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HomeMy WebLinkAbout0143 BAYVIEW CIRCLE - Health 143 BAYVIEW CIR., OSTERVILLE ` .a A=164-007 i k o f Q -pk- DATE 4/10/06 PROPERTY ADDRESS 143 Bayview circle Osterville - MA 02655 - On the above date, the septic system at the address above was Inspected. This system consists of the following: 1. 1-1000 gai Pon tank 2.1 1- Dizta.igut.ion. Box., -, 3., 3-330 Cuitec aechazgeaz 10'X30'X2' ;-0 Based on inspection,I certify the following conditions: o r 4.1 7h.is .is a 7.itie T.ive zept.ic zyztem 5., Septic .system .is .in paope.a woak.ing oadea at the /zaeZent time: C SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON, .INC.. Tanks-Cesspools-Leachfields b ,� :Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775-64i2 • r . •\ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS a ; DEPARTMENT OF ENVIRONMENTAL PROTECTION ,r TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: 4410 a"yView Circle s ervi le MA `02655 Owner's Name: Daniel Hogberg Owner's Address: 5607 Col I ege Ed KeyWes FT, _33n4n Date of Inspection:._4/1 0/0 6 Name of Inspector: (please print) Robert .A Paolini Company Name: 7. ? (7acomge2 9 S.O.n Inc. Mailing Address: C e n e2vc e, a�sz.-02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 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 1&000). The system: Passes Conditionally Passes. XXX Needs Further Evaluation by the Local Approving Authority Is C Inspector's Signature: Date: y The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to- system owner and copies sent to the buyer,if applicable,arid,the approving authority. Notes and Comments 2-4' Sauna .tukea �o/t deck ane .sitting on toy o� ze/itic tank 1— .ia on .inlet. covet., Othea .ih .in cente2 .o� tank. lank .iz on.2y fi 10 ioad.ing,, In-Pet co.v,e.a .is not .accezzitEe . 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 I Page 2 of 11 OFFICIAL INSPECTIONYORM—:NO FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DI,SPOSAL SYSTEM INSPECTION FORM !` PART A CERTIFICATION(continued) Property Address: 143 Bayyiew Circle Osterville MA_ Owner: Daniel Hogberg Date of Inspection: 4 10 0 6 Inspection Summary: Check A,B,C,D or.E/ALWAYS�complete all of Section:D A. System Passes: y(SS NO I have not found any information which indicates'ttiat any of the failure criteria described in 3 10 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Sel2tic zyztem.iz .in /2aopea woak:ing oadea at the R•¢ezent. time B. System Conditionally Passes: NO One or more system components as described in the"Conditional:Pass":section need to be.replaced:o'r 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. NO The septic tank is metal and.over.20 years old*or the septiF-tank(whethe.rmetal 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: N© 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: N0. The system requited pumping more than 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2_ Page 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 143 Bavview Circle Osterville MA 02655 Owner: Daniel Hogberct Date of Inspection: 4/1 0/0 6 C. Further Evaluation is Required by the Board of Health: DES 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: n o Cesspool or privy is within 50 feet of a surface water a o 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: ILO_ 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. no The system has a septic tank and SAS and the:SAS is within a Zone 1 of a public water supply. n o The system has a septic tank and.SAS and the SAS is within 50 feet of a privatewater supply well. a o 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: 2-4 Sauna tugaz /te on top o K10 use t.ic tank., I- L6 on is e coven -ot-Eaak.l Othen .ih .in cent" o4 .tank., I 3 . Page 4 of 1 l OFFICIAL INSPECTION FORM-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: 143 Bayview' Circle Osterville MA •02655 Owner: Daniel Hogberg Date of Inspection: 4/1 0/0 6 D. System Failure Criteria applicable to all systems:. You must indicate"yes" or"no'.'to each of the.following:for all inspections: Yes No X Backup of sewage into facility or system component due:to overloaded.or clogged SAS.or.cesspool _ X Dischargtor ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available.volume is less than.'/2•day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _T Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a.public well. T_ X Any portion of a cesspool or privy is within.50 feet of a private water supply well. _ X 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 WT..] 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 Systems: 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) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface.drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 43 Bayyiew Circle OGterville MA. 02655 Owner: Tani Pl Hnaherq Date of Inspection: 4.11 n.�ti Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of.Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X• _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage backup? X _ Was the site inspected for signs of break out? X — Were all system components,excluding the SAS,located on site? X _ 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? X _ 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 c�Q _ Existing information.For example,a plan at the Board of.Health. _ X 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 i� Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTtM.j NSPECTION FORM PART C SYSTEM:INFORMATION Property Address: 143 Bayview Circle 0,gtt .-vi 1 1 e nna U655 Owner: na n i P 1 Rpgbar Date of Inspection: a n ti FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): 3 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:0 Does residence have a garbage grinder(yes or no):yet Is laundry on a separate sewage system (yes or no):rz o pf yes separate inspection required] Laundry system inspected(yes or no): n o Seasonal use!(yes or no): a . , 200.4=107, 0.00 g¢.�2ons G!�_293., 15. Water meter readings,if available(last 2 years usage(gpd)):2 D 0 5=7 0,, 0 0.0 g¢��o n� �%[7=191. 7 8 Sump pump(yes or no):-a o Last date of occupancy: u n e COMMERCIALd US111ML Type of esta dent: N/R Y•..• W Design flowed on 310 CMR 15.203): gPd Basis of de4i,"how(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 N/A Source of information: Was system pumped as part of the inspection(yes or no):— If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool T 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: 9 ye¢as inztaUe.d i I/2 5/9 7 6]E /2o9. .srt, Were sewage odors detected when arriving at:the site(yes or no): n 0 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Bayview Circle Osterville .MA 02655 x Owner: Daniel Hogberg Date of Inspection: 4/1 0/0 6 BUILDING SEWER(locate on site plan) Depth below grade: 3 0" Materials of construction:_cast iron _40 PVC X other(explain): Distance from private water supply well or suction line: 2 0 t Comments(on condition of joints,venting, evidence of leakage,etc.): 'eeaka e., Vented t h zou h ouze vent SEPTIC TANK{e-s(locate on site plan)- 1000 ga e e o n s Depth below grade. 12" 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) 8' 6"X5' 8"X4 ' 10" Dimensions: Sludge depth: t a a c e Distance from top of sludge to bottom of outlet tee or baffle: t zaee Scum thickness: t r a c e Distance from top of scum to top of outlet tee or baffle: t 2 a c e . Distance from bottom of scum to bottom of outlet tee or baffle ace How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t6 outlet invert,evidence of..leakage,etc.): PumI2 tank -evesq 2 . eaas � Outiet tees .i.s in /2iaee., lank .seems .6 .auc utia y zoun oweve2 w4-th .sauna tu0ez on ;tol2 dont know ow Ong it wi eazt GREASE TRAP:L c(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.): G/teaze bta/r i.s not P/Iehent 7 Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Bayview Circle Oste_rville MA 02655 Owner: Dani P1 Rngherq _ Date of Inspection:. 4.4 1 0 f n6 TIGHT or HOLDING TANK: NO (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.): Tight o2 hoid.inu .tank. .a.ae no.t R2e3eni- DISTRIBUTION BOX:Ye-3 (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.): /3ox .iz ievei., 11a.6 1 $ate2a& No zotid ea22pove2 oft .2eakaGe .in oa ou.t o�e 9ox" PUMP CHAMBER:no (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.): l ump chamge2 iz not /22eaent 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: 1 43 Bayview Circle . s ervi a MA 02655 Owner: Daniel-berg Date of Inspection: 4 10 0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Loca°ted zee /zage 10.1. Type leaching pits,number:_ X leaching chambers,number: 3 3 3 0 cu i e c 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.): Lodmy to medium znad , No igaz oP �aiPune oa Rond.ina Soi2•S ate .6 d2u. yPcetaL.iorz zA nwanz CESSPOOLS: no (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 br no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ce3.3/2ooiz aae not /2ae.3ent PRIVY: N0 (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.): aiv .iz not e nt 9 r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DIS'P.OSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Bayview Circle Osterville MA 02655 Owner: Daniel Hogberg =: Date of Inspection: 4/10 0 6 S.KCETCH OF SEWAGE DISPOSAL SYSTEM ProVide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchrri-arks.Locate all wells within 1,00 feet.Locate where public water supply enters the building.. n '.� S gyp,��C.''er� 0 r` vS Kill NMI MR, 1. x � 1 i a ,,. i. h 3 � Cv WS 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY C ION FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE PART C SYSTEM INFORMATION(continued) Property Address: .143 Bayview Circle s erville MA 02655 Owner: Danie �or) Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6� feet 16 Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e z Observed site(abutting property/observation hole within 150,feet of SAS) u"Checked with local Board of Health-explain:a s L 1 p.- -a d — n o . Checked'with local excavators,installers-(attach documentation) i e 3Accessed.USGS database=explain t;E/t town.l a/tazta e-,ma. u!s You must describe how you established the high ground water elevation: 11�ed Ca e Cod Commiscon !Jatez Cori95 find %ukjic ldatea Su/z��y Nei head aotecttoa .a.eea�5 ma Set IJate2 ae�ouace.s o .ice cage cod comm.i�s.ion. Cround Leaching Pit • ;eet Groundwate Feet Below Bottom of Pit High Groundwater Adjustment 1..8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 aIr- ` •f111nTrrwl•nr•Iranrrwutrww�^nn•wfltnll'► aw*Ie�af1•w�w•• iw•Itn!7:ier.r'•�' 'rowN OF. BARNSTABLE BOARD RF HEALTH SUnSURFACR SFWAGO DISPOSA4 SYSTEM INSPECTION FORM - PART D•a•• CERTIFICATION «•T1ryT•t917}T1111'ST.TTaMf1111'IpIRf77a!!f�•/�1n1llTI�AR � '�� so" 1'7"`f1 mot• -TYPE OR PRINT CLEARLY- PROPERTY rNSPHCTFI? STREET ADDRESS 143 :Bayview Circle Osterville 02655 A•SS•ESSORS MAP DLWK AND 'PARCEL OWNER's NAME Daniel :Hocfbera PART'.* D CFRTIF?CATION NAME 'OF INSPECTOR Role.tt Pa.o.9ini • COMPANY NAME :P:- Naconriz?-k� Son Inc T �OblPANY ADD.RSSS Box 66 •' 'Czna o_,tv.i.2.Ee Oa.6b' 02632 ` StrQol Town-or C ty. •- Atau. LIP COMPANY TELEPHONE ( 508. Y�75 - 3338 FAX 508-IP90 f 578. CERTIFICATION. STATEMENT I certify that. I have persotiallly ..ins-pected ..this' sewage 'dia.i0i3 1. system at :his address and that .tti$' Information reported ,is true,, aoeUra-te-, and ;omplete as of the time .qf�inspeetion..• The in,qpevtiQn was per-Formed and any ,ecommendations regard.ing upgrade-, .ma-intenance,' abd icepa•ir .are. eon$is'tent ' lith my trainik% and expq-rience in the proper functi,'on- and maintenance of on— oite sewage disposal. systems. ;heck one: r •� , Systeoi RASED .Neo��. � J ' The inspection which •I have conducted has .,n•ot found any information . which indicates that the system- lails to adequately. protect .publi-o health or . the envi.ropment as defined in. .310 CMR. 1$' 30.3•, -Any failure criteria riot evaluated are as stated in the FAI•LUI CRIVERIA .section o-f this form. System FAILED* The inspection which I have 'con ted -has :found that the system fails .to protect the public health and the enm4ronmen•t ' in aoaotd•ance with Ti,t'le 61 310 CMR 15 . 303, and as - specifically noted -on .PART' 0 • . FAILURE CRITERIA of this spec'tion '.form. ' ns.pector 8ignatur -Date !ne' copy of this eeirtli f i.oat•ia•)l must -be �rovi'dad :to :the •QWN9R•, tbt. BUYER where aypli•.ceblo) and thin DgARD OV HEA TII. If the inspection FAILZb., the .owne'r' .or 9perator •a:he13, . upg•re►de'•the system. ithin o'ne year of the da't•e of the in�apection, unless. allowed Qr• requi;red h.horwise as Provided in �110 CMR 16 ,300 ., Town of Barnstable F ZHE.raY Regulatory Services Thomas F. Geiler,Director :sntixsrpBte, •. � MASS. 1639. A Public Health Division ATFD N1p'� Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax:. 508-790-6304. October 23, 2006 To Whom It May Concern: Enclosed is the Septic Inspection for 143 Bayview Circle, Osterville. The septic system passed the inspection. Please feel free to contact me at 508-862-4739, if you have any further questions. Thank you. Sincerely, Sharon Crocker Administrative Assistant Health Division r :4 TOWN OF BARN STAB L E Health Division— 200 Main Street - Hyannis, MA 02601 11 oil �pF ZHE Tp�� �P p FAA Date: 4/� * BARNSTABLE. v MAC Number of pages including cover sheet: 039. �0 To From: SHARON CROCKER Town of Barnstable Health Division Mail to: 200 Main Street Phone: ' ,'��� n��' r6 Hyannis,MA 02601 Fax hone: �d — v Phone: 1-508-862-4644 CC: Fax phone: 1-508-790-6304 REMARKS: ❑ Urgent ❑ For your review ❑ Reply ASAP ❑ Please comment ILI-A vtg'� - T.a_-A 1 P. 1 COMMUNICATION RESULT REPORT ( OCT.18.2006 8:19AN ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 452 MEMORY TX 915084370591 OK P. 12/12 ---------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR (LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION i TOWN OF BARN STABLE Health Division— 200 Main Street Hyannis, MA 02601 �' Date: Q FAX Entid�rsJCASLC, . Number of pages including cover sheet: To From: SHARON CROCKM ? � Town of Barnstable Health Division Mail to: 200 Main Street Phone: - - � �/, �6 H wmis MA 02601 Fax hone: bAV, r Phone: 1-508-862-4644 CC: Fax hone: 1-508-790-6304 COMMONWEALTH OF MASSACHUSETTS "a(0 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS No DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—.NOT,FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: .143 Ba yview cili c ee Owner's Name: Danie i fro gR ea g Owner's Address: 5607 Co eeege Road Keywezt TL 33040 Date of Inspection: Name of Inspector: (please print) Robert A Pao.lini Company Name: �, %. N comgea .S:o.n Inc. Mailing Address: centzAvizze, Alazz. 02632 Telephone Number: 5 0 8-7 7 5_3 3 3 8 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, training and experience in:the proper function and maintenance of on site sewage disposal systems. I yam a DELI approved system inspector pursuant to-Section 15:340 of Title 5(310 CMR M000). The system: r XXX Passes _ co ' Conditionally Passes Nee Further Evaluation by the Local Approving Author. CO ctt. cr Inspector's Signature: _ Date: � 0 CIO The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is.a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to- system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments .the 2-4' sauna tugez ,Po z deck . have aeen zemovecl.c,12om toB o� ze/2tic tank., ****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 r Page 2 of 11 OFFICIAL INSPECTION,.FORM—NOT FOR VOLUNTARY ASSESSM9NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 143 Bayview Circle Os ervi a MA Owner: Daniel Ho ber Date of Inspection:1,0 10/0 6 Inspection Summary: Check A,B,C,D or.E 1 ALWAY&eompiete all of Sectioo:D A. System Passes:#Es NO I have not found any information which'utdicates'thatlany 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. Comm nts: SeI2 Lc .sy temjz in 121topea woaking oadea at the Raesent. time B. System Conditionally Passes: NO One or more system components as described in the"Conditional-Pass":section need tote.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. NO The septic tank is metal and.over 20 years old*or the septic tank(whether metal or:not)isstructurally 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: NO 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 it removed distribution box is.leveled"or teplaced ND explain: N 0 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: { Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1413 Bavview Circle _ .sterville MA 02655 Owner: Daniel Hoctberg Date of Inspections C. Further Evaluation is Required by the Board of Health: N0 Conditions.exist whichrequire 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: 0 Cesspool or privy is within 50 feet of a surface water n o Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t 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: \ n o 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. 20 The system has aseptic tank and SAS and the.SAS is`within a Zone 1 of a public water supply. n o The system has a septic tank and.SA&and the SAS is within 50 feet of a private water supply well. a The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froth a ll**.Method used to determine distance private water supply we **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organty and ic compounds indicates that the well is free from pollPpon fromded that that fac no other the presence of ammonia nitrogen and nitrate nitrogen is equal to or Tess than 5. m,p 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 TOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART.A CERTIFICATION.(continued) Property Address: 143 Bayview' Circle Osterville MA -02655 Owner: Daniel Hocrbercr Date of lnspection:E/1 0/0 6 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the.following:for all inspections: Yes No X Backup of sewage,into facility or system Icomponent due.to overloaded or clogged SAS.or cesspool _ X ' Discharge or ponding of effluent to the surface of the.ground or.surface waters due to an-overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2.day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or priry" is below high ground water elevation. — -T Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within.50 feet of a private water supply well. X 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 co liform 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 fort..] 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 ownenshould 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 10,00.0 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Lnterim 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 n "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 1 t Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 143 Bayview Circle Ost:ervillQ MA 02655 Owner: Dani Pl wnaherg Date of Inspection:y� /fin/0 6 Check if the following have been done.You must indicate"yes"or"no"as'to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of.Health X Were any of the system components pumped out in the previous two weeks? _ X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available''note as N/A) X _ Was the facility or dwelling inspected for signs of sewage backup X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ 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 nQ — _ Existing information.For example,a plan at the Board of.Health. _ X 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 i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEj?VAGE.DISPOSAL-SYSTE INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 143 Bayyiew Circle �ZGt-rui 1 1 c Nin U.655 owner: n;4 n; t=1 Hnrrhr­rrT Date of Inspection: FLOW CONDmONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): 3 • 3 3 Q DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd is#of bedrooms): . Number of current residents:0 Does residence have a garbage grinder(yes or no):Y.e-3 Is laundry on a separate sewage system(yes or no):h o [if yes separate inspectionxequired] Laundry system inspected(yes or no): a o Seasonal use:(yes or no): no . , 200.4=107, 000 ga i20n�s G%(7=29 3. 5 Water.meter readings,if available(last 2 years usage(gpd)):2 0 0 5 7 0., O 0,0 .qa on G =191., 7 8 Sump pump(yes or no):2 Last date of occupancy: June . COMMERC4016USTRIAL NIA , Type of estatttrient: Des} n flow ed o god n 310 CMR 15.203): m, g � > Basis of d 0611flow(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 h��A Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool ; _Privy :. _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be ob_tained 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: �.. 9 yeaa.s .instaiiecl. 11125197 Of Roki&AonWere sewage odors detected when arriving at the site(yes or no): a 0 6 Page 7 of 11 OFFICIAL INSP ECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 BaVview•.Cir.cle . Osterville .MA 02655 Owner: Daniel Hocrberg Date of Inspection:1'Et�10/0 6 BUILDING SEWER(locate on site plan) Depth below grade: 3 0' Materials of construction:_cast iron _40 PVC X other(explain): Distance from private water supply well or suction line: 2 0 f Comments(on condition of joints,venting,evidence of leakage, .Eeaka eo Vented thltou h ouse Vent SEPTIC TANK{/e Z(locate on site plan)' 10 0 0 ga.Q t o n s Depth below grade: 12' Material of construction:7 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) 8 6"X 5' 8'X 4 ' i 0' Dimensions: Sludge depth: t a a c e Distance from top of sludge to bottom of outlet tee or baffle: t/La ce Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: taa ce . Distance from bottom of scum to bottom of outlet tee or baffle. c e How were dimensions determined: Coments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels m as related to outlet invert,evidence ofleakage,etc.): Pump tank even 2 e ;� OutQet -tees .i•s in /�2ace.. lank .zeem.s nuc r�2a y •Souria, , GREASE TRAP: n c(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 of baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and out tee or baffle condition,structural integrity)liquid levels as related to outlet invert,evidence of leakage,etc.): -Gaease taa,p i4 not a.esent 7 Page 8 of l 1 .OFFI:CIAL TNSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Bayview Circle OsterviIIcm- MA 02655 Owner: Tani Pi Ragherg Date of Inspection:,-Ijo/1 py(p 6 - TIGHT or HOLDING TANK: NO (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 Ievel: Alarm in working order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 7.i.qht o2 ho ediaq .tanks a,za not DISTRIBUTION BOX:y a (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.): Box .ins ieve:2.1 Kays 1 eatesae., No zoeid caaayovea 62 2eakaae .in oa out o,� 9ox PUMP CHAMBER:n o (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.): Pump chaM9ea iz not R2ebent '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: 143 Bayview, Circle Osterville MA 02655 Owner: Daniel Hogberg Date of Inspection:10 Z ITT 0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located zee /gage 10., Type leaching pits,number:_ X leaching chambers,number: 3=3 3 0 c u 2 t e c 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.): Lodmt/ to medium .snarl , No zignz o,e 62 12onding So.iiz ate d2y veaet¢t ion 1.6 n.aa a aP - CESSPOOLS: no (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.): ce/b12oo-iz a/Le not /22ebent PRIVY: N'0 (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.): Plt.ivu -ih not R2ae.6en 9 d v y Page 10 of 11 J OFFICIAL INSPECTION'F'ORM:—NOT FOR VOLUNTARVASSESSMENTS SUBSURFACE SEWAGEDIS'POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) tY Y, Property Address: 143 Bayview Circle Osterville MA .02655 y.x Owner: Daniel Hocgberg Date of Inspection:1 ./1 0'/0 6 .-WTCH OF SEWAGE DISPOSAL SYSTEM Prov'i4e a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or u benehm'arks.Locate all wells within 100 feet.Locate where public water supply enters the building.. ' ` �n , � ✓ ��*nip.{,x ' • • i "`• ' • 6ac`e zf a • i. rsY y � :` 10 Page 11 of 11 OFFICIAL INSPECTION RORM—NOT FOR VOLUNTARY FORM ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C SYSTEM INFORMATION(continued) Property Address: .143 Bayview Circle Os erville MA 02655 Owner: Danier Ho berg Date of Inspection: 0 1 0 0 6 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e z Observed site(abutting property/observation hole within 150>feet of SAS) U E i5 Checked with local Board of Health-explain:a,y PULL, r^ 7 d .n o Checked4ith local excavators,installers-(attach documentation) Accessed USGS database-explaintt/� t own. &aansta� Ee. ma.,u¢ You must describe how you established the high ground water elevation: /Ihed. : Cape Cod Comm.i,6ion 1date2 7a&.2e C ritoulth And %uktic 111ate2. SuR/%Qy G1eii head 2otect.ion .a/tea-6 mal2., Se Pt 19 95 Uatea aeh6uace.3 o ice cape cod comm.i.s.ion u Leaching Pit • ;eet Groundwateq'("�Feet Below Bottom of Pit High Groundwater Adjustment.l..8 ft per Frimpter Method Therefore,the vertical.separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 I DATE 4/10/06 PROPERTY ADDRESS 143 Bayview Circle Osterville MA 02655 On the above date, the septic system at the address above was Inspected. This system consists of the following: 1: 1-1000 gaiion tank 2.1 1- Dihta igut.ion Box., 3.� 3-330 Cuitec aechaage2z 10'X30'X2' `• Y : mt Based on inspection,I certify the following conditions: G: 4.1 7h.iz i13 a 7.it2e Tive zept.ic zystem 5., Septic .3yntem .ins .in paopea woak.ing oade2 at the pae,3ent t.imeo SIGNATURE ' Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc Address: P. 0. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 CJ :SEH P. MACOMBER & SOND Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections ox 66 Centerville, MA 026.3 775.3338 775.6412 • i i .\ COMMONWEALTH OF MASSACHUSETTS I EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION ,y TITLE 5 OFFICIAL INSPECTION FORM-.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: . 141' '' diew Circle 0s-erv11Te MA '02655 Owner's Name: Daniel Hogberg Owner's Address: 5607 College RrI Kevwest FT. -nn4o Date of Inspection: 4/1 0 f 0 ti Name of Inspector: (please print) Robert .A Paolin Company Name:1 % (Aacomle2 S:o.n Inc. Mailing Address: Cen eay.c e, u�.s. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 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 ithe proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant m Section.15:340 of Title 5(310 CMR I.&000). The system: Passes Conditionally Passes XXX Needs Further Evaluation by the Local Approving Authority Is c Inspector's Signature: Z Date: '0-6 y` The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system,is a shared system.or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,atid,the approving authority. Notes and Comments 2-¢' .6auna tuke.s &/t deck ate .6.itt.ing on top o� ze/at.ic tank 1- .ih on .inlet covet., Othe2 .ins .in eentea ,o/ tank.. lank .is oney 11 10 ioad.ing., Inlet cove.a i.s not accese.igie ""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 ASSESSM9NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 143 Bayview Circle Osterviiie MA Owner: Daniel Ho berg Date of Inspection: 4 10 0 6 Inspection Summary: Check A,B,C,D of E/AL WAY&completeall of Section:D A. System Passes: qES NO 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. Commggnts: Sel2lic .3yntem.iz in /2,zopea woltking o/tdea at the /22ebent, time B. System Conditionally Passes: NO 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. NO The septic tank is metal and.over20 years old*or the septic tank(whether metal or:not)is..struct urally 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: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or duo 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 br replaced ND explain: NO. The system requited pumping more than 4 times a year due to broken or obstructed pipe(s).,The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 143 Bayview Circle osterville MA 02655 Owner: _Daniel Hogberg Date of Inspection: 4/1 0/0 6 C. Further Evaluation is Required by the Board of Health: IFS Conditions.exist whichrequire 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: n o Cesspool or privy is within 50 feet of a surface water no 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: no 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. no The system has a.septic tank and SAS and the:SAS is'within a Zone 1 of a public water supply. n o The system has a septic tank and,SAS and the SAS is within 50 feet of a privattwater supply well. no 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: 2-4' Sauna tugez ate on to o t K10 Ze t.ic tank.. 9- .is on inlet covet o an , Othea .iz .in center of .tank., 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 143 Bayyiew' Circle Osterville MA .02655 Owner:_Daniel Hogberg Date of Inspection: 4/1 0/0 6 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the.following;for all inspections: Yes No X Backup of sewage,into facility or system component due:to overloaded or clogged SAS,or cesspool _ X Discharge or ponding of effluent to the surface of the.ground or.surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available.volume is less than'h•day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. -Y Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a.public well. _ X Any portion of a cesspool or privy is within.50 feet of a private water supply well. ......� X 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 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 now of 1.0,000 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary.to a surface drinking water supply _ X 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. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 143 Bayview Circle OG rvi11Q MA 02655 Owner: na n i P 1 TinghPrg Date of Inspection: 4.110.4 n 6 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of.Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? A _ Were as built plans of the system obtained and examined?(If they were not available iiote as N/A) X _ Was the facility or dwelling inspected for signs of sewage backup? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS,located on site? X 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? X _ 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 t�9 _ Existing information.For example,a plan at the Board of.Health. _ X 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 I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL-:SYSTEM-iNSPECTION FORM PART C SYSTEM INFORMATION Property Address: 143 Bayview Circle Owner: Dania 1 uagherg Date of Inspection: a /1 0.10 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): 3 . 330 3 0 DESIGN flow based on 310 CIVIL 15.203(for example: 110 gpd x#of bedrooms): . Number of current residents: 0 Does residence have a garbage grinder(yes or no):y.e-3 Is laundry on a separate sewage system(yes or no):n o [if yes Separate inspection required] Laundry system inspected(yes or no): a o Seasonal use!(yes or no): rto 2004=107, 000 ga eionz q1 t7_29 3. 15 Water.meter readings,if available(last 2 years usage(gpd)):2 0 0 5=7 0.,'0 0,0 .ga i 2 o n a Gi/7=191., 7 8 Sump pump(yes or no): Last date of occupancy: u n e COMMERCIALaNJ USTRIAL N1 4 Type of estabish Design flow(1i°ased on 310 CMR 15.203): gpd A: Basis of d0sign,&w(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 NIA of information: Was system pumped as part of the inspection(yes of no):_ If yes,volume pumped:_____gallons--How was quantity pumped determined? Reason for pumping: PE OF SYSTEM v 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 ob_tained 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- 9 yean s .inzt-ai eed 71125197 IVE RoUninn. Were sewage odors detected when arriving at.the site(yes or no):o0 6 Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Bayview Circle . Osterville .MA 02655 Owner: Daniel Hogberg Date of Inspection: 4/1 0/0 6 BUILDING SEWER(locate on site plan) Depth below grade: 3 0" Materials of construction:_cast iron _40 PVC X other(explain): Distance from private water supply well or suction line: 20 f Comments(on condition of joints,venting,evidence of leakage,etc.): 2eaka e., Vented thzou h ou�e vent SEPTIC TANKy a(locate on site plan) 1000 ga.2 i o ns Depth below grade: 1 Z" Material of constructio— n: 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: 8 6 X 5 8", " X 4 10„ Sludge depth:_ tR a c e Distance from top of sludge to bottom of outlet tee or baffle: t a a e e Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: to a c e Distance from bottom of scum to bottom of outlet tee or baffle:Ta c e How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence ofleakage,etc.): l um tanke�ve2�_Z . ean:s , Out eet tees iz .in /2&ce., lank .seems Z 2u t-ey .noun owevez w.e .sauna tugez on ;to12 dont know ow Eorig it wite eazt GREASE TRAP:�glocate 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.): Gaeaze bta/z .i s not Pae sent 7 r Page 8 of 11. OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Bayview Circle Osteryi l 1P MA 02655 Owner: Dani P1 Nngha�_ Date of Inspection:. 4.1 1 C)/0 TIGHT or HOLDING TANK: NO (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.): 7.ight oA ho ed.ing tank. .¢ice not 2aezent DISTRIBUTION BOX:y e,6 (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.): [3ox .is —evee. 11a.3 I 2ateaae., No zo-eid cailwove2 oa 2eaka.ge .in oa PUMP CHAMBER:n o (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.): lumI2 cham&ea its not 12ae6ent 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: 143 Bayview Circle s ervi a MA 2655 Owner: Danie o berg Date of Inspection: 4 10 0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located zee_ 12age 10., Type leaching pits,number:_ X leaching chambers,number: 3-3 3.0 c u Qt e c 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.): .� Lodmy to medium hnado No h.ignh o O a.iivae oa ponding So.iis aae day_yegetat.ion i:s o2mQp CESSPOOLS: no (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.): cehh/2ooiz aae not Raehent PRIVY: N0 (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.): p a.ivy .ih not Paehen 9 Page 10 of 11 f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE•DISPOSAL;SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)' Property Address: 143 Bayview Circle tda Osterville MA- .02655 �r ' Owner: Daniel Hogberg x ,,. Date of Inspection: 4/1 0/0 6 WTCH OF SEWAGE DISPOSAL SYSTEM :r Provide a sketch of the sewage disposal system including ties to least two permanent reference landmarks or xx g P Y g w , benchmarks.Locate all:wells within 100 feet.Locate where public water supply enters the building.. kill t �F fi J -W f� � it j� "�,���, �; •'. �' + atu �at fJ. rt > A gtg a4 - ff tit 3+ 1 n w � I t a`FTceW�`.O* a: 40 q .. zt 10 r t i kp k Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY C ION FORM SSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PART.0 SYSTEM INFORMATION(continued) Property Address: ..143 Bayview Circle s erville MA 02655 Owner: Danie Ho berg Date of Inspection 0 06 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e�s Observed site(abutting property/observation hole within 150,feet of SAS) u e Checked with local Board of Health-explain.z P u.i.P t a 2 d n o Checked:with local excavators,installers-(attach documentation) t e m a. u.s z Accessed USGS database-explain. �.. You must describe how you established the high ground water elevation: llzed : Cape Cod Comm.iz.ion !date. Tag-ee Corn•touzz And P ukeic 6)atez Sul2piy IJeii head aotection .a2ea.6 ma Se t 1995 Oate2 aezouacez o ice cape cod comm.is.ion., GroundTup of Leaching Pit • Beet GroundwatePFeet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Ftimpter Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 ,•Y *4e •Ana+r.-w.•en-w'r"anr�anrennw�•�nr M*rwy +wnne!7rer.r-••`' 'TOWN OF. BAR STAELE 13OA4D QF 11$AIT11 .SUBSURFACE 89NA09 DISPOSAL AYSTRM INSPECTION FORM — PART D•a- CERTIFICATION _.tn-r•s-,:,-.�n,rasr+++�rnn•w,r..r..r.rt+••+nnrr++r-aw ' "'^ n**.•- • -TYPE 01 PRINT CLEARLY— PROPERTY INSPEQTIs11 STREET ADDRES$ 143 ;13ayview Circle Osterviile 02655 ASSESSORS MAP, DLWK AND 'PARCEL !� OWNER's NAME Daniel Hoaberg ' PART'.' D CERTIFICATION NAME OF INSPECTOR Ro 8 eat P,a.o Un i ' n�T�YIR����Iq��-1 '•� �,�� 1 1 1■ la��l ■��I���*1 ,�— COMPANY NAME o.6P.ph :P., Nacontlz?-2 Son Inc I 1 111��, Ilan w I COMPANY ApD.RESS Box 66 &6.6' 02632 ` ' stro I' Town or City. - Eta • LIP COMPANY TELEPHONE t 508. )' �. 7.5 - 3338 .PAC (' 508' )190 f 578 CERT-I'FICATION. STATEMENT I certify that I have personally .inspected .-the sewage 'digposal. system at this address and that 'Wid information reported .is true,. aoo0ra•te•, acid omplete as of the time qf 4nspeetion.o• The inspeetiQn was per•Fo.rmed and any recommendations regard.ing upgrade•l' •maintenance,' abd repair .afie- oon$is'tent with my trainip,9 and exp.s'rience in th@ proper functi'on' acid maintenance of on- site sewage disposal. systems. Check one: A X� Systed PAS9*D '�!' . -Uaw eva ✓ " ' The inspection which 'I have condu(;ted has .,n•vt found any information . which indicates that- the system' falls to ' adequately. protect .publi•o health or the envi.ropment as defined 10- .310 CMR. It' 30.3•, Any faiitu•re cri•ter.ia o6t •evaluated are as stated in the FAIWIM CRI.`i'RRIA .section o•f this form. System FAILED* ' The inspection which I Crave co'n ted 'has .found that 'the System fails .to protect the public heaWi and the environment * in aoaoxdemce with Title 61 310 CMR 15 . 30�1 and as • specifically noted .on -PART C - . FAILURE CRITERIA of this WsPection '.form. ' Inspector $ignatur m 'Date Ycopy of this eerti,fioat.foh must •be provided 'to : the •QWNLR•0 tho BUYER re appli:oa.ble ) and the 33QARD OF t1EA Tli. ; * If the inspection FAIL-ED., thb .owner'.o:e�"operator a�:hall, . upg•r:ade'•the system. within one year of the aat•e of the inspection, unless. al-lowed qr' regiti;red -h.harw{se as Provided in q;10 CMR 15 ,306 ,, TOWN OF BARNSTABLE 1/ LOCATIGN�C '�"Ni�y i I�( ^` SEWAGE # 9 7-G iZC VILLAGE 143 1 �y�:�tF , t2r'Ic: ASSESSOR'S MAP & LOT 1 INSTALLER'S NAME&PHONE NO. WE 1-25 r 7 A SEPTIC TANK CAPACITY 11,666 LEACHING FACILITY: (type) C v I (size) 16 r('-3 ci y;2— NO.OF BEDROOMS BUILDER OR OWNER i PERMTTDATE: _ l 6 1'4 01"1-) COMPLIANCE DATE: Ste/ Separation Distance Between the: Maximum Adjusted Groundwatei Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ' within 300 feet of leaching facility) Feet Furnished by DO `+ r. (47 s TOWN OF BAKTST:'�,BLE LQCA-MQ,'i� A/ a� Gf, 1 rC-L4— SEWAGE# VILLAGE CAS'-r&,Clhl 0455 , ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 Leachin Fac• ity(If y wed ds xist within 300�qhijnfa Ityy2� Feet Furnished b " � . W �� D � � �� C � � O � � •. �� ` �` �� . , �� . . f No. f C ;; ® � ` Fee. 5 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , : es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for r3igozal *p5tem Congtruction Permit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 4 3 Ba yv i ew Circle Owner's Name,Address and Tel.No. 4 2 8—6 5 4 6 Assessor'sMap/Parcel Osterville, MA Edward Wille 02655 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089 , Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms' 3 Lot Size sq. ft. Garbage Grinder( nd Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of three stonenacked H-20 infilt-ratnrG 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 issued by Byard of Healt Signed Date if—v'� i--9 Application Approved by Date /n 7 Application Disapproved for the o lowing reasons Permit No. Date Issued No. _ Al �� Fee 5 0.0 0 ' / Entered in computer: „ THE COMMONWEALTH OF MASSACHUSETTS es / PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migogaf *pztem Construction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 14 3 Bayview Circle Owner's Name,Address and Tel.No. 4 2$-6 5 4 6 Assessor'sMap/Parcel Osterville, MA Edward Wille 143 Bayview Cir, Osterville, MA 02655 Installer's Name,Address,and Tel.No. 775_8776 Designer's Name,Address and Tel.No. ` Wm E Robinson Sr Septic Sry PO Box 1089, Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3' Lot Size sq. ft. Garbage Grinder( no Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per Ay.�Calcdlate daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand _ Nature of Repairs or Alterations'(Answer when applicable) Title 5 Leaching consisting of three stonepacked H-20 infiltrators. Date last inspected: r: 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 issued by th' B d of Healt . Signed Date -9 Application Approved by Date//'3-,2,o- C/7 Application Disapproved for the fo lowing reasons i Permit No. Date Issued i .`: -------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Wille BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X4 Upgraded( ) Abandoned )by at 43 Bayview Circle, Osterville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 Z dated Installer Wm E Robinson Sr Septic Sry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date I I •Z E✓1 �`� Inspector V' . . j t�+ ——Q —/—————————————————————————————————— No. / 7 10 a40 Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH.;DIVISION - BARNSTABLE., MASSACHUSETTS Wille EJ i5ogar �pgtem �ongtruc ion hermit Permission is hereby granted to Construct( )Repair( X)Upgrade( )A andon System located at 143 Bayview Ci rnl P i. Osterville, MA Installer,: ,W '�f Robinson Sr Septic Sry and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 aid the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: (7 - 2)(9 Approved by�n NOTICE: This Form Is T6`Be Used For The Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated f( -2-9— 9 .1 , concerning the property located at 143 Bayview Circle, Osterville, MA, meets all of the following criteria: *,�(ere are no wetlands within 100 feet of the proposed leaching facility. *1 here are no private wells within 150 feet of the proposed septic system. *!Where is no increase in flow and/or change in use proposed. *11here are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: e<� . L DATE 16 9 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). I TOWN OF BARNSTABLE V LOCATION C ; tFiZV i I I( + SEWAGE`# VILLAGE 14 hgV�>t E 1� C I c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. I.JC— i Ob6i �.,J {C---n iL 775 El 74 SEPTIC TANK CAPACITY 1, CLU LEACHING FACILITY: (type) ��y (size) r A 3 LV1 "z- -NO.OF BEDROOMS L I BUILDER OR OWNER PERMTTDATE: 0 4 C " 1 COMPLIANCE DATE: I A2 - fT_ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by w� 64 II "� oFI„E, Town of Barnstable Department of Health, Safety, and Environmental Services BARNSTABLE, = Public Health Division 39. 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health Mr. Edward Wille 143 Bayview Circle Osterville, MA 02655 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 143 Bayview Circle, Osterville was inspected on October 13, 1997,by Joseph Macomber, Jr. a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • The liquid depth in the leaching pit was less than four(4")inches below the invert or available volume was less than 1/2 day flow. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00,The State Environmental Code,Title 5 within(30)thirty days of receipt of this notice. You are also directed to bring the septic system into compliance within sixty(60)days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean,R.S., C.H.O. Agent of the Board of Health q\health\dbfiles\title5i.doc �\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS x DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F.VELD (ED TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 143 Bayview Cir, Osterville Address of Owner: Edward Wille Date of Inspection: //—A 5�'! " (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �Im E Robinson Septic Servi rp- Mailing Address: PO Box 1 089 , C nt er vi 1 1 a r� 02632 Telephone Number,,' 5 0 8 7 7 5—8 7 7 H CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: L'Passes _ Conditional.ly Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: GU Date: 0 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Aj SY TEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) YSTEM 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. Indic a yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. y _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpWwww.magnet,state.ma.us/dep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Will e Date of Inspection: 11 -z f—q - B) SYSTEM CONDITIONALLY PASSES (continued) ; `� j' _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] URTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Wille Date of Inspection: r/ D SYSTEM FAILS: Yo must indicate ei;?,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] RGE SYSTEM FAILS: You ust indicate either "Yes" or "No' as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of 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) The ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 143 Bayview Cir, Osterville Owner: Wille Date of Inspection: //—,2 9 'J Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓/ _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ 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. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. / _ All system components, excluding the Soil Absorption System, have been located on the site. _V _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _V/' _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. J _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [1 5.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 143 Bayview Cir, Osterville Owner: Wille Date of Inspection: //—off•$--�/' FLOW CONDITIONS RESIDENTIAL: Design flow: yyd g.p.d./bedroom for S.A.S. Number of bedrooms: -1 Number of current residents:11 Garbage grinder (yes or no):&—o Laundry connected to system (yes or no)�� Seasonal use (yes or no)j�g—s Water meter readings, if available (last two (2) year usage (gpd): 1995 — 36 , 000g Sump Pump (yes or no):_A, o 1996 — 42, 000g Last date of occupancy:l` ';�S-9 7 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available. Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Syster,Kpumped as part of inspection: (yes or no) ./L If yes, volume pumped: gallons ') Reason for pumping: LS S TYPE OF S�STEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: i- O � Sewage odors detected when arriving at the site: (yes or no)�L J (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Will e Date of Inspection: //—;L5-97 BUIL NG SEWER: (Locate o site plan) Depth bel w grade: Material f construction: _cast iron _40 PVC _other (explain) Distanc from private water supply well or suction line D iamete Commen s: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:1/ (locate on ,site plan) Depth below grade: Material of construction: 1/concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: t a� • y Z Sludge depth: / Distance from top of sludge to bottom of outlet tee or baffle: L!p Scum thickness: U —/ ' � Distance from top of scum to top of outlet tee or baffle: X Distance from bottom of scum to bottom of outlet tee or baffle: f 1� How dimensions were determined: 6 i.X Comments: (recommendation for pumping, condition of inlet an outlet tees or baffle , depth of'�quid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rd G GRE E TRAP: (locate on site plan) Depth elow grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensi ns: Scum t ckness: Distanc from top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date of I st pumping: Comme ts: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri , evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Will e Date of Inspection:f� S_ 97 TICT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota. on site plan) Depth elow grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimen ions: Caps ty: gallons Desi flow: gallons/day Alarm vel: Alarm in working order _ Yes; _ No Date of revious pumping: Commen s: (conditio of inlet tee, condition of alarm and float switches, etc.) V DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ _ Comments: (note if level and distribution is equal, evidence of solid ryover, evidence of leakage into or out of box, etc.) PUM CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarm in working order (Yes or No) Com ents: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Will e Date of Inspection: //—e2 s'-9 'J / SOIL ABSORPTION SYSTEM (SAS):✓ (locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:-3— leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, vel of ponding, condition of vegetation, etc rz j Z, CE POOLS: _ (Iota a on site plan) Numb r and configuration: Depth- p of liquid to inlet invert: Depth f solids layer: Depth c scum layer: Dimensi ns of cesspool: Material of construction: Indicati n of groundwater: inflow (cesspool must be pumped as part of inspection) Comm nts: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Materials of construction: Dimensions: Depth of olids- _ Commen (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 jn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Wille Date of Inspection: f'j.--7 S-- 9'7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) l (,1 L? / - 36— � � 3 (revised 04/25/97) Page 9 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Cir, Osterville Owner: Wille Date of Inspection: //— 1- S-4 7 Depth to Groundwater /, -feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 COMMONWEALTH OF MASSACHUSETTS 10f30f 7 I r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROT l2 ONE WINTER STREET. BOSTON, t,tA 02108 617_29' �.FO(r `� Jam./ 1 OC T "G GoNemor ® \ �/? y)c ARGEO PAIL CELLUCCI t . ��'ry99ti 1,9 D Lt Goscmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION�FORM °�QT9e4r `9� yn7 PART A CERTIFICATION 44 9 5 Property Address:143 Bayview Circle Osterville,Mr ss of owner: Date of Inspection:. 1 0/1 3/97 (I i erent) Name of Inspector: yy,, I am a DEP p ys m e t`3PA sua;FtG Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.MACOMBER & SON INC. Mailing Address: BOX 66 C'.Pni-PrVl 1 1 Pe MaGG _ 02632 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informa(,on reported relo- s and complete as of the time of inspectton. The inspection was performed based on my training and experience in the proper runcl,on a maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ eeds Further. Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System inspector shall submit a copy of this inspection report to the Approving Authority within thirty (301 days of compJFnnp !n , inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the nspector and the system o-TeT sr•..;!, s;:)- the report to the appropriate regional office of the Department of Environmental Protection The original should c-e sent to -re s:ve^ o, and copies sent to the buyer, if applicable. and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure cruer,a as dei,ned r`, 3!0 C ? 3 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 7ne s,;:e— completion of the replacement or repair, as approved by the Board of Health, will pass. indicate yes, no. or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined'. expla nn., -,o: The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Ce a:e o Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date rf t.e rS -PC1 Or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or e)�iiiva:ior o, 1. failure is imminent. The. system will pass inspection if the existing septic tank is replaced with a conform,ng sra, c as approved by the Board of Health. (r.v%#.d 04/25/97) Page 1 of 10 DEP on tr,e Wono Wice Weo nnp.1rwvrw magnet state ma us/oeo Pnnteo on Recycued Paper i 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propeny Address: 143 Bayview Circle Osterville,Mass . 02655 O»ner: Edward Wille Date of Inspection: 1 0/1 3/97 e1 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to oro'"er or o s _.— P'petsl or due to a broken, senled or uneven distribution box. The system will pass inspection I (—In aDDro•a Board of Health). Describe observations: broken pipets) are replaced obstruczlon is removed distribution box is levelled or replaced The system required pumping more than four limes a year due to broken or obstructed pipe(s) The systemass inspeclion if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require funher evaluation by the Board of Health in order to determine if the system s fa,hng to xc;ec. :-e publ,c health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONItiC lw A •����:� WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: AZO Cesspool or privy is within 50 feet of a surface water &v Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (.AND PUBLIC WATER SUPPLIER, IF APPROPRIATES DE-TERol , S Tr.+T THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a s:riace -ate: s_D: tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public eater suDD r -el, The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private eater suDDI, -el The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more fro^n a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compouncs nc•cates :-•a. the well is free from pollution from that facility and the prese ce of ammonia nitrogen and nitrate nitroger s ec_a' .� less than 5 ppm. method used to determine distance �I (approximation not valid) 3) OTHER �� -- Ir.�l..d 0�/15/f�l Ysp. 2 of 10 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORm PART A CERTIFICATION (continued) Properly Address: 143 Bayview Circle Ostervill6 Ma O�n Date o: Edward Wille ate of Inspection: 10/1 3/97 D) SYSTEM FAILS: yo must indicate er: et "Yes' or 'No" as to each of the following. I have determined that the system violates one or more of the following failure criteria as defined n 310 C•�•,R t: 30S '�e for this determination is identified below. The Board of Health should be contacted to determine what will bz neczss o the failure Yes ^o ZBackup of sewage into laciliry or system component due to an overloaded or clogged SAS or czssaeo Discharge or pondrng of effluent to the surface of the ground or surface waters due to an overloaeee or c:c-93e cesspool. Stain liquid level in box above outlet inven due to an overloaeed or c!oggec SAS e cess c - f Liquid depth in 6.¢.tipovi•,s less than 6" below invert or available volume is less than t.'? da: Requ,red pumping more than 4 times in the last year NOT due to clogged or obstructed pipe!st Number of times pumped _ Any pon,on of the Soil Absorption System, cesspool or privy is below the high groundwater ete•a: e ZAny portion of a cesspool or privy is within 100 feet of a surface water supply or tabular; to a s.;riace -a!er Any portion of a cesspool or privy is within a Zone I of a public well. ZAny 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 a,e: -e-i . acceptable water quality analysis, if the well has been analyzed to be acceptable. anacn co:),,. ci -ell -3a t- dra coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen E) LARGE SYSTEM FAILS: you must indicate either "Yes' or "No" as to each of the following. The following criteria apply to large systems in addition to the criteria above The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a s 3r•.!.__n: :^tea: :c public health and Qfery and the environment because one or more of the following conditions exist Yes No 4114 the system is within 400 feel of a surface drinking water supply /tiy the system is within 100 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Pro(eaion Area • IWPA) or a public water supply well) The owner or operator of any such system shall bang the system and facility into full compliance with the grovnd.:ate requitements of 3.14 CMR 5 00 and 6.00. Please consult the local regional office of the Department lot funhet inierma,,c^ I ➢•0. 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properly Address:1 43 Bayview Circle Osterville Ma Owner: Edward wille Date of Inspection: 1 0/1 3/97 Check if the following have been done: You must indicate either "Yes"or "No" as to each of the following: Yes No X1 Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recen:l� c as pan 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. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout.,,// _ All system components, including 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 cond,t,on of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum — The size and location of the Soil Absorption System on the site has been determined based on The facility owner land occupants, if different from owner) were provided with information on the proper ma,n(enance c Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) 115.301(3)lb)) L i—d 04/25/97) D&g. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 143 Bayview Circle Osterville Ma Owner: Edward Wille Date of Inspection: 1 0/1 3/97 FLOW CONDITIONS RESIDENTIAL: Design flow. `�' pig./bedroom for S.A.S. Number of bedrooms. Number of current residents:e Garbage grinder (yes or no): 1,0 Laundry connected to system (yes or no)JIe—e—, Seasonal use (yes or no):�d Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): Last date of occupancy A)# COMMERCIAUINDUSTRIAL: Type of establishment. /fl* Design tlow: Al,* xallons/day Grease trap present: (yes or no)&4 Industrial Waste Holding Tank present: (yes or no)�� Non sanitary waste discharged to the Title 5 system: (yes or no) IU4 Water meter readings, if available Last date of occupancy: OTHER: (Describe) Last date of occupancy' GENERAL INFORMATION PUMPING RECORDS and source of information: ille Y �i� System pumped as pan of inspection: (yes or no)d..b If yes, volume pumped: _gallons Reason for pumping OW N-Y- i91,0 TYPE OF SYSTEM �eptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or not (if yes, aaach previous inspection records, if any) I/A Technology etc. Copy of up to date contract Other AP,ROXIMATE AGE of all components, date installed (if known) and source of information: L� Sewage odors deteced when arriving at the site: (yes or no) (r.vs..,d 04/25/97) Y.9. 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.Sn PART C SYSTEM INFORMATION (continued) Prooert,f Address:143 Bayview Circle Osterville Ma O"ner Edward Wi l le Date oI Inspection: 1 0/1 3/97 BUILDING SEWER: ;locale on site plan) Depth belo, grade material of construction L/cast iron _Z/40 PVC _ other (explain) D'slance from private Water supply Well or suction line Diameter AJA Comments tcond,t,on of joints, venting, evidence of leakage. et .) g k S ) 10 T i — SEPTIC TANK:f�YJQJ1�'L5 you e on we plan; Depth below grade ly material of construction Zoncrete _metal _Fiberglass _Polyethylene _other(explain) u tank is metal. list age t4 Is age confirmed by Certificate of Compliance (dimensions / y'M&ei yI;Y / '16 �t! '�� Sludge depth C. D,stance from top_sJ sludge to bonom of outlet tee or baffle L Scum thickness Z!''fIG D-stance from top of scum to top of outlet tee or baffle:rpi4 Distance from bonom of scum to bonom of outlet teen of baffle "oW d,mens,ons Were determined. 5- k+4 Comments irecommendal�on for pumping, conditi of inlet and outlet tees or baffles, depth of liquid level in relat,ontoo outlet ntegnr�, evidence of leakage, et .) o/ a T G 61 CREASE TRAP/ rfJ� notate on site plan) Deptn below grade AM rvtater.al of consvuct,or✓��concrete4Wmetal _Fiberglass,10 PolyethylenWWother(explain) .4* Drmensrons: .6/0 Scum thickness, D,sldnce from top of scum to top of outlet tee or baffle: D,stance from bonom of scum to bonom of outlet tee or baffler Date of last pumping lity Comments trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet nver,. sr-7,.; a -ntegnry, ev,dence of leakage, etc I ir.�,s.a 04/25/31) D.g. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Circle Osterville Ma Owner: Edward Wille Date of Inspection: 1 O/1 3/97 TIGHT OR HOLDING TANK:, CC�{Tank must be pumped priur to, or at time, of inspection) (locate on site plan) Depth below grade: 4`1 Material of constructjon,t/4 concretVAmetaVvAFiberglass*t,/ yethylene,(! other(explain) AM Al Dimensions A14 Capacity: AA gallons Design flow:_ gallons/day Alarm lever ^)A Alarm in working ordedV,4 Yes;.U� No Date of previous pumping /w Comments (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth o: hcwd level above outlet invert: //0 Comments: (n If ever nd distribution i equal, evid ice o solids carryover, evidence of leaks a into or out of box, etc.) lelv S A) A 7' ! c h L o PUMP CHAh1BER:,Uk/e— (locate on site plan) Pumps in -Of,King order: (Yes or No).J( Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r•�is.d 01/25/97) P.g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address:1 43 Bayview Circle Osterville Me Owner: Edward Wille Date of Inspection: 1 0/1 3/9'7 SOIL ABSORPTION SYSTEM (SAS): ( , ,locate on site plan, if possible. excavation not required, but may be approximated by non-intrusive methods) if not determined to be present, explain: Type l leaching pits, number: leaching chambers, numbe leaching galleries, number: —42 leaching.trenches, number,length: leaching fields. number, dImsions: overflow cesspool, number V Alternative system: .U14 Name of Technology: ` Comments (note condition of soil, signs of hydraulic failure)level f ponding, condition of vegetation, et .) CE55POOLS: dP�' (locate on site plan) Number and configuration: Depth-(op of liquid to inlet lnven: 4242 Depth of solids layer: ) Depth of scum layer: Dimensions of cesspool. 7 Materials of construction: AW Indication of groundwater: 424 inflow (cesspool must be pumped as pan of inspection) Comments. (ncitr,fond,00n of s°J'I, signs of h�yd,rJaulic failure, lev ( ponding, condition of vegetation, etc.) P R I VY:i�,�jff (locate on site plan) Materials of construction: /L�/ Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) / lr•v1s•d 00/ 5/911 D•g• 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 143 Bayview Circle Osterville Ma O.ner Edward Wille Date of InsPect,orn: 1 0/1 3/9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: l ,^.;rude t,es to at least two permanent references landmarks or benchmarks locale all wells within 100 (Locate where public water supply comes into house) J / r / Ir•vl.•e 0�/79/fyt Y•y• 9 of 10 SUBSURFACE SEwACE DISP, t SYSTEM INSPECTION FORM C SYSTEM INFOI. :ION (continued) Properly Addressl 43 Bayview Circle osterville Ma owner: Edward Wille Date of Inspection: 1 0/1 3/9 7 /�J�` 1 Depth to Croundwaier/k /Feet Please indicate all the methods used to delermine High CroundwalCP alton: _ Ootamed from Design Plans on record Obseryat,on of Site (Abuning p(operty, observation hole, basensc.rst simp etc.) �etermine it from local conditions Check with local Board of health Check FEMA neaps heck pumping records ZCheCk local excavators, installers Use USCS Data Descooe , yow own words how You established the High Croun<J-'j1cf-E levation. Must be completed) Used Cape Cod Commissiom Map. September 95 Water Table Contours And Public Water Supply Wellhead Protection Ares Ir.v1..G 0 U 73/97) Y.S of 10 �1 n.-+ n,rr—r� rn-mnrm ra-r.�.rs,'r.rr.r•.r+-+wr:+.�-em*n r�s--ii+'ru'�rtrm >rtTo+>n-.�rrn ern-irr-r.--r-. _. __ TOWN OF Barnstable BOARD OF HEALTH S1JHSHFACF SFHAGE DISPOSAL SYSTEM IN311ECTION FORM - PART D .- CF11TIFICAT10ti ` �'•.•-•�•T .-T.II���.T.T.�11'R:ITITT.4T.TTTT'.r•.1 "'f11T'R��il'RNr T�'.RtT�'f 1�!'MIR�1i-.'TT�1 TRI1 T.Tfi'T i9�TTTR+T.:-.1-n�.r-._. -. J -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 143 Bayview Circle Osterville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Edward Wille PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & 'ion , Inc . COMPANY ADDRESS Box 66 Centerville , Ma . 02632-oo66 Street Town or City State LIP COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendatioris 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 : System PASSED The inspection I+hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 16 . 303 . Any failkire criteria not evaluated are as stated in the FAILURE CRITERIA section of t is form . System FAILED* The inspection which I have con 'ilcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date � , �- ST:sue:�'�S�.T--.....� �. �.�• One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD or II2AL1'il. • If the inspection FAILED , the owner or"'oporator shall upgrade the system within one ,year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 16 , 306 . partd . doc W 't 7 � ti THE COMMONWEALTH OF N -A.SSA.CffUSETTS DEPARTMENT OF ENVIRON-NMNTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualif-icatiQns as required and is hereby authorized to use the title CERT + i D TITLES SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the- General Laws . Issued by The Department of Environmental Protection. Acting [)hector of the 1 < ton (if W21ct Pollution Control �ti1 4 he,C AST 1`0N Y S E W A C E� Pl RMIT NO. VILL'ACE Qa'& INST LL 'S NAME & ADD.RESS ® U I L D E R OR OWNER DATE PERMIT ISSUED ,?.. F DATE COMPLIANCE ISSUED y � ria IT . � a TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT r i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching;Facility (If any wetlands exist within 300 feet of leaching facility) Feet ` Furnished by Q1 \ i , �. � ���� � J� y �\6 �� d ��` W 11 �� C ' 1 �i� '�� v � ►+ _ o ; � . � � _ ���� a �\ c DATE. 12/15/95 _ .. .. PROPERTY ADDRESS: 143 Bayview Circle RECEOVED Osterville ,Mass . DEC 2 1 1995 02655 H KOERV On the above date, I Inspected the s-eptic system at the above Address. This system consists of the following: 1 . 1-1000 gallon septic tank. 2." 1 -Distribution box. 3 .. 1 -4' Leaching pit packed in stone . Based on my Insvactlon, I certify the following conditions- :1 This is a title five septic syt•semr. ( 78 Code . 2. The septic system is in proper working order at the ° present time . .3 . The leaching pit is dry. . 4. Septic tank heavy with solids , Pumped par.t ,of iris�ection. A SIGNATURE: A/, - ` Name: J. P . Macomber Jr... Company:_J. P_Macon)ber &- Son-_Inc . Address:_��_.6 ,-------- ---,-- CentervilLe LMas_s__02632 Phone:---5Q8_7_7_`L__333a------- - THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY IT19519M JOSEPH P. MACOMBER & SON, INC. Tan krCesspoolrt.eschf Ields Primped Installed Town Sewer Connectlon: P.O. Box 66 ' Centerville, MA 02632-0066 775-3338 775-6412 t I Commonwealth Of mossocfiusens Executive Offlce of Envifonmentol Afoifs Department of• Environmental Protection Wllllam F.Wold , aw.ma Trudy Coxe • S.u•t.ry,EOEA Davld 0. Struhs (gnxnlNlon•t SUBSURFACE SEw.4,GE•DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Address of Owner: BOX 325 Property Address: 143 Bayview Circle 0sterville0f different) Dale of Inspection: 12/15/95 West Hyannisport, Mass . Name of Inspector:Josep f Ma �l$ ,er Jr. 02672 Company Name, Address a e ephone u J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage inspection s,rassperforn edtem at sbaed on a my training information nd experienceint eepr pertfunctionuand and complete as of the time of inspection. The maintenance of on-site sewage disposal systems. The system: ,Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ fails �'' Date: Inspectors Signature: ) days of The System Inspector shall submit a copy of this inspection report t°i0 000 g d or Approving g eaAuthority terr, the inspector thirty and0the systemcownertshall this submit inspection. If the system is a shared system or has a design flow of 8P . the report to the appropriate regional office of the Department of Environmental Protr and the approving authority. The original should be sent to the system owner and copies sent to the buyer, ii applicable INSPECTION SUMMARY: Check A, 8, C, or D: At SYSTEM PASSES: have not found any information which ',ndi;ates that the system violates any of the failure criteria as defined in 310 CMR 15,303. Any failure criteria not evaluated are indicated below. 81 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired., The system, upon completion of the replacement or repair, passes inspection. Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will'pass inspection if the existing septic Lank is replaced with a conforming septic tank as approved by the Board of Health. t (revised s/15/W Ono Wlntor Stroot • Boston,Ma:sachusotts 02108 • FAX(617) 55b 1049 • Tolophons (617)292.5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143 Bayview Circle Osterville ,Mass . Owner: Marie Fortunato Date of Inspection: 12/15/9 5 B] SYSTEM CONDITIONALLY PASSES (continued) Y der' 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 pipe(s) are replaced obstruction is removed distribution box is levelled or replaced ,/[jj The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. �1) SYSTEM WILL PASS UNLESS BOARD-OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN AMANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ALI- Cesspool or privy is within 50 feet of a surface water A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: L „ The 5\'S1PR1 nd> J Se(JU n l ld � atlU )Un dU5UfptlUll ))')tCll'i af i' iG i \1 itnli� 1'�U fee', to d SUrfoCC 1'ratt:r supply CC tC a surface water supply. p The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. .Ajo The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. J/[O The systen-, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15,303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. -` jO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143 Bayview Circle Osterville ,Mass . Owner: Marie Fortunato Date of Inspection:1 2/1 5/9 5 DJ SYSTEM FAILS (continued): 3/D Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in 6o6spoel.is less Coan 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q�Mdr�UCl�1l,^— hny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. AA Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ALa Any portion of a cesspool or privy is within a Zone I of a public well. AL4 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ALA Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: A10• The design flog• of system is 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: 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 Qj the system is located in a nitroger. 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6115/95) 3 00 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 143 Bayview Circle Osterville ,Mass . Owner: Marie Fortunato Date of Inspection: 12/15/9 5 Check if the following have been done: 4/- Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �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. The system does not receive non-sanitary or industrial waste flow y_/The site was inspected for signs of breakout. All system components,g'.xxcluding the Soil Absorption System, have been located on the site. _/he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. the size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. YThe facility ov,r1c: ia'1d occupants, if different from owner) .were provided with information on the proper maintenance of Sub- Surface Disposal System. Recommendations . 1 - Septic tank must be pumped. 2. Broken distribution box cover must be replaced. 3. Cover on the leaching pit could be raised. Cover 3011 below grade . (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 143 Bayview Circle Osterville ,Mass . Owner: Marie Fortunato Date of Inspection: 12/15/9 5 BLOW CONDITIONS RESIDENTIAL: Design flow:j ay pv►rdrl y Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): ki Seasonal use (yes or no):1 d ,� ) L Water meter readings, if available: J� l Last date of occupancy: 40WAI COMMERCIAUINDUSTRIAL: Type of establishment: A)d Design flow:_Ald_gallons/day Grease trap present: (yes or no)-&4 Industrial Waste Holding Tank present: (yes or no) n-sanitary waste discharged to the Title 5 system: (yes or no)AV ater meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and source of infor anon: System pumped as pan of inspection: (yes or no) If yes, volume pumped /GO6 gallcns Reason for pumping:,�(yt TYPE O YSTEM Septic tank/distribution box/soil absorption system A)a Single cesspool Ad Overflow cesspool _j_ Privy A)6 Shared system (yes or no) (if yes, attach previous inspection records, if any) JV� Other (explain) APPROX MAT AGE of all components, date installed (if known) and source of information: cage odors detected when arriving at the site: (yes or no) /vl/ (revised 8/15/95) 5 C7D SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cuntinued) Property Address: 143 Bayview Circle Osterville ,Mass . Owner: Marie Fortunato Date of Inspection:12/15/9 5 SEPTIC TANK:L-4000 Gad" TA09, (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP _other(explain) Dimensions: 4 1 vF,7 A!, lie-- Ec1F Sludge depth:_ Distance from top o: sludge to bottom of outlet tee or baffle._ 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:_Q_ Comments: r "rommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ;rity, evidence of leakage, etc.) Garbage disposal is resent ' sond; nticOutlet & in e tee are s ruura u tank ; s structurally sound With no si ans of 1 eakaRP Septic tank was pumped as part of i n sDect•ion GREASE TRAP:& (locate on site plan) Depth below grader Material of construction:/dconcrete _metal _FRP —other(explain) AJA Dimensions: AM Scum thickness.tI Distance from top of scum to tole of outlet tee or baiiie:_aa_ D!!c ace fr0^i botton, ry -w- i� [tr_i!!i,n' C!l ,i r_ir !i�nu,• � Comments. (recommendation for pumping, cunoitiun o, inlet and outlet ties or Wffles; depth of liquid-level in relation to outlet invert, Structural integrity, evidence of leakaec etc r Wee, — (revised 6/_5/55) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Circle Osterville ,Mass . Owner:. ~ Marie. Fortunato Date of Inspection:12/1 5/9 5 TIGHT OR HOLDING TANK: V (locate on site plan) Depth below grade:ALd Material of construction: 40oncrete _metal _FRP —other(explain) A)fi Dimensions: A)A Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float snitches, etc.) DISTRIBUTION BOXIS (locate on site plan) ' Depth of liquid level above outlet invert:—AM Comments: mote if level and u,striL.:,,,;. • cti . c,�dcnce of su' : s r Idence of lu,tk,we into or t of box Ic.) D- box is level;Has evidence of" solic�s carry over ; No evidence in or out of the box. Uover is broken on the - ox ancL must e replaced. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)_&B Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 R SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 Bayview Circle Osterville i Mass . Owner: Marie Fortunato Date of Inspection: 12/15/9 5 SOIL ABSORPTION SYSTEM (SAS):L61 (locate on site plan, if possible; excavation not required, buts y be approximated by non intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number: 6 leaching gall4ries, number: leaching trenches, number,length: leaching fields, number, dim nsions: overflow cesspool, number:, e Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Loamy sand to medium sand: , eaetation is normal _ CL. DOLS: AD (locate on site plan) Number and configuAn Depth-top of liquid tDepth of solids layerDepth of scum layer: Dimensions of cesspMaterials of construcIndication of ground inflow (cesspool must be pumped as part of inspection) 1111� Comments: (note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /�✓� (locate on site plan) r Dimensions: �1/9 Materials of construction: !ir�i Depth of solids: q Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ' B (revised 8/15/95) f I • w I f 1 1 4 1L` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143 }ayview Circle Osterville ,Mass . Owner: Marie Fortunato Date of Inspection: 12 5'9 5 o SKETCH Of SEWAGE DISPOSA�SYSTEM: include ties to at least tvq permanent references landmarks or benchmarks locate all wells within 10l Town Water �Y. r I I DEPTH TO GROUNDWATER Depth to groundwatera 2 t + feet method of determination or approximation: Plan on file at the Board Of Health Of the Town Of Rarnstahl P . 'Doe C' Y (revised 8/15/95) 9 `� � c 1 ,. Ic' ��. •, � n� � ��� � '� ; 1. � i o .-::� �� j � CAJ • r t � k All o �* O �� : •� yr,� , �=; I o �� _ tj bC sn, o � �� 1 f a d � �� �I Ci z � �, � •� . �� w � `? -1 i � v to � lelo � d � Q �� 0 � � � � � �::.,•. �� fin► � ` � � � � � �: v� � .. :,+ '°Ph �; � � r t I� for �V ti r �► o ND 03 1 tt •r IT ill j'� h ci '� .',� ®�� to � i.t �, :)` `� � �`• y.�, �' �'.� ►�i �, i rn �h1 `. � � 2 .i In t � . 1 C LA 'TOWN OF Barnstable WARD OF HEALTH S(II)S(IRFACE SEWAGE I)ISPOSAL SYSTEM INSPECTION FORM PART D .- CERTIFICATION .......... ...... -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 143 Bayview Circle osterville ,Mass . ASSESSORS MAP , BLOCK A14D PARCEL 4 OWNER' s NAME Marie Fortunato - PART D CERTI1,ICA7ION NAME OF INSPECTOR Joseph P. Macomber Jr.. COtiPANY NAME J.P.Macomber & Son Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street -' Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 1578 CERTIFICATION STATEMENT I certify that I have; personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and complete as of the time of ;inspection . ;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: XXXXXX Systeui 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 public health and the environment in accordance with Title 6 , 310 CHR 15 - 303 , and. as specifically noted on PART C FAILURE CRITERIA of this inspeption form . Inspector Signatu Date 12/16/95 One copy of this certification must be provided to the OWNER, the BUYER ( wheris applicable ) and the BOARD of 11BAL111. If the inspection FAILED, the owner or"'o*P' erator shall upgrade ' the system within one year of the date ,Iof the inspection , unless allowed or required otherwise � as provided in 310 CHR 16 . 305 , partd.doc � z _ w � Ln THE COMMONWEALTH OF MASSACHUSETTS ti• -DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT - Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' -ion of Water Pollution Control ` ----- .�y Fm$... .. ................ THE COMMONWEALTH OF' MASSACHUSETTS _ BOAR® OF HEALTH �:(Tu`. ..............OF.........GAL&'1 S.:�'4`A-' -................................... Apphratiun for Diipuital Works Tiamitrnrtiun Vamit Application is hereby made for a Permit to Construct (i'/ ) or Repair ( ) an Individual Sewage Disposal System at: ...... - t. 1 2�... -..._._... ......--•............................................ Loc 'on- dr ss or Lot No. t Owner Add ress �J a ----------•------`..--...... /�� _ems. --------------------•------------- ------......------.!.!!;�..................................................... --- Installer Address dType of Building Size Lot....t l.A_�..Sq. feet Dwelling—No. of Bedrooms--•---- ----------. Expansion Attic (Noj Garbage Grinder a----•------ No. of persons ------------- Other—Type of Building �®®.._ p �- Showers (02.) —.Cafeteria ( ) p' Other fixtures -----------------------------•.-. . W Design Flow.......5 .........................gallons per person per day. Total daily flow--------3 3 v...._..........._.._gallons. WSeptic Tank—Liquid ca citye allons Length._..(.�..... Width....4........ Diameter-----Ce Depth.....__ . x Disposal Trench- No..: A9CWidth.................... Total Length.................... Total leaching area.....;;LA�Y..sq. ft. Seepage Pit No----------------------- Diameter:------------------- Depth below inlet.........:........ Total leaching area..................sq. ft. Z Other Distribution box (V) Dosing tank Percolation Test Results Performed b --------- ". . .i...._/__ '� !n p�2 Date....... ..minutes per inch Depth of Test"Pit...tp 1 S... Depth to round water Test Pit No, L_L.�— p p .. _ p g �. (i Test Pit No. 2...!L ....minutes per inch Depth of Test Pit.....C�..... Depth to ground water------N-PM�•`F__. ------• --------------------------- ----..............•_....n.. O Descripti n of Soil._.1 ...._.��a-Y.......� ....`�� ..5_ts%_�......... .... _....._$1eY,5e (� fj-•- ••--- ------------ �!w..�....IML.�'.. ... 116-._.�_t� Y!!� ... _ sal. M -d_i.j_.V)L._..__SM.A------------------------------------------------------------------------------------------------------------------------ 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 iITI.E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. D e ' Application Approved B � mac_- i Date Application Disapproved f th following reasons:.............................................................................................................. ---•----•....--------••----------------------------------•------------------------------•------••-----••------------•---•--------••------------------------------------•---•---------------••---------- Date' PermitNo......................................................... Issued....................................................... Date Fics ............... r'` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v', oJ...:...........,,........... q:ci S `.�f ....--..--... Appliratilan for Elispasat lVarks Tomitrnrtiun jJermit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: � Loca n A dr s or Lot No. , 9r Owner Address •-----•--...........'J.._......ba!!O ... Q.:5t.............•-•----..__....._............--••----.............. Installer Address Type of Building Size Lot..... 1 I G?_a:_ ....Sq. feet U Dwelling—No. of Bedrooms__...... -?.............................Expansion Attic .(PQ Garbage Grinder (60 pa, Other—Type of Building ......pP�._...___... No. of persons_..._............... Showers (A) — Cafeteria ( ) P 1 Other fixtures -----•-----•----•--------------- W Design Flow......., .............................gallons per person per day. Total daily flow.........3.:�'_v...................gallons. WSeptic Tank—Liquid cap it __ _ gZallons Length__.._j_0..___ Width................ Diameter......GQ Depth_._._. x Disposal Trench—No. _.__�� __EWidth.................... Total Length. ....... Total leaching area..____ _�_��_sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ( Dosing tank Percolation Test Results Performed by.......... _�_�1 '.�:..:__ .w? !_!�e .!2 Date........ Test Pit No. l_._�_�-:_mmutes per inch Depth of Test. ,it..__(a i.s Depth to ground water....... Li. Test Pit No. 2._._............' minutes per inch Depth of Test Pit._..._ _�.____ Depth to ground water....... .d!V a -•- ---... --------------------------------------- --n O 5•r _•-•-•• _-----Yr ___-_- �?A;w� o` �-•-•-•--•--• _' '_��1' ......_..�--•-•-ra-----_-_-_-•c_IL_-c�.VZlr Descriptlqn of Soil_...1.............Q.- �F_._....� f.. ...s�_. ;.: - .........D_•t.s.•- A-•--� C 6011,1111 _ �.............. .. �s 0 �R���- -T t VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -••---------"---------------•--••---•--.....----•-•---•------•-•-------••-----------•-•-----•-----------.._..-••----------------•---------•----------------•----------....-----•••--__.........____..._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. he 'Y � ✓l C•••............... .....0 •p? ..... �J D Application Approved By.......... .._.. . '' --------••---•-------------------------••-----•---------------- .......... ....... J' Date Application Disapproved fo he ollowing reasons:................................................................................................................. ...................•----.....---•--...._.._..---•----...--------------•-----------------•---••------•----.--.....------•----•--•---•---•-----•-----__....-----•-•--------••-----••---._...._.._._...-•--- Date PermitNo--------------------------------------------------------- Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 1..Q1r!, ................0F........: h°,t- .C(�'.�.........._.............................. �rr�if irttte gf �nnt�li�nr�e THIS 1 TO CERTIf , That the Individual Sewage Disposal System constructed ( .) or Repairedby ( ) ..................................................................................................................................................................I.. ..P1U..C>KA1( .In er ff at -.Qt_.__..1. ` ..._..__ __....-- fu.i.+s ._Cl_t .lC ............ has been installed in accordance with the provisions of TIT r , 5 f Th to Sanitary Code 'des i d in the application for Disposal Works Construction Permit No____ __________:9-- r. __ dated-...- .-.-a`�.-__-- ...._..._____._ TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................•----•--........--•-•-----------••••...--•---.....---------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p A—t G . N_OF._........ESL :I.Wt;iTj!�.bLl ............................. y®O.._ ........ FEE.........lf........... 0111pos f Works Tnnotnutinn -per'U, - ` Permission is hereby granted__:__._ ._Q"� ��:Y4!L£` :__._�_..... 1 �: r---- - --••.......................................... to Construct ( or Repair ( ) an Individu 1 Sewage Disposal System ft BI_ ui_ i_S�.C_ .............. at No........ ---- ---•••-•--•-•--•--••-•-----•-••----•••-••-••••••--- Street as shown o/theli ion for Disposal Works Construction Permit No_____________ ___ "ated. -_._�_._.�l ..B rd of alth DATE-•---- -- ............................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS •- i Permit Number; _Date . Completed b.y . >=UJIP_f_--DUU 1[ J�P.. . HIGH GROUNQ,-,WATE,R LEUE.L .COMPUTAT I ON Site Loca.t`ion: GII[GLE � 'T �./ILt,C— Lot 'No. I� Owner: A`t�StD{� �L.6C=. Address:'. C�W Q L.Y1i= �/ILE c�I-co='- Contractor:. AS f ( �Il✓. Address.• A,� C Notes L,=sr D9oP!3 FkA Lcw4 6 � s�Z' G— Ft Li.'11 E5 i�:t /1sa u�Er,tT', Soil A I Pl=' :L.)w be 2 GELI.l V- �FL.cx�Q Fa P_ FvTv P-5. I�Q.a�/lT I�fKT 1-4 F d'A STEP 1 Measure depth .to water table to nearest 1/1'0 ft. . . date STEP 2 Using Waxer.-Level Range Zone and Index Well Map locate site and determine: - . TSW EN 19 A) Appropriate index .well . . . . . B) Water-level range'zone . . STEP 3 Usi.ng monthly. report"Current Water Resources :.Condit ions".. - - --determine current depth to ( 10.15* water level for index well . . 3/63 mo yr STEP 4 Using Table of Water-level Ad'ustments for index we.l1 i STEP 2A current depth "to water level for index well (STEP 3) , and water-level. . zone (STEP 2B) determine water-level adjustment ' . . . . . . . STEP 5 . Est.inate depth' to high water by subtracting the water- level adjustment (5TEP :4) from measured ' dep.th to water v(o!p level at site (STE_P , l)' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1r SST tiJ eW F F ICE H oe. lEaD H-i e=i h+Esl' Q ECc L1E� 4mA-?r-72- LEJE t.- Fc f`'_ EF"o. ©F= AF MnN , ►� a� r Xh o o ('c f �i O IN I v'j, CIA�.. 41 0 F _ .. 0-U.��5?<Pq./✓5%O N .i 01 .. p`"'�,•..tom'./ � ` ,-.:0p.� � � �+f r!"'�4.-...� 'I .. ,LSE OF Lo' F s,f3, n g C06 4.n susw� M� LEGEND � OF ss CER1'IFIEO PLOT PLAN EXISTING SPOT ELEVATION OxO ,o AL F EXISTING CONTOUR -- 0 - -- r rn LET i�fr x'YYicvv c� �- . FINISHEp. SPOT ELEVATION RSE N FINISHED CONTOUR 0 No.1o951 p G�ST6P \�R, I N APPROVED , BOARD OF HEALTH QEvISE (- / DAT E AGENT SCALE, / /�—¢ v DATE r S�� LDREDGE ENGINEERING CO. INN( CLIENT ys,v i CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO, F30-v BUILDING SHORN ON THIS PLAN CIVIL LAND DR.BY, �. ,�}- �� CONFORMS TO THE ZONING LAWS ENGINEER U.RVEYOR OF BARNSTASL , ASS. 712 MAIN STREET CH. BY, `.R, HYANNIS, MASS. E) S 83 --� SHEET/ OF 3 DATE REG. LAND SURVEYOR Al:. • i NO?E /F E/TNER THE SEPTIC TANK OR 20 J97 /`•///V. .17�E.4CN/1vG ,Ir ARE MORE TN A,-41 /2"BE40JN 1 •• /D PT. M/N. .1.RAOE, � 2a �O/AM ETER COrYCR ATE COiiER SHALL 9E BROUGHT 7"0 G,TAOE.��+.'✓ EXTRA CO/VCRC'TE r 4110-VC P/PL h'EAVY CA S 7- /RO/V C o VER Sh+,4 Z.L. 3E US EO All"- P/TCN /F/N DR/VEJ-1/A Y covE/es yB'R--R-r. ' - - GRADE CU VE'R CLEAN SAND A _•- ir= A BACk-F/,LOr U L/10 LEVEL - 4 - Q �! •� 2+LAYER 4 CIS ? RGN _ • a o / P J O U� GAL. • t • . . • . • • • e • M/N. P/TGX D/ST, o • e e • , • • s WASHPD S7rNE %4"Port 1'r. SEPTIC TANK . b • • BOX o • t $ • • • o • �' .•e o� r•' t •EFFECT/VE ' : ; 314"- 1 VZ e • o • • D/�Tt/ • • • v o WASHED STONe Cie p 7 • • • • • • • I p o • /PE ♦ • • • • • • • • 1 • 3 7T o ' PRECAS T SEEP E as It3 o'n� • • • • • • • • pe•p 99 P/7 OR E - / q..qU GA��DA �.� • • • • • • o • • a o /NVGRT ELEVAT/O/V5 P/rc�t/'Ac_r - ' a T = 7 V. 6 rT D/A1y. t INVERT AT BUILDING 64•O FT. T10N INLET SEPTIC Ti4NK. BZ,o F� tic r� moo: , , I Z FT. VIAPI. � !. S FT'. �otz ►-+►fie+ �«.�D wrt'�3. OtJYLET'SEPTIC TANK ;QcQ tJ f Q-a-= (5e-E St-4 3) INLET DJSTR/6UT/G/bt 80X al CO SECT/ON OF MA/ GROUND Wf1TER TA4BLE ELF C�`�.S O1S T D/S IB 1/TR7/ON®OJir 8 (,4 FT. MX HI G Ft G p�Jc/�� W�n C RC e" --r- SEZVAGE POSA L SY.S77EM a �cvrult ;,aEy O!/TLEldV4-T LEACHING PIT 78"S FT- TAQU1eAT/G/V LE4 CHI/Nrip P!T o1ME/Vs/oN A 9 AFT DE5/5/d CRITERIA NUA9BER OF BEDRa4MS 3 O/MENS/O/d C S FT.� �4'Mi�.t GA RBAG,Ev15POSALUhV/r rr�r,>e SO/L LOG SB/L T�.3�' TOTAL E.3T~reD FLOW 33 " GAL./DAY SO/L..TEST lit/ SO/L TFST.�2 NUMBER OF 40ACNING /'/rS— r'F—zed �s,S �ELFY, gf a DATE OF SOIL TEST 3 % S/DE LEACHING PER PIT t s/ St.� RT. p - / RESULTS W1T/VESSED BY ���� �� c.D i3/ L - Z PCRC04A7-/OJV R�4TE At/ M1/V•I1NCH BOTTOM L�rgCN/NG PER P/T l/ 3 �?• & ( a a �Yi �� L�S.S TOTAL LEACH/NG AREA 2 AEjeCOLA-r10,V RATE,�2 � `v^ M/N.1/NGN RESERVELIEACNINGAREA / - P�- �As� ,�:._.. sZ � !Zl�NNPC Lo �. �6•f, P. /�,L.,,;,: �; _ OF• j- '- :. �� s �� j LBEI2T•�' tiG\ 'A G� RSE ? 'K POW -+ No.10951 !� o- 'Al O c n -v•,i s q,� �`' e ELOIRZOGE ENCrJNE NG�R1 CO,JNC. •°•, 7/2 MAIN ST. , f►rYAic/NrS. MAS3.- /�� p ❑ NO GROUNL7 yi�i4T,EfP ENCQUNTERE� CL/ENT:&A Is`'''= DRTE 5 i ho SUR GRD UNO. yti/ATER AT EL EL! 9•.;� i .ter f crini t ►;w l>er: Date u Goml�Ieted by EL���L�C�, HIGH GROUNDWATER LEVEL COMPUTAT ION S i to Luu,,t iOil �LEE C=>- P./ILL Tot No. ----18� Owner: �A .IC�i 1�'.0 /-� Address: �= ir►. �tH:-L lt.L.L7✓ Contractor: A-- A Address: A-OS A-R-= r Notes Lr�T CCc�Fx F",!.� �. C j nt.5'� `1 C-yd��dkC f t .,Li T I CL i,mot so�L �r'GG u_��.,C�� c1=t�A-Q.. FL.�!?. FCC_ f•:'�,.,�t�':c=.:. I3�...M-r' R.7FY�-r� �-�c.,� Tt�S STEP l Measure depth to water table —� to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . /83 date._ STEP 2 Using Water-Level Range Zone and Index Well Ma_p locate site and determine: A) Appropriate index well 69 B) Water-level range Zone EE� _ STEP 3 Using monthly report"Current Water Resources Conditions" — '--`-_.- determine current depth to water level for index well . . . . . . 3/83 mo yr STEP . 4 Using Ta_b)e of _Water--level Adjiv tments^ for index well STEP 2A� , current depth to . water level for index well (STEP 3) , and water-level I zone (STEP 2B) determine water - level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-I LP 5 Estiriale depth to high water by sut;tracting the water- level adjustment (STEP 4) r--- f i bin measured depth to water level at site (STEP 1 ) . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . T' r,,I F\ .J H 16.H o ESA L L E'.i L u 1,AA H . . . PLAA MAC-H , A� 5 , I� A3 r� T cn P rCrriiit "NLJMbcr: [)atc: _ �. Completed by : >lLlJ�1=1 �..f�_�[ r< HIGH GROUND-WATER LEVL L COMPUTAT ION Site_ l.e�c..�t iconCI {LGLEE C'3-�1 Q_,JILLC Lot No. i8A 0��rier: �A ;1f`t� -,L�jf�____ Address: t i e. -T-L:—L,1ILi� C��.(v=Z,'L _ Contractor: Address: Ar-S doh JC Notes: Sc�i L r GG L.au DC P- c>L.t1 P_ F[cx=�-L. fi!!�,0_ f STEP l Measure depth to water table O� to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . date STEP 2 Using Water-Level Range Zone and_Index Well Map locate site and determine: - T�W A Appropriate ro riate index well . . . . . . . . . �--a B) Water-level range zone STEP 3 Using monthly report"Current Water Resources Cond i t ions" - determine current depth to water level for index well . . . . . . 3/$3 ------ mo yr STEP 4 Using Table of _Water-level AdW-11ments for index well (SiEN 2A� , current di`_pth to water level for index well (STEP 3) , and water-level �- zone (STEP 2B) determine water-- level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1LP L t il:i,,ic depth to high water by subtracting the water- level adjustment (STEP 4) ---` from measured depth 10 water lcvel at site (SILT 1 ) . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . _. L=7C I-!••LJM C��.�.i A(_f T` •v',�/�4�a<: Y.. ..`...c.tiV LC�'-__. t._.c7�..J1�: �1Ca tom( _ l tJ CF t�CTrl'��L I•.I�_'.t.J �..I•J;`_:i_��....IL% MA, 5 , 1933