RT,,,�J SEWAGE #9 6� VILi�ArE "`Q�J �c.?-Al 1 h ASSESSOR'S MAP &LOT -- INSTALLER'S NAME&PHONE NO. A A '��hT1.��S A c I S—26®g SEPTIC TANK CAPACITY _ ) S 0 0 A:: 1 4- 01 Z LEACHING FACILITY: (type) ®® (size) D® 'K �. NO.OF BEDROOMS BUILDER OR OWNE a-DW O Q0VJ`Z0k1C9 PERMITDATE: I —COMPLIANCE DATE: I I }7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility i S Feet Private Water Supply,'Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of eachin facili ) Feet Ftunished by y 2i BV a< !J w aS 'P7 w 1� w 4- TOWN OF BARNS I ABLE LOCATION �� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEVnC,TANK CAPACITY LEACHING FACILITY: (type)# /2/ IA l;S (size) NO. OF BEDROOMS BUILDER OR OWNER �G,�,r PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: , Maximum Adjusted Groundwater Table and Bottom of Leaching:Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Le Ching Facility (If any etlands exist within 300 fee of I �E acility) Feet Furnished b t, —\ \�` \�/ 1 a' � _ _ © \ �O e . �.� "� � \ \ "'f' t !��, � �� <. � �_. e i;..0 -• II� h � �,� ��. 1=, �:k'•1.' c n "�bb.?b� /I ASSESSO4'S MAP NO. 1I PARCEL LOCATION -0Z0 SEWAGE PERMIT N0. G �i/ - VILLAGE INST'A LLER'S NAME i ADDRESS R U I L D E R R WM � P DATE PERMIT' ISSUED112-7h7 - DAT E COMPLIANCE ISSUED �- �_ 5-7 , { �, �_ �-�J� �,� � >>� � �� r,� OAS � Q� r�i7 � g . 1 �� .� ���� ..a � \�• �� .. L0 CAT /!ON /yam { SEWAGE r RMIT NO• VILtKGE Y I N S T A LLERIS NAME & ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED ATE COMPLIANCE ISSUED 3 1 �o - � f t OF Y 'a v No.�Tq 7—� 1 Fps . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH dV14.Q oF..... `Jf- Zi..� �esL. ........................... Appliration for Dispasal Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at: .:�. .._.. . e, l LC....... .......................... ........... ....... _ .........____ _ .....a... ...)60 Lo -Address ..... •- Ad - w �l !�� a •.._..-•---••. ��----------------------------------------••--. �..�'..:._.__ .... ....... ...�........ ----•--.....-- • Installer (� ..... Address Type of Building -�2o c7 ,4 O TAB_ Size Lot___'�S` ' ___._Sq. feet Dwelling—No. of Bedrooms..F_�§]E A ___.___-_-Expansion Attic ( Garbage Grinder (145 aa Other—T ype of Buildin g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------•-----------••••-•-- Des Flow......5.15- _5`D 6.............gallons per person per day. Total daily flow... -0------------_--------- 9 F—_§ . ........ ._.......__..... .______..eptic Wank—Liquid capacity_ -_ allons Length.. ..... Width Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length...................:.. Total leaching area....................sq. ft. x Seepage Pit No..........Z,__.___ Diameter......IZ....... Depth below inlet......�x.......... Total leaching area.�7o_s�....sq. ft. Z Other'Distribution box WAS Dosin ank (Ujb aPercolation Test Results Performed by:._ ......... Date Date.. _ Test Pit No. 1-----, ...._minutes per inch Depth ,of Test Pit..... Depth to ground water.gC>i_.�@ ccLw . 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p+' ------------------------------------------- -- •-•-- O Description of Soil....... __ x W x ........................................... --••-•-•-••---•--•---•------••-----------•--------•••-•---••----- ----•--- U Nature Repairs or Alterations—Answer when applicable._.._.. TAD.....0 1us5—a____-_ ! t i'1______________. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL IL4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in p ion til ficate of compliance has been issue y b r/f health. A lica 'on roved Da - PP PP Y �.--?.............. Date Application Disapproved for the following reasons--------------------------------•------------------------------------------------••---•-•---...........••-•-•--- ......................••-•--•••-••--•---•-•--•••---.....••-•-•••---••-•----•-•••.._...__...•--•-•---•....._.....•••--•-----•-•----••-•-•----••-•-•••••-•---•---•-•-------•------••-•-•••-•-••-•---•...._. ---� pp,, Date PermitNo................................r�.__1-------- Issued_....................................................... Date ...... - Fins................:........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration' for Dispoti ai Works Tonstrnrtiun r' rntff Application is hereby made for a Permit to Construct. ( ) or Repair ( ) an Individual Sewage Disposal S stem!at: \/ +I Y Location-Address or Lot No. ......................—.......................................................................... -••--•--••-------•----•---•----••-•------•---•---•-•---._....-----•_...-------:................... W Owner Address ` {.. ti r Installer Add ess ...__ ...'� ` ........... � d Type of Building '_ a -z-A�• Size Lot....._.�....:...........Sq. feet Dwelling—No. of Bedrooms._._ -:.':'`----_- �-s._ .........Expansion Attic ( ��j Garbage Grinder ( 4`S PL4 Other—Type of Building ____________________________ No.. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ____________________________ --------•-•------- Desi Flow____._ _T_=��` _____________gallons per person per day. Total daily flow.......6_��___________. gallons. W Septic Flow —Liquid capacity.k-_��allons Length................ Width................ Diameter................ Depth,............... x Disposal Trench—No_____________________ Width..................... Total Length.................... Total leaching area....................sq..'ft. Seepage Pit No.......... ......... Diameter.__:_.. ...... Depth below inlet______6 .......: Total leaching area__C.._ f,.-�...sq. ft. Z Other Distribution box (qo—s Dosin nk (1., `-' Percolation Test Results Performed by.__ __ _-`_ ---..---_. Date:__ ---------------------------------- Test �='v _ 1--• Pit No. I.__G:__.___.minutes per inch Depth of Test Pit.....I_ ....... Depth to ground water.......................",< )(�a'iT-���„' 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ......... - ........ - -•------•------------•----- -•---•............... O Description of Soil._----0 :.L v�ti4n ?!.�-_ _�tZ �s A .................................... U ------------------------------------------ •------------------------------- ----------- •------------------- •----------W U . Nature of-Repairs or Alterations—Answer when applicable..*----- D_ ... _..__ > a=�.__ ---------- � ....... _ \-_-_--•---- ------ --- c=c_CX..AC. L .._..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in o r tion nti fica C te of he board of health. Compliance has been issued by t --.... ...----..... yf fr1]P _ 9 Datqf Application Approved Y...... ---- ` ram:..=� - •__--••--......_. 71. ............`- r Date 'Application Disapproved for the following reasons:------•---------------•"----•---------------•---------•----=-•-------------•--a---------------•----•-•--•-••- ....................................................... -----...-----------•••-----•----•-----------................................................................................................... Date Permit No.......:...: :",------f.. e"' . ...... Issued.................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH .......................... F................1...., :. -- ..................................... �rr�ifirtt#r ,af f�unt�r�i�nr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal"System constructed ( ) or Repaired ( ) by--- ------ �" -1.��[.._..1...-f (+� .� ................................................ ------------------- t r � % ................... Installer— r 4�c has been installed in accordance with the rovlslo of TITIE_ of The State Sanitary Code as desc >bed in'the application for Disposal Works'Construction Permit No_________________ f '____ dated-,.-------- -- . ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE. SYSTEM WILL FUNCTION SATISFACTORY. _..,. -- - DATE............:.5_.::..1.__�_..::...5-�................................... Inspector_..--•- .._ _ ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.......... No:� :•{.Ge� .. .. � .. ..................................•--•--........_.. FEE....... "�.;`'::.�.� aio nsal Works Tuntr ion amit Permission is hereby granted..... _____-__�✓:��_A-Ar/_____.__.___ to Construct ( ) or Repair aniIndivldual Sewagce Disposal System f . Street------. -----•-•-----•--- - J........... as shown on the application for Disposal Works Construction Permit NoS?. 21 Dated... DATE. J Board of Health FORK 1255 -HOBBS & WARREN. INC.. PUBLISHERS IDES/G/V QA 7`,Q `k-ntsTt►..����f.,,.c.��e •t-a�r+�t��( 3 $Et7�..OpPtiS � �t;:� �jt-�.�'c-.:.�. t ��. o n ` P-T: o SUL LI` AN 1 t " ��. v Ste Z�. 1� O �s.`�taK,. � i� 1..�.��-•w,��i: �ti No. va c5 i C- ,, .ov{ v4 C-c C7 K 1 S = '�h CJ �••Q, M. �o-no� 1���,,�• � t3 s�= T -Ha �99 .'yew FG �� i/�• ^- �_. � � o`' f;�C.�;,i 1.,,�4h '�::-,;:.� � �" oisr, l�'�a�� l��� /� � /.tom✓. ' • 1 CX :s /a y, Box 11V G.4G.• ' y �+��... '' 96,E �.,.� S.E•PnG `�•`�' •, Z• z:; •o�,�,7 ,• T,q.vic � y LF,ALN /NK /NV 587 Br4XT�.2 ,c/YE I've. 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E ADD St=T'TiAG�C R�1?J�P�.M��T� OF TWF-- Tr�v✓� o� ��i��iT�i�l.c�.A.l.ty t S• I..;��`� �.�t�r. , , L.uGATEt�> WInAl T"E: FLoob PLA.1W. . vA.rG_ i 12=3j- L. $A.X•re2 � U- — I"C.�,� sr evE e 'T4414 FLAW t4 t.3OT 8A5ED oU AU tWVTZUMEUT OeVTE=-Zvtt.I r- mA.5►y. TNr- 0t=1=5e.T; 15140OLD UOT 15S tJyej> APPLICA.w " To �t-TE-Cm1�Jr tro'T LIUS*. A ll 36:Z - 6 .............. THE COMMONWEALTH OF MASSACHUSETTS B®AR® F HEA T of ......................... Xpli iratiun for Disposal Works Tonstrurtiun runtit Application is hereby made for a Permit to Construct (101 or Repair ( ) an Individual Sewage Disposal System gL . {.. ,..._.._.... /� /........ or No d yj&j� C� in o. ......................... .... r , ne --------.---.-.-.- __. � n Address 40 Q Type of Building Size Lot... ... ..Sq. feet U Dwelling—No. of Bedrooms____---�...........................Expansion Attic ( ) Garbage Grinder (�^ `PL4L4 Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity _..gallons, Length................ Width---------------- Diameter................ Depth................ x Disposal Trench=No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date---------------------------------------- aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.___________________.._. ;T-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------- W ------------------------------------------------------------------------------------------------------------------------ --------- --------------------------- 0 Description of Soil........................................................................................................................................................................ x V ....................................................................................................-----------------------------••---•-------•-----------------------------------------------------. W UNature of Repairs or Alterations—Answer when applicable.-_---------------------------------------------•-_-_____---__--_.-._______---._______:---_.___. ----------------------------------------------------•-------------------------------------------------------------......-----------------------------------------•--•-•.........-...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by oar f lth. . 1 d =------------- ------ --•- •• •- APPlication Approved BY---- ------ !o ---- ----------------------------------------••------•---.................. Date ......-- -- - lrngrApplication Disapproved or az e¢sons_________________________________________________________ ----------------•-------•--•--------•--------------------------••-•-•--•------••......------- ------------------ Date PermitNo......................................................... Issued........................................................ Date .�.4 __�s_ ---------------------------- ---------- --- - -- --- - ---- --- FEl&.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ I .....--- ----OF /.Ul..... Appliration for 43Wposa1 lVarks Tons#.rurtion PrrBnit Application is rereby made for a Permit to Construct (✓K or Repair ( ) an Individual Sewage Disposal System at; ............ .., -�'� .Location-Address ( or Lotr No. ............................... ...--------- ----....----- --•- - ---- - ---- . --- - Owner // � / Address� a --••-••••-••------•---- ••--------- .......................................... ..-----•--••---•------••-• •-,-•---------.....-------•------------••--•-----•-------••---•ec t Installer Address � !J d Type of Building Size Lot----------;_ ------Sq. feet Dwelling—No. of Bedrooms........3...........................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) QIOther fixtures ------------------------------------------------------..........-............................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity -gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—I\o..................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. 3 Seepage Pit No.•-__-_•-_____.-__. Diameter.................... Depth below inlet.................... Total leaching area------------------sq. fI. Z Other Distribution bcx ( ) Dosing tank ( ) aPercolation Test Res-xlts Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---_---_-.--._----_----. fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ....................................................................................................•-------•--•--------------------•••-----•--•-•-••••--•-•------------•••-----•----------•-----•--•............................................................ 0 Description of Soil........................................................................................... ----••--•••-••-•••••---••-------•--•---------------------------------•------ x W --------------------------------------------------------------•---------------------..._...........-----------•----•••---••----••••••--------••-•-----••-••----•------------------•---------•-•--•----- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ ----------------------------------------•---------------------------------------------------.....••••---•••-•--••----•---------------•---------•------------•-•-----•---------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued byy the-boaarr'd�$f health. Signed.......... i � Application Approved BY�olr ' ------------ Date Application Disapproved the following reasons:----•---•--•-------•------•-----•-•-------•------•-----•---•---•---•---•---•--•--------•------------------------ -----------------------•-------•---•--------------.....---•-•------•-----....---------•-=-------•----------------------------•--------------•-•-------•-----•-----•--------------•----•............... Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (11rdif iratr of font li�nrle rS IS TO.ETTIFY, That the Individual Sewage Disposal System constructed 0114)"or Repaired b ( ) X �l le. Installer at -- ----- ----------- -------- -----------------------------------------------------------r------.A..-----•----------------- has been installed in accol�d„�nce ith�the provisions of Article XI o The State Sanitary C 4 as e cribed in the application for Disposal Works'f*6nstruction Permit No.. �' '� .................. datedf :` _ ...._._.___.._.._.__... THE ISS A CE OF THIS CERTIFICATE SHALL NOT BE CONST U AS A GUARANTEE THAT THE SYSTEM W L�/ UNCTION SATISFACTORY. DATE.... ..6-y-............................................................. Inspector r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 3- ..........................................O F...................................... Not...................... FEE_ ... ,-- �t�����al or�•��on��r�tr�iun prntt� Permission is ereby granted....-..................°____ E^'" r__ _ --- -- - --------------------------- to Conset!T,�) or, e�air ( /l ,'''p y 6�,C''� rs' f � an Individual Sewage-Disposal oral S stem at�No. = ;:.._•.r.:...........•-r:...:.......-••-•---•------.---------------------•--- --------------------•--f------;... -------------- Street a as shown on the application fo>:--Lisposal marks Construction Permit No-----------p_ Dated'__ r�!....................... - � Board of Health rDATE--- .... .............................................. j FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS _ d:UuC,t,E FAMILY! W1-r 42 CAZBACCis `sRlWVeZ •-T-�.�� .....,...,t,.----•t _ �- -� �7--- 1• t10 3 '��/.'"TI .P1Dt ffrl• ,.. y TA64K.9 9401 OO Ire'p' o�s PosAt_: p jr y lac t= Iry G/u 3 S�oIJE 1'' � .� ; � 1 : • ' + • •' b I � !, AA t3oTTOM �REA w j t t 'SF 1 ,94 !d 71 + : : : .-"�`D�to�/A 1,1.��"'F�:Dw"a�'s• �D. :.t• � ,;t. . : , } ; I . �I , ` .. � . .•I I PuLTto�.i E�T�.' laatN IWIJ 1 yH AF AQ. .' a A. 1 • I Il , b ; NE$ ( " T a ! ,exP- , BAXTER I�-w 4 ii : .. .._.'ti.t. -•_-•... ,I * - ...... .;..r,T .... .1 .. '.�.. '.. 5' t t 't' ! `t r � l ,., _ r . s..: c- M,-. it ♦ .. 1 ': 1 - '.1 . - ! .. � 'T'tr$T �'�� -" I - �w. I' . . _.. �� � _ • .. .F,;4, 9'Q:. . . _ __ afi TAP F�•,v= pa 97 piST. IMK 4dL. gG•fi' �: ) 1 . Ic TAUSL: LZACM VAT cto N� :. . i. C X T I s=I Ea PL.o r Pt_Q� p20 t=t t,�- ' ' L.c�loartow ��j VlL 8(o 12•. .. O . � � � �� �AT t�' 12 31 6Z.; qO . .. . 5GA► .�,,c"_:(gip . t ClLcrIFY TµAT TM16c -Du tst)AT 10 SNowat HE2EON 'GoµPL-YS WtTH 'rT"6. SMF- .lF.tl�. AWD yk'•t-SAG�C RGc?J�t .M�t'r+S OF THE To� of �3�iTL�hTA�t„8,put� t 5, ! - . '. . , .A b C®u2T ' p��a . �G- (� L.oca.-r� wl-R-rl N �E �r✓o c� Pt.alu:.1.... . . : ; _ _ ! ' A-r� 12-3t-�L. 04400.004L.00ow ; e A xT e Q t;. OA dzt 61 � ,4t�tsTa mam >La J`C, - 4L)evl=pery ` TW4 PL&Ll4 1f. Uar BASED OU AU 16KT MWT OtTF:RV%L S- MA rw a• Suc%laq 4 TOrw 06-F•'StjT; 1"OULD UOT ISO uSeJD APPI.tGA"M Tp veYer-meuE , ,.OT LINE.;. Aec� w % u v Te. Osterville, MA Map 114 1.) Assessor's Mop 114 Parcel 72 2.) D1334694 Parcel 003002 �,. 3.) L.C. Plan 2664-139 Lot 283 4� Bayberry 4.) This property is not in a Groundwater �0 Protection District Way 5.) This property is not in the Flood Zone. West 6.) This parcel is located in the Saltwater Prop. Estuary Protection Area Bay /Map 114 Gate Parcel 003001 Wianno " _ ' -- Head \ � — ` o Road \ N '` � — ' f c ND � Ave Sec L OCUS \ 0, 0 o, \\ Map 114 LOCUS Mop Lot 11 \ P . .y- -- ,-- '` O- \2° Parcel 73 N.T.S. 1 . 23± Acres ` N Zone: RF-1 \ i 1 43,560 Sq. Ft. \ Deck `� `e No 20' Frontage 125' Width \ Existing Septic shown \ per Septic As-Built Setbacks Proposed Pool Equipment Front 20' \\ 4- `-, Prop. Side 15' \ J Gate Proposed Chain Link \ 0 Pool Code Fence Rear 15' \ House #70 e \ Driveway ,} 1 Patio L — — J CD \` — — — — "js/ �1 Gazebo 1.0 Site Plan Q I \ Garage for Proposed Pool ` ` 1 A \� Prepared For \� \I Viola Associates .- located at / Existing Septic shown \ i per Septic As-Built 70 Bayberry W a y 0sterviIIe, MA \ S r Date: December 28, 2018 Scale: 1 " = 20' \ Prepared by: 114 �1�OFMAss All Cape Septic and Survey TE\ MPP �' SPHEN9cti \ Parcel 71 I3. N 618 Route 28 M06RE M West Yarmouth, MA 02673 � No.39398� v, (sob) �7�-4200 o ss� o sup all capesepticCa?gm oil.com NOTE: %;' !144_14(�' LOCATION OF UTILITIES IS APPROXIMATE AND ALL //�,� ` GRAPHIC SCALE UNDERGROUND AND OVERHEAD UTILITIES MUST BED/, DETERMINED IN THE FIELD PRIOR TO COMMENCEMENT 20 0 10 20 40 80 OF ANY WORK, THIS INCLUDES, BUT NOT LIMITED TO, 63 Ili REQUESTS TO DIGSAFE, ANY PRIVATE UTILITY COMPANIES AND THE LOCAL WATER DEPARTMENT. ( IN FEET ) 1 inch = 20 ft. DWG AC-163