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Home My WebLink About0025 BLANID ROAD - Health 25 alanid Road Osterville P r A = 140 050 r. It No. J Fee�W THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Apphratton for Otgogal *pgtem Comaruction Verna Application for a Permit to Construct O�)Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's N e,Add ss an 1 No 15 5LANIrD "AD osrs�v,u� �rc� � Assessor' ap/Parcel 1 140760 0 nst 's Na_me,�ddress Designer's Name,Address and Tel.No. lw (� I P.o . q0X 413 l./6<T bfNN)f mA 6Zt (5 Type of Building: Dwelling No.of Bedrooms .S Lot Size 15) 954 sq.ft. Garbage Grinder( ) Other Type of Building F-GS No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 556 gallons per day. Calculated daily flow gallons. Plan Date 2—11 -h 3 Number of sheets a6:& Revision Date Title 51rg A,'vD JSEW.GW LA/---' Size of Septic Tank Mob Type of S.A.S. S /N�1 L7►t�+TDrL 3u,p Description of Soil 6 'wd' A" 2o-13 Z A')F9 QAy Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Tit 5 of the Environ enta de and not to place the system in operation until a Certifi- cate of Compliance has been issu is Boar of eal ignedIvA Date 6-7 -5-03 Application Approved by Date CJ k' Application Disapproved for the following reasons Permit No. Date Issued l •'r y;-.r- .. G "s No. � `¢�� Entered m computer: THE COMMONWEALTH OF MASSACHUSETTS F Yes `\ PUBLIC HEALTW'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS: ., - _ Appiftation for Miopo�al 6potem Cori.5tructiom Permit - Application for a permit to Construct k)Repair( )Upgrade( )Abandon( ) ❑Complete System IJ Individual Components Location Address or Lot No. Owner's Name,Address and 1.No Assessor's a /Parcel l`A 9 Install 's Name,Address el. o. ��.. Designer's Name,Address and Tel.No. ��l� • m � ►� bEN)A&f'ST— Mc�lr�t o,� ��vGln�t A n. 2 G J P.O . qoX 463 r.,�-�'(T r�EN l� MA 9 7 "`e of Buildin g: g: s Dwelling No.of Bedrooms � Lot Size 15�) $5.6 q.ft. Garbage g Grinder( ) Other Type of Building R-FS No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5 S b gallons per day. Calculated daily flow gallons. Plan Date Z-1 Z -o Number of sheets 0 Revision Date Title S 1 -C 6/-0 5iPW.46r LAN Size of Septic Tank 50zi Type of S.A.S. 5 //JP L7rL1;70 1 3o50 Description of Soil d -20 A ' 20- 13 Z M F!? <4A 9 �- sew y4 i Nature of Repairs or Alterations(Answer when applicable) t 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 TD4p 5 of the Environments -ode and not to place the system in operation until a Certifi- cate of Compliance has been issu ~,y this Board of Healt ....� Signed ° Date 11` Application Approved by Date ft r Application Disapproved.for the following reasons — Permit No. Date Issued ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS , BARNSTABLE, MASSACHUSETTS . Certificate of (compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded(� ) Abandoned( )by A n A + at 15 d has been construct d ip accordance x1 with the provisions of/Title 5 and o ,ysposal System Construction Permit No. 2003 7 g7 dated (oo to 3 Installer '�� -- p ` f — Designer The issuance of this permit shall not be construed as a guarantee that the system w i afu - 1-52d. Date Inspector - Ps r NO. Fee�p ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpozal *pgtem Construction Permit Permission is hereby granted to Construct 'Repair( )Upgrade( )Abandon( ) System located at and as described iri the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ' Provided:Constructio must be completed within three years of the date(ofthis pe : it. Date:_ /lt Approved,by~' a :a TOWN OF BARNSTABLE LOCATION -)-S V) d ad SEWAGE # Z,0&3 ZS� �iI LAGE �T�"' //'P' nn ASSESSOR'S MAP &LOTS 146' 0 IN NAME&PHONE NO. t n Ai -5-`dlf 370 ' y2 ZI SEPTIC TANK CAPACITY (�d� LEACHING FACILITY: (typo S� ��/�T�hY� (size) t NO.OF BEDROOMS 3 BUIIER OR OWNER PERS DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by " Y f e V �w y 1: TOWN OF BARNSTABLE �d SEWAGE# Zad�''�SoZ .LOCATION IO- ,✓jf 1I ASSESSOR'S MAP &LOT VILLAGE � 5 INSTALLER'S NAME&PHONE NO. ( IS'av SEPTIC TANK CAPACrrY (� ) Pl/ h tdY (size) V1 LEACHNG FACIUN: (ty NO. BEDROOMS 3 i 4 BUII:k?ER OR OWNER PERMIT DATE: 3 COMPLIANCE DATE:_ Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) exist Edge of Wetland and Leaching Facility(If any Feet within 300 feet of leaching facility) )furnished by jo i r ... a` ax � a ry Q ry 1 , u 10.. .Y/fi L-.9 a� p a1 iv CE YCa WY c JHmo1q o a 6 b b 01 511�Y�� m 1 up ry oro a t o - �°� a b/L b-4XY/ 1- =0J � �� • � 4 � Q 1�7 C-9YYLa9W �X ° ry m" sy m e n .L,1 9-.9 .0'.6 ,O-.b 1 5 •4 E` ~ v no mot. am Ua d4 Q .O-,C 1 Town of Barnstable r# V THE TOjY O Department of Regulatory Services Date RARNSTA111 : Public Health Division MASS" t639 �0 Z i1lFa►M��' 200 Main Street,Hyannis MA 02601 p /-,Lay Fee Pd. ( ��• Date Scheduled Time__�_____ Soil Sy uitabilit Assessment for Sewage.Disposal Performed By: THom,o,' Witnessed By: _ , .F"e`dNFll$�'"@i'��...m:jr lli � t�n�h4�ti��! 4 .r. u\ ► .. . l sName grl o7T/ r •. t)wner' r� Location Address-� Q JG��, ✓ Address Engineer's Name Assessor's Map/Parcel: ` 6 •,-0�U NEW CONSTRUCTION REPAIR Telephone# Yq S- 71 1� Slopes(%) Surface Stones Land Use ft Drinking Water Well N ft ft Possible Wet Area N�__-- " Distances from: Open Water Body ft Drainage Way /V ft Pioperty Line `d`_ft Other SKETCH Street name,dimensions of lot,exact IgcaGons of test holes&perc tests,locate wetlands in proximity to holes) 41,1 0b.0\ T14—I �ll•gi, 6 LAAO j b rL�) p j.,g!w` � A Parent material(geologic)�ZwQS�— Depth to Bedrock Ad& Depth to Groundwater: Standing Water in Hole: /JONb Weeping from Pit Face Estimated Seasonal High Groundwater /"� jar d irnfti' J b itN II �Hi � .� P, b��i�JRhiA.'ta il ` yili "Md• Method Used: /V in. in. Depth to soil mottles: . ft.Depth Observed standing in obs.hole: in. Groundwater Adjustment Depth to weeping from side of obs.hole: Ad j,factor.Adj.Groundwater Level_ Index Well# Reading Date: Index Well level i y�itkN p�[ia�I!+ + ',1 IA�:�+ • ' 'i0. �W N Observation .: Time at 9" — Hole# Time at 6" Depth of Pere d Time M-61 Start Pre-soak Time — End Pre-soak Rate MinAnch Site Failed: Additional Testing,Needed(YIN) Site Suitability Assessment: Site Passed ------ Be Completed on Back iT—Ith Nvicion Observation Hole Data To --- �ry.M� -.w --•vn•� 5"'a' .i "i. gip. -.�;� �,�;'�rr '� r�"u�i� �.�:• �. .E4 ;.,r soil Other.. Depth from Soil Horizon Soil Texture Soil Color Mottl � Surface(in.) (USDA) (Mansell) ing Structure,Stones,Boulders. Consisten "/°Gravel t,s lo'ir�- 713 tioNE �U4Q- 5-/o /VoNb 76 3�P, L 015 2 S '1 7l� NUNC Soil a Other Depth from r Soil Horizon Soil Texture Soil Color Surface(in.) (USDA) (Mansell) Molding Sducture,Stones,Boulders. � Consistent %Gravel Soil Other Depth from Soil Horizon Soil Texture Soil Color Surface(in.) (USDA) (Munsel Mottling Structure,Stones,Boulders. Q B Consistency.%Gravel -''u+' °^�'i m ..i ! 1'I��j�i i �K,�i rI� ,yd,: �I'd 'i. :ilijtl j�,+!• !�o-�i�{��'Y°4?k�'ii[oU�4�b� 'W k' 'i «wlu.,�' n�r•��C fih i- '�'`�" .. Soil Other Depth from Soil Horizon Soil Texture Soil Color Moulin Structure,Stones,Boulders. Surface(in.) (USDA) (Mansell) Consistene %Gravel Flood Insurance Rate Ma Above 500 year flood boundary No_ Yes in 5o0 year boundary No Yes within y Within loo year flood boundary No Yes Depth of Naturally Occurring Pervious Material. Does at least four feet of naturally occurring pervious material exist in all areas'observed throughout the area proposed for the soil absorption system? 4 U If not,what is the depth of naturally occurring pervious material? Certification • I certify that on 4 q (date)T have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, rtise a xperience described in 310 CMR 15.017.nd TOWN OF BARNSTABLE 4 LOCATION �� 1 � SEWAGE # (3 VILLAGE + ASSESSOR'S MAP&"LOT INSTALLER'S NAME&PHONE NO s b SEPTIC TANK CAPACITY '%'LEACHING FACILl TY: (type) (size) -- �!: NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: S m'D COMPLIANCE DATE) tZ 6 -Separation Distance Between the: 'Maximum Adjusted Ground er Table to the Bottom of Leaching Facility-.-, Feet r Private Water Supply We and Leaching Facility (If any wells exist. S. on site or_within 200• eet of leaching facility) Feet Edge of Wetland and aching Facility(If any wetlands exist within.300 feefof.leaching tacility) ; " Feet Furnished .l L -40 As i, b 'a r cal 3 r r' i �I I Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zi pprication for ligpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 25 Blanid Rd. , Osterville Steven Costello Assessor's Map/Parcel l t y o — n s- —o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089,Centerville Type of Building: Dwelling No.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder( ) 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 septic system consisting of a tank, D-box and 4 concrete leach chambers with Al "', stone all around. 6;,, 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 this Bard f Health Signed i i •/d—'" Date Application Approved by zde, Date Application Disapproved for the following reasons Permit No. raeo l ;Zl?z Date Issued ——————————— -------------------------�� — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es' 4 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS- RppYicaction for Migpoal *pgtem Construction Permit Application for a Permit to Construct( )Repair,(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. RsaessRr1 ceF,d.!, Osterville Steven Costello - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089,,Centerville Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 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) consistingA A o ! stone a.11 around.--6e}A.—�.�L 3r* ti Date last inspected: V Agreement: p The undersigned agrees to ensure the construction and maintena ee��lr~e'afo�e:desc ed 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 this Board of Health. Signed r . Date — 8 / Application Approved by Date Application Disapproved or the followin easons ^3T i i r Permit No. i;�Z� _� i Date Issued --------------- ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Costello Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( ) Abandoned ( )by�� Rsbinsen S e pt l Gerviee ar at )5; _n i:4n i d Rd. , 0r_4_Lmry i 11p has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NW >dated /.+.•,/ '- Installer Designer The issuance of this permits all not b oAtrued as a guarantee that the system will function as°dtesigne l4 Date 1 t- Inspector W /t 1' V rL"Itly iil/ ——————————————————————————————————————— No. 3! Fee$ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Costello 1Wi!6po,5a1 *pftem Construction ermit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) . System located at 25 lbianid Rd a'♦+_rvi11s and as described in the above Application for Disposal System Construction Permit.'The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this e t. Date: /.r / a ��%� Approved by r ? � 116J99 - y' ' NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMPf(WITHOUT DESIGNED PLANS) i, W i 11 iatn E. Rob ins on,s e y certify that the application for disposal works construction permit signed by me dated // CP` , concerning the property located at 2 5 B 1 an; d Rd- , Q s t-P ry i 1 1 P meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associat;' ed the dwelling. The soil is ci as CLASS l and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic astem 8y There are no private wells within 150 feet of the proposed septic System There is no increase in flow and/or change in use proposed • There are no' requested or needed. The bottom of the proposed leaching facility will tt t be located less than five feet above the ma�mum ad listed groundwater table elevation: !Adjust the groundwater table using the Frimptor method tivhe applicable! • If the S.A. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching f ility will njot_be located less than fourteen(14)feet above the maximum adjusted groundwa er table elevation, Please mplete the following: A) Top of Ground Surface Elevation(using G1S information) B) G.W.Elevation _ +the MAX. High G.W. Adjustment DIFFERENCE.BETWEEN A and B SIGNED :�i 1 j��./li�-.-. DATE: [Sketch proposed plan of system on backl. y:health folder:ccn �,� .�- 1 - � � �� :. I 4� ,_ TOWN OF BARNSTABLE LOCATION IS' 614 --'J d R4 SEWAGE # 0) `6 '3 VILLAGE 0 IS + ASSESSOR'S MAP& LOTIM-00 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �``' �° '� �`�— (size) 12 W NO.OF BEDROOMS L BUILDER OR OWNER G c, ri:PI 6 PERMITDATE:. COMPLIANCE DATE)-c' - V Separation Distance Between the: Maximum Adjusted Groundw er Table to the Bottom of Leaching Facility Feet Private Water Supply We and Leaching Facility (If any wells exist on site or within 200 eet of leaching facility) Feet Edge of Wetland and aching Facility(If any wetlands exist within 300 feet o, leaching facility) Feet Furnished by i o rR� s j 'L atnme � 1 Q COMMONWEALTH OF MASSACHUSETTS G) EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ZC i31 DEPARTMENT OF ENVIRONMENTAL PROTECTION s ' R TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2` R l an i d Rd - !I e MA Owner's Name: Steven Ees el=a-- Owner's Address: Date of Inspection: Name of Inspector: (please print) Wi 1 1 i am E_ . Robinson Sr. . Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA ' Telephone Number: (5 0 8) 7 7 5—8 7 7 6 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 Sec ' "n 15.340 of Title 5(310 CMR 15.000). The system: _ asses . . Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: - Date: 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving , authority. Notes and Comments „ ****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 l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 B l an i d Rd. Osterville Owner: Co s t e l l o Date of Inspection: f-^g5/.—a Innlspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D rA/ Sys Passes: llV// have not found an information which indicates that an of the failure criteria I ha y y descried to 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Zll System Conditionally Passes: One or more system components as described in the Conditional Pass section need to be replaced or r paired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. swer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please e lain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally ound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the e isting tank is replaced with a complying septic tank as approved by the Board of Health. * metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance dicating that the tank is less than 20 years old is available. D explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 tines a year due to broken or obstnicted pipe(s).The system will pa inspection if(with approval of the Board of Health): i broken pipe(s)are replaced obstruction is removed explain: *Page 3 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 B 1 an i s Rd. Osterville Owner: Costello Date of Inspection: C. urther Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failin to protect public health,safety or the environment. 1. Sy tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sys em is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is unctioning in a manner that protects the public health,safety and environment: _ he system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surf a water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a rivate water supply well**.Method used to determine distance * This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fa lure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther, 3 Page 4 of 11 t v. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Blanid Rd. osterville Owner: Costello Date of Inspection:Y=�z fit— e) / D. stem Failure Criteria applicable to all systems:. Yo st indicate"yes"or"no"to each of the following for all inspections: Yes Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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 a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gP Yo must indicate either"yes"or"no"to each of the following: ( e following criteria apply to large systems in addition to the criteria above) s no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a smface 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 . P PP Y 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 bas failed.The owner or operator of arty 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 � T Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2, B 1 A n i d R rl _ Osterville Owner: Costello Date of Inspection: Q� t1--13 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks.?, Has the system received normal flows in the previous two week period? _ _ZHave large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _✓_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 n OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Blanid Rd Osterville Owner: Costello Date of Inspection: d FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): T DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): C e O Number of current residents: Does residence have a garbage grinder(yes or no): ,L d Is laundry on a separate sewage system(yes or no):n,c) [if yes separate inspection required] Laundry system inspected(yes or no): A.,d Seasonal use: es or no :� (Y _A) Water meter readings,if available(last 2 years usage(gpd)): 2000 78,000 gal. Sump pump(yes or no): -D 1999 103, 000 gal. Last date of occupancy: —C7 , C MERCIAL/INDUSTRIAL Typ of establishment: Desi n flow(based on 310 CMR 15.203): gpd Basi of design flow(seats/persons/sqft,etc.): Gre a trap present(yes or no): Indus ial waste holding tank present(yes or no):_ Non- anitary waste discharged to the Title 5 system(yes or no): Wate meter readings,if available: Last ate of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: f Q Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? ReasjOF n for pumping: TY)� SYSTEM ptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):L6 6 Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Blanid Rd. ' Osterville Owner: Costello Date of Inspection: /--.z L1-0/ B LDING SEWER(locate on site plan) Dep below grade: Mat rials of construction:_cast iron _40 PVC_other(explain): Dis Ice from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:v(locaie on site plan) Depth below grade: `� 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) a k ' i Dimensions: -+ 6 0- 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: $� t Distance from bottom of scum to bottom of outlet tee or baffle: l �. How were dimensions determined: i J .7— r. r, CIS Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): ti.-y 6& 7 Lam/ G ASE TRAP:_(locate on site plan), r Dep below grade: Mate al of construction:_concrete_metal_fiberglass polyethylene_other (expla ): Dime sions: Scum hickness: Dista ce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: Dat of last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ° Page 8ofII ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Blanid Rd. Os rviIIP Owner: Date of Inspection: —`"e T• HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dep h below grade: Mat rial of construction: concrete metal fiberglass_polyethylene other(explain): Dim nsions: Cap ity: gallons Desi n Flow: gallons/day Al present(yes or no): Al level: Alarm in working order(yes or no): Dat of last pumping: Co ents(condition of alarm and float switches,etc.): N BOX: y if resent must be o ened locate on site plan) DISTRIBUTION ( p p )( P ) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PU P CHAMBER: (locate on site plan) Pu ps in working order(yes or no): Al s in working order(yes or no): C mments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Blanid Rd. Osterville Owner: Costello Date of Inspection: /:7a V—a f SOIL ABSORPTION SYSTEM(SAS): (/. (locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,number:—Z71 _ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration: Depth—top of liquid to inlet inv rt: 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.): PR (locate on site plan) Ma rials of construction: Di ensions: De th of solids: C ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page.10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Blanid Rd. Ost-Prvi 1 1 P Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. do Z � �1 11i u 1 r Goti a 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Y Property Address: 25 B l an i d Rd_ Osterville Owner: Costello Date of Inspection: 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: tained from system design plans on record-If checked,date of design plan reviewed: l/ bserved site(abutting property/observation hole within 150 feet of SAS) V Checked with local Board of Health-explain: ��a i�h n S �j Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ow you established the high ground water elevation: 11 ASMMSORSMAPNOS, PARCEL Wz_� Z ';EDIFIED SEPTIC SYSTEM REPORT RECEIVED LOCATION I' MAY 2 1995 25 BLAN D I D RD . HEALTH DEPI. OSTERVILLE, MA 02655 OFBARNSTABLE MAP 140 PARCEL 050 LOT 2 PREPARED FOR SELLER MR. STEPHEN CASEY ESQ. 18 ELLIS FARM LANE MELROSE, MA 02176 BUYER MR. S`l'EVEN COSTELLO 235 SCUDDER RD OSTERVILLE MA 02655 PREPARED BY HILLIARD HILLER, JR. 41 MAPLE AVE CENTERVILLE, MA 02601 508-778-1472 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property. o?S QG�,vo/p �Qp Owner 's name /7/� 5. Y A-50 Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. tl 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. 1,44 As built plans have been obtained and examined. Note if they are not available with N/A. 'Phe facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. _.v/ /,v_ All. system components, GR cludi.ng the SAS, have been located on the site. T H,6 E sS� -i wG•2 E OA/c:,�/a�o �•�� T� %�idic S ✓.�5 �7�r,q ---- uac.oU.er-edry--0pC'1 ed,-- xid—the-_] n t e r i o r o f . ..a-fl^r € 1a€€1 e s a r—t-ee-s; m��t e�,..i_a:1----o-f--cor-rs-t r-t�c t- -o r-�,---d- uae►��o-��s-,--d�{3�—e�1-i�.u��--. 1�--o-f- II The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. _V"' The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FI.,OW CONDITIONS If. residential 3 number of bedrooms —L number of current residents _ ✓� garbage grinder, yes or no _y— laundry connected to system, yes or no J/ seasonal use, yes or no If nonresidential , calculated flow: 3S, Water meter reading�: if available: �`�s3 /7� l99y j HEs6 Last date of occupancy GENERAL INFORMATION Pumping records and source of information: _YES System pumped as part of inspection, yes or no it yes, volume pumped Reason for pwnp.ing: Type of system Septic tank/distribution box/soil absorption system _._ Single cesspool overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) n��E�r.oximate aye of all components- Date installed, if known. Source of information: 1J0 Sewage odors detected when arriving at the site, yes or no 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued 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 and number leaching chambers and number _ leaching galleries and number leaching trenches, number, length leaching fields, number. , dimensions overflow cesspool , number _ L 7 'D�LP C'4S •(�_'' of ccx iC/1 Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) G ss�'�C o-Z t�'es ,O�% z o"y Ty / '� !.y C -a1 S/-f%roE CESSPOOLS (locate on site plan) : number and configuration wo / depth-top of liquid to inlet invert depth of. solid, .Layer depth of scum layer dimensions of cesspool 6'q5 materials of construction �LoG indication of groundwater inflow (cesspool must be pumped as part of inspection) �/p Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) 1 EIS oiy /�G i.T q,ri� ovT�/ i AG So /1 G o�,,o� pjo l3v�LpiG A �/,:5 PRIVY : (locate on site plan) materials of construction dimensions depth of solids (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' �O LIf 6/19 TimAl "83 3.�0 DEPTH TO GROUNDWATER 23 �7 Z— -7C> i ,S %O depth to groundwater a3,17 s-� III method of determination or approximation: �7 'y7 17 �s cs cvQ/l c�iv v 17/1v o�c _ Fot� / //iGLI �/r�v�U�is77i:it Ylr;,r.;;, -r+, jr .�4 'h- 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) _L Backup of sewage into facility? _A Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? _Al Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? /U Required pumping 4 times or more in the last year? number of times pumped >iy Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: lV below the high groundwater elevation? Al within 50 feet of a surface water? _ It/ within. 100 -feet of a surface water supply or tributary to a surface water supply? _ within a Zone I of a public well? _ t/ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? Al _ within 50 feet of a private water supply well? _ L// 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i' PART D CERTIFICATION Name of Inspector /GG-i',? Company Name Company Address w ZiX5� Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and rnanitenance of on-site sewage disposal systems. Check one: I have 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. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. ].nspector ' s Signature) Date VI"FI j Original to system owner Copies to: Buyer ( if applicable) Approving authority t V /JAI\J�5 i Y I C� CERTIFIED SEPTIC SYSTEM REPORT RECEIVED LOCATION MAY 2 1995 OF BARNSTARE HEALTH DEFT. BACK COTTAGE AT 2 5 B L A N D I D R D . TOWN OSTERVILLE, MA 02655 MAP 140 PARCEL 050 LOT 2 PREPARED FOR SELLER MR . STEPHEN CASEY ESQ . 18 ELLIS FARM LANE MELROSE , MA 02176 BUYER MR . STEVEN COSTELLO 235 SCUDDER RD OSTERVILLE, MA 02655 REPARED BY HILLIARD HILLER, JR . 41 MAPLE AVE CENTERVILLE , MA 02601 508-778-1472 t 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORDS ,QfIG.� cvrTf/GF Address of property aS 9Z,1A1W o Ro oS7l=2&//6GE A1y owner's name /`"Y' 6. Date of Inspection y1719S_ PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. _1 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. _�//l 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 site was inspected for signs of breakout. _ 1,,/ A1.1 system components, excluding the SAS, have been located on the site. The Ent The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. !,,/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms _o number of current residents _Al garbage grinder, yes or no Al laundry connected to system, yes or no -_YES seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: NvvSE, 1919V /�i�a a?9 000 • �y Last date of occupancyS3 /7, o00 y GENERAL INFORMATION Pumping records and source of information: �110 System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: _G SS pool w.i9S dh Type of system Septic tank/distribution box/soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: _AO Sewage odors detected when arriving at the site, yes or no 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued 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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition. of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration pN,� depth-top of liquid to inlet invert ;7�,o>-y depth of solids layer depth of scum layer _ dimensions of cesspool materials of construction l3Coc/C indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) L4:r-lICtO !N Ta0,0 S !?fI�E ley`" -I,- Cave PRIVY : (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. )_ a , 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' /V 1 I I i L I I � I 1 1 1 l DEPTH TO GROUNDWATER � o� 30,E GrPcYit� ,rC2 3,� depth to groundwater a3. 5 7 method of determination or approximation: /7 .87 l�OUtio Gr rtTC/! /iLr!//aTi�' FiPUrhr �3i9/1L�sTi4/116' �119� 7'/TG,�� al.�S�illi.�°G7 GviP TL/1 T/9�GF J'vt/ /y�,� `► - 3 cn` i,5 G S Go�PR��Ti vv ,y/ -0), 2z v vE L3) - a 7 I Fob kid. Y/ h' 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Al Backup of sewage into facility? _ 1 Discharge or ponding of effluent to the surface of the ground or surface waters? /U9. Static liquid level in the distribution box above outlet invert? —� Llowid depth in cesspool <G" below invert or available volume< 1/2 day Al Required pumping 4 times or more in the last year? number of times pumped A111 Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? k. Is any portion of the SAS, cesspool or privy: _Al below the high groundwater elevation" within 50 feet of a surface water? Al wi.thin. 100 feet of a surface water supply or tributary to a surface water supply? /V within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? _IV within 50 feet of a private water supply well? Less than 1.00 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 analysi for coliform bacteria , volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D " /3�9�:�; Gvrli96/•' CERTIFICATION Name of Inspector /-1146�114,,o Company Name Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and .repair are consistent with my training and experience in the proper function and maiitenance of on-site sewage disposal systems. Check one: I have 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. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this IOI"l11. Inspector' s Signature Date original to system owner copies to: Buyer ( if applicable) Approving authority i 3 KEY NUMBER <1365 > NAME <CASEY, JOHN, T, MRS > B-C 1 B-C 2 B-C 3 B-C 4 STREET 18 ELLIS FARM LN CITY MELROSE ST MA ZIP 02176-2911 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 1319> DATE READING CONS STREET <BLANID RD 140. 25> 12/31/94 310 11 CITY OST T ST LOC 06/30/94 299 1 PHONE ( ) - 12/31/93 298 n 06/30/93 285 4 ROUTE NUMBER 13 12/31/92 281 15 SERVICE DATE 09/13/51 06/30/92 266 14_ METER DATE 01/29/85 12/31/91 252 17 CAPACITY 7 06/30/91 235 18 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR LS OF CHIMNEY ADDITIONAL CONS 0 ALTERNATE MIN 0 a a 19,y la�o✓o GiIG t a �, ,.,dam, ., �� ^°8'z+ s'....., _. +„-p-yz^�•^�` . �t K 1 f x � T r�^ • TiltdY�%•'u y t ':R 11r �'t': fi �r .i3 y �Ci� ;s-x� � 1 s i �1K i • • 2 y 1l B 1/2' 12'-0• P 9 2 1 V p 6 0 6 0 b 0 p O UU • ; U aA Pa xu a •e Q �P P U I I- P '3 o k La X'R 6 •2a46-9 ort mUI. •@ Ana•3446 �� , —• r0.-1-q9/B•x4-q 1/a .0.•3'-b i/B'x4'-9 1/4' .PLL N p •,pa 2 �O Q pp6 gu a c� 4'-1O1/4' A; U:3 3,E G O .. 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PROJECT the custom The6e drtlgs are protectedunder Pederal y Copyright Law..The.orlghal purchaser of thi, P.O.Box 156 plan I authorbed to construct p and.Ay 24 School Street Mattison Residence °AO h°"e ro^g thb yen r4odincatlon or West Dennis,MA" reuse le prohibited without express written la t,, perml.elon of the Dc.lgner. (506)394-50410 gap'ea�� • d w 11 REVISIONS: p /u p� gR�z JBo f O o LOCATION: 1/23/05C—.tructl-Prawh,gs TI\A Design Gr9u g�i, �� ;g : w 25 Bladd Road Prof esslonal Bullangveslgn 4 4;11 "°fie v�_ Ostet"VIIIe,Massachusetts Residential•Gommerclal P.O.BOX 1701•"OMI.,MA 02601 500-160-6466 506-280-6.173 . 'LTGAP0000.AOLCom 4 • T N 140 � ASSESSORS.MAP. .. TEST �r l , rJ THOLE LOGS �+ �r �r PARCEL: 50 L V G KJ 1 V �T�rJ . C R _ CURRENT BONING• 1. VERTICAL DATUM. ASSUMED FROM QUAD NGVD + d ENG l EE , I R T D H MAS MILE LAN ~�s L , P.E.- BUILDING SETBACKS. 2. MUNICAPA:L WATER IS AVAILABLE. WITN.L'SS. _sAM WHITE �, s HTE .F'. S. R. S. SCHEDULE 40 -- 4 d 20 10 10 PVC FIFE TO BE USED THROUGHOUT SEPTIC SYSTEM. - .. DATE: 2-4-03 BUILDING COVERAGE. 18.6% _ 4. ALL PRECAS T UNITS TO WITH AASHTO H-1`0 & H- 20PERCOLATION RATE- < 2 MINIIN LOADING 'SPE CIFICATIONS. FLOOD .ZONE. G PIPE PITCH 114 PER FOOT UNLESS NOTED O TH 1 _ TH• 2 , 6. FIRST 2 0 P - r sf.o F PIPE OUT OF D BOX TO BE SET LEVEL. •ry ELEV.. •� - 7. THE SEPTIC SYSTEM HAS S NOT BEEN DESIGNED TO ACCOMODATE THE a , A HORIZON USE O zocrls F A GARBAGE DISP05AL. EXISTING COTTAGE LOAMY.SAND A fOYR 3 3 7" / so,4 B. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH TO.BE REMOVED TH.THE STATE OF MASS V B HORIZON . ENVIRONMENTAL CODE TITLE FIVE AND LOCAL LOCATION MAP ( � LOAMY SAND s2 _ HEALTH REGULATIONS. ' LOT 5 1OYR 518 1 20„ 29.3 9. CONTRACTOR To VERIFY LOCATIONS OF ALL UTILITIES 95,856 ± S.F. C.HORIZON PRIOR (0.36 AC. .. .---- '`� MEDIUM SAND T O CONSTRUCTION. 2.5Y 7 6 .` r 90 01 /1 10. GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3.0, 11.<EXISTING SEP TIC SYSTEM SEPTIC TANK AND LEACH AREA, AS SHOWN IS TO BE PUMPEDA / •-'`"' �--",� AND :REMOVED. ) � �. t32 0,0 5FIEA `-_ - 1 I ` CONCRETE BOUND NO GROUND WATERENCOUNTERED BENCHMARK ELEV= 30.28 30 t� r- ', �-- --"' r „ If �-it DECK f4 \ f2', : . ...• IN SEPTIC SYSTEM DESIGN 26' . _ .. I N 6 40, ..••. :..;�.•_ . . it . it .FLOW ESTIMATE:: \ i it PROPOSED it 5 . .BEDROOMS AT 110 GAL DAY BEDROOM 550 GAL DAY 5 BEDROOM 5 r, II 2� q, 8. DWELLING "1 - MI SEPTIC TANK: MIN ,, BH I, 550 GAL/DAY x 2 DAYS 1100 GAL l r ,t U 1500 00 1 r + ,, USE GALLON SEPTIC TANKt t \1 , 36' r EXISTING SEPTIC SYSTEM l \ R (SEE NOTE 1f) EC IC LEACHING AREA; i r�-.. I r, it -32 USE 5 INFILTRATOR CHAMBERS MODEL 3050 WITH It - ( ) f 4' OF STONE ALL AROUND (45.5' x 12.2' x 2' DEEP) 3 pROPOSEOM a EXISTING WATER SERVICE 5 BEpRO G n TO BE ABANDONED so DWELLd s _5 ` SIDE AREA: (45.5 + 12.2)2 x 2 231(.74) = 171 GAL/DAY 24' t top , , BOTTOM AREA. 45.5 x 12.2 555 SF (.74) 411 GALL DAY � " EXISTING DWELLING w TO BE REMOVED CAPACITY 682 GALIDAY if: BH U I O _ FPR POSED DWELLING mx SEPT I C SYSTEM SECT ION • • r- i p 11 - ,,,...,.•- . covERs WrrxlN f2 OF r-----=-•-�• -- .,.•.r--'=.`.-'-. . . FINISHED GRADE 1 32.5 ( 2 PEASTONE r • . . r' ONE INSPECTION COVER . .r . , 3f TO BE WITHIN 6„ 0 so : . TOP of FOUNDATION F GRADE) I �.. - ;< <, , 314 1 I 2 J' 3 MAX WASHED STONE COVER I �, h .• ELEV.-• 28.5 1 r 1 . 28.75 29,\ ELEV. • . . r a \. . : . . 2s.o D Box 1500 GAL 0 ►, 28.12 - '.:ELEV. ,�•-�. •�-� _, �, .. . S 28.29 6 D ELEV. EPTIC TANK ( F' 4 . : ELEV. 4 .w.. „ o 29.5 6 OF STONE UNDER OR ELEV . �.-:. : ( STONE 45.5 .. ELEV. MECHANICALLY COMPACTED UNDER ., ) ) S INFILTRATOR CHAMBERS MODEL 3050 28.0 ( ) I TEE SIZES. , WITH 4 a S 1 11 1 GAS BAFFLE F TONE ALL AROUND AT OUTLET TEE ELEV. 45.5 x 2.2 <x 2 DE 11 91. 91' INLET. 6 UP, 93 DOWN ( DEEP) (H 20) OUTLET � -0- •. 6 UP,;14 „DOWN EDGE OF PAVE 28. 6 0. 0 EXISTING DRIVE T n�� KEY: TO BE ABANDONED B L A,�'I D, ROAD ,' SIT E AND SEWAGE PLAN APPROVED BY. DATE: EXISTING CONTOUR: ........... ... .... A LOCA ON PROPOSED :CONTOUR. EXISTING WATER ,SERVICE . � . : �,�.� fi TO BE ABANDONED _ .�'•tt+ �.� .,� EXISTING SPOT ELEVATION. S 25 BDANI D READ a.4 r �� s � r r PROPOSED P . , S OT ELEVATION. 25 , - . p, . TEST 1'i`OL � ��.�,.. �.: •. OST.E'RVILLE MA E. . .. UTILITY 3 POLE-. .;-{.)-• o.3Es�359 a M _ PREPARED FOR. FENC I .. .,E;L NE. .�~ , C' .. y ..�..yt. ."64 A 'y.:s., •X wart HYD ANT. ,-�• •.. o � .,�. REEF REALTY a^ f RETAINING WALL.- , I DEMAREST MILE A . . - LL N ENGINEERING . SCA E: 1 - zo �` L DATE. 211210 3 TREE. - _ _2 SCHOOL STREET P.O. BOX 463 WEST DENNIS, • PLAN . OD 4 DM 02--72 MASSACHUSETTS 02670 REFERENCE. BOOK 6 PACE 11 a s # _ TH MA McLELLAN P.E.' JO . Z. PHONE � FAX;. (508) 3J8 77f0 HN Z DEMAREST JR. P.L.S.