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HomeMy WebLinkAbout0038 BLOSSOM AVENUE UNIT UNIT A - Health 38 B!®SSOM Avenue Osterville P A = 117 051 ° ° ° 1 ° , c n commonwealth of Massachusetts 4 Title 5 Official Inspection = p Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A Blossom Ave. _ Property Address Joyce Chasson Owner Owners Name information is required for every Osterville Ma. 02655 03/18/2014 page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1 Inspector: key to move your cursor-do not Michael T Bisienere use the return key. Name of Inspector Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee. Ma. Cltyrrown . 02649 State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes. ❑ Fails ❑ `Needs Further Evaluation by the Local Approving Authority 014 Inspector's.Signature. . Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to-the appropriate regional onal offic e of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I t5ins- 3113 Title 5 Official Inspe Subsurface Sew ge Disposal System•Page 1 of 17 r Cornhnonweealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce.Chasson Owner Owners Name information isequired for every Osteryille Ma. 02655 03/18/2014 page. Cityrrown State Zip Code _ Date of Inspection B. Certification (cont.) ` Inspection Summary: Check A,B,C,D or E/always complete all of Section D ' A) System Passes: ® I have not found any information which indicates that any of the failure criteria described ih 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Shared leaching system. B) .System,Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound,'exhibits substantial infiltration or.exfiltration or tank failure is imminent. System will pass inspection if the.existing tank is replaced with.a complying septic tank as approved by the Board of Health: A-metal septic tank will pass inspection if it,is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N. ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts u Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.' 38 A Blossom Ave. Property Address Joyce Chasson Owner Owner's Name information is required for every Osterville Ma. 02655 03/18/2014 _ page. City/Towri State Zip Code' Date of Inspection B. Certificati®n (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ 'ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): f ED The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16 303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a.surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 Corr>Im®nwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce Chasson Owner Owner's_Name information is Ma. 02655 03/18/2014 required for every Osterville page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) .determines that the system is functioning in a manner that protects the public health, safety and environment: Ej The system has a septic tank and soil absorption system (SAS)and the SAS is within A.00 feet of a surface water supply or tributary to a surface water supply. Q The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. . 0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply.well. ❑.' The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or `more from a private water supply well**. Method used to determine distance: `* Th,s system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El z Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Cornirnonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce.Chasson Owner Owner's Name information is required for every Osterville Ma. 02655 03/18/2014 page. Cityrr6Wn State Zip Code Date of Inspection B. Certification (Cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipeW. Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] F The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design:-flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or,"no"to each of the following, in addition to the questions in Section D. Yes : No El the system is within 400 feet of a surface drinking water supply 0 . ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have'answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 k Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _W Title 5 . Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce Chaisson Owner Owner's Name s information is required for every Osterville Ma. 02655 03/18/2014 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes : .No. ❑ Pumping information was provided by the owner, occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ® this inspection? Were as built plans of the system obtained and examined?p y (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based.on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 V Commonwealth of Massachusetts ---_W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4,y - 38 A Blossom Ave. Property Address Joyce Chasson' Owner Owners Name information is required for every OSterville Ma. 02655 03/18/2014 page. City/Town, State Zip Code Date of Inspection D. System Information Description: , The design is for both houses they share the leaching area only. i Number of current residents: 1 Does,residence have a garbage grinder? ❑ Yes ® No Is laundry on-a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No. Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pufmp? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design,flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water-meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -,w 38 A Blossom Ave. Property Address Joyce Chasson. Owner Owner's Name information is Osterville Ma. 02655 03/18/2014 required for every page. CitylTown i . State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other'(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑. Single cesspool Overflow cesspool Privy ❑ Shared system (yes or.no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract FT Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal Sy stem Form Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce Cnasson Owner Owners Name information is required for every Clsteryille Ma. 02655 03/18/2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Were.sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 5011 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet -Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): _Depth below grade: 48"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) ` -Iftank is metal, list age: years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions:. Standard 1500 Gallon H-20Septic Tank Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts T itle - 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce Chasson Owner Owner's Name information is required for every Osterville Ma. 02655 03/18/2014 page. Cityrrow.n State Zip Code Date of Inspection Do System Information (cont.) Septic;tank(cont.) Distance from top of sludge to bottom.of outlet tee or baffle. 3911 < 1 Scum thickness Distance from to of scum to to of outlet tee or-baffle p P4" . Distance from'bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? field instruments .Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank only severs this house. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distkce;fro.m top of scum to top of outlet tee or baffle Distance.from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official In Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments *M 38 A Blossom Ave. Property Address Joyce.Chasson Owner Owner's Name information is required for every Osterville Ma. 02655 03/18/2014 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: " Material Hof construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: .. gallons Design now: gallons per day Alarm 'present: ❑ Yes ❑ No Alarm.level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach`copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Tifle' 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A Blossom Ave. Property Address Joyce Chasson Owner Owner's Name information is required for every �Osterville Ma. 02655 03/18/2014 , page. City/Town State Zip Code Date of Inspection Do System Information (cont.) Distribtation Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Olt Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d=box only:severs this house. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in:working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *:If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 A Biossom Ave.y Property Address Joyce Chasson Owner Owner's Name . information is required for every Osterville Ma. 02655 03/18/2014 page. City/Town State Zip Code Date of Inspection Do System Information (cont.) Type: ❑ leaching pits. number: El leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: -� leaching fields number, dimensions: apx 14'6"x 42'5"with overflow cesspool number: El innovative/alternative system Type/name of technology- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The laeching is shared with the house behind this one. t Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ,Depth-.top of liquid to inlet invert Depth`of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Insp ection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M •° 38 A Blossom Ave. Property,Address;. Joyce�Chasson Owner Owner's Name information is required for every Osterville Ma. 02655 03/18/2014 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy.(locate on site plan): Materials of construction: Dimensions - Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:)` t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form a Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments M 38 A Blossom Ave. Property Address Joyce Chasscn Owner Owners Name information is required for every Osterville Ma. 02655 03/18/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Skeich Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public.water supply enters the building. Check one of the boxes below: 15� hand-sketch in the area below 'El drawirig attached separately IJ -- 3 � �3e,.c►� us< ►i�uSG iA �N 3 S. . S of n Froe.), 3 � 8 t5ins•3/13 Title 5 Official Inspection Form:Sul surface Sewage Disposal System•Page 15 of 17 1 Commonwealth`&Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 38 A Blossom Ave. Property Address Joyce Chasson Owner Owners Name information is required for every Osterville Ma. 02655 03/1$/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ® Surface water. ®. Check cellar ® Shallow wells 'Estimated.depth to high ground water: 132 plus inches feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/26/2006 Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You mast describe how you established the high ground water elevation: Plans at B.O.H r - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 OfficialInspection Form A a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A Blossom Ave. Property.Address Joyce Chasson Owner Owner's Name information is required for every Ostervil!le Ma. 02655 03/18/2014 page. Cityrrown State Zip Code Date of Inspection E. Repor.t Completeness Checklist Z.Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 CONTRACT Customer Name, J e e14S Sad 38/� -524S'$pin /9VF SKETCH Contract Date__- �� a3 /3 � �S ,e✓/(Ci )Yliti_ QZ6sS� ATTACHMIENT Customer Phone,. SCJ�� `��� Contract Price .39 9i3. ,9 t9 a 21 2 23 24 2S 26 21 IN 29 0 3t 3 33 U 35 39 32 33 39 10 1 52 43 ` <I 41 49 9 51 52 5, 60 , I t a - +- }.. t .., -lLS r- + J - - .9 f fi � � .IW � �� � N � 1..� j ._. .. _...� .'•}"n ��.___i_ 'I -r---•�- i�� ..!- ..j_...._r.. _.1 —{---''� ;-• n 1 � �, -- G C f _�_G I Y _• ...f t t i ,. �.- i p�_ V fmlad , F 16 ... � .._ _.. .,.. _,..+�i ,,.lam;_ :.,..;__�--.�'' .:,._ ., 1 .--• - -; - ,' - b�3�r4e .; .....,~ j t 01. ....... --------- f t , �tGi/rs _ No S 9 �4 If4LI +6 , _. .,tlo Ixrf�t(%� .rY/rC/Titer nn T , NOTES: 11V1,Cdf:0 o wl rNr ze ZI e0 j�yr� ���m 'Each box equals one toot unless otherwise noted,This sketch is a good faith `/ r representation of the work to be done, it is understood that all dimensions >< X ZL LC- S S em e�Z ���� TY r /l derived from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,'jacks and/or switches are subject to change if necessary. � s No �^ , j�`' r FEE COMMONWEALTH OF MASSACHUSETTS Board of Health,�i�,t�r t i S Oe dP r�, , MA. APPLICATION 11 DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location �� , lip Owner's Name Map/Parcel# t . , Address Lot# R JCL— Telephone# Installer's Name i Designer's Name 42 CANTERBURY LANE t. Address �13, 3 y. �,fJ ,l" _��j Address 508/640-2534 Telephone# Telephone# sy Type of Building Z O \,\ t Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Buildings . �\�y�A 4. No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) AAQgpd Calculated design flow_AC � Design flow provided gpd Plan: Date . N-L 47 (p Number of sheets n Revision Date Title Description of Soil(s) ✓tC,�-� �� L_ r s Soil Evaluator Form No. (\ / Name of Soil Evaluator m S.+ Date of Evaluation i'Z- 1 fJ DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date j �Z- G'6 d p No. '*1r FEE t t COMMONWEALTH OF MASSACHUSETTS Board of Health, la,nr�._x 5fN t'ft�r0_ ,.MA. APPLICATION R DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair(-) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location (J1 �� �D��„� , �� Owner's Name i Map/P,arcel# 1-7 Address Lot# �A� , 1 Telephone#" Installer's Name Desi ner'sName 1).�SS9�ELaTES c AG g 42 RY LANE .. Address Address OUTH.MASSACHUSETT$®2j46 PI 13�x 3 3 �' il/1st 57`a�f iN-//s,b! SCe/640-21534 Telephone# r ✓��' I Telephone#_, r �* Type of Building Z'1 �V r t) Y c7�oo 1�1 �lY+ r'%f'1,��.Y Gt 4. Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder( ) Other.-Type of Building �ic!` ! r wliv ra 4:�` T No.of persons Showers ( ),Cafeteria ( ) t' Other Fixtures Design Flow (min.required) A44 o gpd Calculated design flow Design flow provided ��D gpd Plan: Date (o Number of sheets t Revision Date s Title +!v rL A_x Description of Soil(s) , C-�"^� �,,fa.,,:a, �°`►, (�➢stf f -' Soil Evaluator Form No. i Name of Soil Evaluator ��' " .Date of Evaluation `-- 1 s oib DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed /" /r✓' Date 10'1-'Z-Z1f/4 Inspections No. FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, i CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby ce)rti that the Sewage Disposal System; Constructed Repaired ( ),Upgraded ( ),Abandoned ` ( ) by: <! o l�n ll ///���(r��i/���? y/ (,c a� at A has been installed in accords ce with the provisions of 310 CMR 154 (Title 5) and,the approved design plans/as-built plans relating to application Noa&,- , dated Approved Design Flow (gpd) Installer Designer: tin 1'`1451 Inspector:l 4 ,�,%f� Date: - 9 `y The issuance of this permit shall not be construed as;a guarantee that the system will function as designed. CGS V L% FEE COMMONWLALTIT OF MASSACHUSETTS Board of Health, / I(ih I/ �� , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(}/ Repair( ) Upgrade( ) Abandon( )-an individual sewage disposal system at R .� �J�� ,,� (yvJij�/..�YJ/f Y�as described in the application for Disposal System Construction Permit No. �r/,�dated Provided: Construction shall be completed within three years of the date of tlfi p�irmitt All local conditions mus be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ltq3lK Board of Health "/!/ �/ F, II V V TnWn of DIME roy�o Regulatory Services Thomas F.Geiler,Director • snxxsrnBte. • 9 MASS. Public Health Division 163q. ♦� A'�►�'�° -Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fix: 508-790-6304 Installer & Designer Certification Form Date: - 0,--co,'.� Sewage Permit# A 006' Assessor's Map\Parcel At 5 ' Designer: STEPITFNr DOI, gin Installer: �ssOCIATES 42 CANTER13URY LANE Address: FAST FALMOUTH,MASSACHucFrm osss�Address: �� /aV L 608/540-2534 On `-a 3 7° �`\v;x���, �.Yr was issued a permit to install a (date) (installer) septic system at \ 6a r based on a design drawn by (address) �j dated Z,-.2V —(desi er) Othecertify that the septic system.referenced above was installed substantially according to design,which-may include minor approved changes_such.as lateral relocation of-the ,- distribution box and/or septic-tank. Stripout (if required) was inspected and the soils. were found satisfactory. I certify that the-septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or. certified as-built by designer to follow. Stripout (if required)was inspected and the soils were found satisfactory. aAA tH OF 4e- �,► C _ CHRISTINE �G "�G�o,cR FAIRNENY.. (Installer's Signature) No. 926 �I o STEPHEN GISTE� ® =3Z- �► SANITARIP�> (Designer's Signature) G� 4 (Affix Designer's Stamp a .e) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BA "�TST, B ,E I'I .:C F ';$7'i'�LT T1�[?TC?YfIAT THANK YOU. oflime� Town of Barnstable P# 1 L! Department of Regulatory Services MA asi Public H - l ealth Division Date I I ) 3 ' �A163y. �e� 200 Main Street,Hyannis MA 02601 lFO AAA't Date Scheduled 0/ µ Time 1 Fee Pd. Soil Suitability Assessment for ewa a Di osa Performed By. ✓+ �fl�,j L .: Z �— �- Witnessed By: 7 Location Address LOCATION& GENERAL INFORMATION �?ea Owner's Name Address .c"o/�GL9�LU�zGE( Assessor's Map/parcel: 11 S yNiLCc= 7 J ( Engineer's Name 17D/Y NEW CONSTRUCTION y REPAIR Telephone# pSs—S �jd —� 7C Land Use ' Slopes(%) G `J Surface Stones Distances from: Open Water Body7 ft Possible Wet Area ft prinking Water Well �2tt Drainage Way i Jt9 ft Property Line �jt Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands�n proximity to holes) Y 1. �o� �. 13;.G•�r7 a a r` �d-V.9 Parent material(geologic) ~.Depth to Bedrock �✓ Depth to Groundwater. Standin�Waterin 3 1= Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE �� i•�� Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: In. Index Well# Reading Date: Index Well level in, Groundwater Adjustment }t, .�,..,.-..� Adj.ftetor Ad.prpundwster bevel PERCOLATION TEST Date ,ti .i F�Gn./Inch2 -- � Time at 9" CTime at 6"k Time 0 Time(9"-6") [D% 1>/ C / SAch 2 W, Site Suitability Assessment: Site Passed_�� Sitc Failed: Additional Testing Needed(Y/N) . Original:Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil then Surface(im) (USDA) , (Munsell) Mottling (Structure,Stones;Boulders. tenGravel) '114- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsi e c %Omni) jj L t� l9 trC"^-rxL DEEP OBSERVATIONHOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Csis%ncy,%Gravel) IL91 aL t (L DEEP OBSERVATION HOLE LOG Hole# ! Depth from Soil Horizon Soil Texture Soil Color soil they Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. • Co;' t n 5�o"TsT. Ja Flood Insurance Rate Map: Above 500 year flood boundary No_ 'Yes Within 500 year boundary No= Yes„...P Within 1.00 year flood boundary No— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s mate 'al exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pery us material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with . the required training,exp tise and experience described in 310 CMR 15.017. Signature P' Date i 2 �j fir D� • Q:\,SEpnMFRCFORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P RECEIV JUN 2 6 2003 TOWN O OF DEPTABLE TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 38 Blossom Avenue Osterville, MA 02655 Owner's Name: Bonnie Withington Owner's Address: Same Date of Inspection: June 20, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 117 Mailing Address: P.O.Box 49 Parcel: 051 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes NeeAs Further Evaluation by the Local Approving Authority Inspector's Signature: Date: June 22, 2003 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and 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 f Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie WithinVon Date of Inspection: June 20, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box, System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie WithinAton Date of Inspection: June 20, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 9 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie WithinQton Date of Inspection: June 20, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h 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 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered'a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a 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 M 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 0 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie WithinQton Date of Inspection: June 20, 2003 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,of Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? n/a 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 F e Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 38 Blossom Avenue Osterville,MA Owner: Bonnie Withimton Date of Inspection: June 20, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied CONEVVIERCIAL/INDUSTRLU, Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: The owner had the system pumped after the inspection for maintenance. 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) innovativ&Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie Withington Date of Inspection: June 20, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: 1" Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 4'T x T bottom to grade Sludge depth: 24" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): No outlet tee was present. The outlet pipe was higher than the inlet pipe. The inlet pipe will always be under water. Recommend pumpnnlz every two Years for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie Withington Date of Inspection: June 20, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie Withington Date of Inspection: June 20, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 4 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.): One overflow 02)was M1 with 2"ofscum. The cottage flows to this cesspool. The cover was to grade. Another overflow(#3) was full The cover was to grade. Another overflow 04)had 6"of water and the scum line was at 2'. The cover was 10"below grade Another overflow(#S)was dry The cover was 16"below grade. There were no signs of failure. All overflow cesspools were approximateiv S'W x S'T x 8'bottom to grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I I 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: 38 Blossom Avenue Osterville, AM Owner: Bonnie Withington Date of Inspection: June 20, 2003 Map: 117 - Parcel: 051 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. AN �. Lj r 3 a Y Co'Tr,49c. I 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Blossom Avenue Osterville, MA Owner: Bonnie Withinvon Date of Inspection: June 20, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mast describe how you established the high ground water elevation: Using the Barnstable topographic map and Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 NEkN ROOF CONST. ---� 2 x 10 ROOF RAFTERS @ 16"D.C. NEW RAKE BOARDS -5/8"COX PLYWOOD ROOF SHEATHING TO MATCH EXISTING -ASPHALT ROOF SHINGLES EXIST. EXIST. -15LB.FELT PAPER 12 12 BATH BEDROOM -BATT INSULATION MATCH @ FLAT CEILINGS(R=49) EXIST. �,2 -SIMPSON H 2.5 HURRICANE CLIPS TOP OF PLATE A'I'ALL RAFTER ENDS —— O -ICF_/WATER SHIELD AT O TO"OF ROOF -PROP-A VENT BETWEENN RAFTERS NEW WALL CONST. WIND WASH BARRIER BETWEEN RAFTERS -ALUMINUM DRIP EDGE i ANDERSEN -CONT.SOFFIT VENTS F `\- AW251 1.2x6STUDS@16"o.c. m " EXIST. 3.1/2"PLYWOOD SHEATHING —2 x 6's(off 16"D.C. LAUNDRY 3.6'(R=19)BATT.INSULATION (5)10A RAILS EACH END x 4.1/2"GYPSUM BOARD �- 5.W.C.SHINGLE SIDING 6.TYVEK VAPOR BARRIER \ \ 12 I I ON. 4.5 1 SECOND FLOOR II \12 SUBFLOOR I I ` \ \ 12 ( 2 x 10 CEILW JOI TS @ 16"o.C. TOP OF PLATE ANDERSEN III - AW251 ' P V 2"QYP.BD.ON I 1x 3 STRAPF(NG@16"o.c. EXPAND. ' ANDERSEN II ��\ w AW25, LOFT EXPANDE o LOFT 3 It \\ SECONDFLOOR z ANDERSEN II SUBFLOOR `- AW251 I 9 1/2"ENGINEERED JOISTS @ 16'o.c. II AW251 !; ---- FRONT ELEVATION II A 2 A BUILDING SECTION @ LOFT ANDERSEN A2 AW251 C EXIST. 11 STOR. � a I NEW FASCIA,FRIEZE,& 14'-0" 10'-0" �, —STEW ASPHALT ROOF SHINGLES TO MATCH EXISTING SOFFIT BOARDS TO I MATCH EXISTING SECOND FLOOR PLAN LEGEND: NEW CORNER BOAR TO MATCH EXISTING O EXISTING WALLS _ — CONSTRUCTION TO BE REMOVED EM NEW CONSTRUCTION NEWW'C.SHINGLE SIDING TO MATCH EXISTING NOTES: _ 1.) CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS &DIMENSIONS IN THE FIELD 2.) CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, ® ® E � DETAILS,&FINISISHES IN THE FIELD WITH OWNER 3.) ALL CONSTRUCTION TO CONFORM TO THE IRC2009 BUILDING CODE 1A W/THE 8TH EDITION MASSACHUSETTS AMENDMENTS 4.) TIMBER FRAMING TO BE SPRUCE/PINE/FIR NO.2 GRADE 5.) 110 MPH EXPOSURE B WIND ZONE 6.) ALL SHEETS OF PLYWOOD WALL SHEATHING TO BE INSTALLED VERTICALLY, OR HORIZONTALLY W/BLOCKING AT EDGES,3"EDGE/12"FIELD NAILING 7.) FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION OF ALL SIMPSON COMPONENTS 8.) VERIFY ALL PLUMBING&ELECTRICAL DETAILS W/OWNERS ON THE SITE LEFT E L E VAT I O N DURING FRAMING CONSTRUCTION THE DESIGNER SMALL BE NOnFIEO IF ERRORS OR OMISSIONS ME FOUND ONY SCALE : DRAWING NO.: COTUIT BAY DESIGN, LLC NEW ADDITION/REMODELING FOR: COSTRUCTN.THE BUILDING DING CONTRACTOR 43 BREWSTER ROAD W�sBERESON BLEFOR TNIECONTENT 1/4' MASHPEE MA. 02649 DE IGNEDRAWIN SI ERROR STRUCTION OROMISSI COMMENCES WITHOUT NOTIFYINGTHE DEERMAN RESIDENCE ' - a DESIGNER OF ANY ERRORS OR OMISSIONS, DATE PH. (508)274-1166 THESE—WINDS ARE ANYOTOLELY FORTHEUSE tOdt OF THE THESE RAW N NOR EO.ANY OTHER USE OF FAX(50 ) 539-9402 38A BLOSSOM LANE OSTERVILLE, MA ACT OF CTU COEOUIRESTHETECTION 8/7/2014 CONSENT OF THE DESIGNER UNDER THE ACT OF ECTURAL COPYRIGHT PROTECTION Al yy + I - 24'-0 -____„_-______ S: 24 " 1 a + m 24X24 . 2'-0' O _ -4 - _ - 24X22-2 -v r � /6 BEDROOM•t 3 BATH Xv 4'-0` ---- -,_ ------------'--- -:'-��F' ----------'--------' - - ------' PER MANU - ° - �-9 i/2"ENG.I JOIST � / z I I -_ -- BASEMENT F,(A VEI / y -m BEDROOM•2 a. 4"THICK x m v u CONC.SLAB - 6 G� r - jd r 9-1/2"ENG- I JOIST - --9-1/2"ENG.I JOIST C. 13 BI-6" 4'-O" I PER MANUF.(ABOVE) PER MANUF-(ABOVE] m J ( i- I _ °' o BATHROOM _ ' - - n iL I t o � 1.�° m I OM y O I -I 4 FAMILY ROOM ° 3 u I a n F 2X5 C.J. •� q a I6"O-C. � �— �� 9-1/2"ENG.I JOIST—>' I• 9-1/2 ENG.I JOIST> "' ,9 is Y O O Q PER MANUF-(ABOVE) P MANUF,(ABOVE) X DINETTE V I O t3'-IOY." 4'-0" 3 10° - LAUNDRY W -� ` `_ BO•CW LNE— -7 NNN Ba 0 LL LL I 3•-0•GO. ROOM4N_� .__ - __zq __ m YP.aaa6 POBT { nr v - .., " O 0 - -_ -_- -_ -_ "� ._______ __ _ __ _________________ W. - " —r I 5/8 F.C.F,C.DRYWALL m m - m _ - C I` I` P; �-U U 1 I - a WALLS a CEILING. `� Q a�l----- tt_ W - L— aA - -a?' ENTRY - - pf - I CAR GARAGE If 4"THICK I' mX ENTRY �,-- OG . - _ O I CONC.SLAB O - LOFT __ 4' 5'-6" m BELOW I, �-9-1/2"ENG.I JOIST—> s BATH I an PER MANUF.(ABOVE) 2XS C.J- - Orl ----------- - 0 v o I6"O.C. I ti n X I 4'-O" 4'-O in A20x20 t 3'S• / r , - - __�____ ___ - COVERED V � 24XI6-2 j 4 _ PORCH � q - 12'-0" �,-- n.-0„ , 5 ' -------------- /------------------------------- --------' �— -- 24 L 14'-0" I SECOND FLOOR PLAN I 24'-0" - y_—_ + FIRST FLOOR PLAN FOUNDATION PLAN i �) .DATE REVISION DRAWN'BY1_1 PAGE SCALE 1. 'j Des igns f w UINIT 38B BLOSSOM AVE =� PROPOSED TWO BEDROOM UNIT CBS g KENDALL B WELCH � w �► ,� ,�of � /i4:,:-0, $ OSTERVILLE MA. o 10-0t-06 W m W I /Il FUAataBE OF DRNUMG9 LEAVEB FlAPOMdBEP RESPONSIBLE�CL1'�'L/4M-_E C2)N OLL 2IXdCl B!ZE dND REfNFC.G�KcNf O•dl OdKYPETF{i�Ol/AG9 /9l d(L iQ71M63 d!<fL E�Elm e6aL FlPOBrME vEPEf DEPM. --- ti PQ BOX.Y9 /SOBl9SO95O 0 LOCdL LzNLpI,yG OODF9 dzm CRD4lenKE4 a DEBKd.•3.car Atli BE M6D RESfx•NyB(E' ATL9f BE DEIERIYMBJ Br LOOdL BC2 ld,VDRlLNU.AROALLFPfK'lE f l vEQ/Ff B11a/G)t/RnL ELQ@/TB FLOP DL"K.Y.G� W:'Bf BaRNJTdBlE?L d.Bt.B ., -T I FOR^.-'tE COMOIPON9 LF FOR 1RE IL OF DIEM ORAINNG9 ONRIRG GC.fIBTlillCl/C.,L - PR.aOf/0E3 P LONBTRICT'CAt vEJP1Fa'D=�"'GR fNIH LGCaL EAYa!N®2 W1M LadL ENOOVEER.IND�O[D�AG OfF+O.at9. TOP OF FOUNDATION 42.0' (FRONT DWELLING BM Top C3 TOP OF FOUNDATION 41.5' (REAR DWELLING) Mev. 41.18' osHUA Dl&t NraVR t• POND SAM Finish Grade El 40.5t POND CB FND! Finish Grade E1 4Q.4 f z� w 49-31 0 6 x, s�, 41.2' r�vv [7777 IP FND IIw 1 37.5' 2fT 11ia. I215EI'i 20'ha+ 1?LSER ( eIIC� N (Both Dwellings) FARE N Parcel 51 �- cy, 4• s�Ro o 1464 _*sq ft 0 40. Gt 31 Acres m, c�a dfi2x s" IN E� EL t,� c� 10" Min, 14" aun. INV EL S-P MAIN 4a4 INV EL �`� �--- INV EL 36.57' Below Flow Line 36. /rye �P°� qs e l�1 I (BOTH T 1G J Liquid Level 48 (�����1 E O F RAZE EXISTING _t0''` DWELLING H--20 LOAD DISTRIBUTION BOX �/ q� - L 40!2' 1500 GALLON II-20 LOAD SEPTIC TANK OCUS MAP ABANDON PROP _ EL= 40.3t' EXISTING CESSPOOLS NG CB FND 1500 GALLON REINFORCED CONCRETE SEPTIC TANK 0' 4�5 - �� 2" of 1/8" - 1/2" Peastone Minimum Construction Materials Per 310CMR 15.226(2) _ El 37.3 Tees shall be constructed of Schedule 40 PVC and shall extend a 404' minimum of 6" above the florw line of the septic tank and be on cP INVERT ��� o oo� EL. 36.26' the centerline of the septic tank located directly under the O,, p 3 _ EL= 36.47 °p°goop0 `0 3/4" - I-1/2" Double Washed goon° �000 clean-out manhole. RAZE EXISTING °°pV 000 °o°o 000 Crushed Stone °°g 000 ° ° The inlet pipe elevation shall be no less than 2" nor more than 3" t0 DWELLING °� oo °� oo o 0 �, °� °° El. 35. 76' above the invert elevation of the outlet pipe. m TOTAL FIELD LENGTH = 42.5' Septic tank shall be installed level and true to grade on a level, stable base that has been mechanically compacted and on which4Q:2 Na. of Fields 1 6" of crushed stone has been placed to ensure stability and s- l PROPOSED c► DRlVEMtAY p No. of Distribution Lines Each Field 2 CO to prevent settling. ' `�' L6 Septic tank shall have a minimum cover of 9" Length of Distribution Lines 42 d 29.3 Two 20" manholes with readily removable impermeable covers t BOTTOM OF TEST HOLE ELEV. of durable material shall be provided with access ports. SEPTIC TANKo ' WATER Strip-out Note: The outlet tee shall be equipped with gas baffle. (H20 LOAD) A Remove all unsuitable material 5 around SAS : PROPOSED �, lINE down to the C layer and replace with clean ADJ. HIGH GROUND WATER <ELEV. 20.0 RESERVE 15M GALLON j granular sand per 310 CMR 15,255 (GIS TOPOGRAPHY) PRECAST REINFORCED CONCRETE DISTRIBUTION BOX SEPTIC TANK Install on a level base (11120 LOAD) x i " ;" . = 2" 3/4 - 1-1/2 Double Washed Crushed Stone Minimum wall thickness 2" of 1/8" - 1/2" Peastone _ Afinim um inside dimension = 12" = � - _ Outlet inverts sham be equal to each other and at _ u._ F, ,r Design" Data: _ - oo oo °°�8 ..+" 9 a 5r o�cb °° Al 0000 ,c minimum below- inlet invert. pRIyE 1 Z o ° o °° cF The distribution lines from the distribution `box shall all have P Four Bedrooms = 4 X 110 gpd = 440 �pd Regraired Flow 00 °° °° o �° ° ° ° 5' 4 No Garbage Disposal Allo rued ° °° $ °° ° °°° ° all T equal inverts as determined by flooding the distribution box to �y cxs g p ° the height of the distribution line invert after all lines have ° ° ° � ° o 0 0 been sealed in place. V 20> Use: Leach Field2 b'L x 14'W x 6'" Eff/Depth °� °� Invert adjustments shall be made by filling with durable and 4' MAX. 6 Max. 4' MAX. or �425 x 14� x 074 = 440 TOTAL DE5IGN FLOW TOTAL FIELD WIDTH = 14' nondeforma ble material permanently fastened to the line SEPTIC TANK �,�,p, EFFECTIVE FIELD DEPTH - 6" reconstructing the lines until all inverts are of equal elevation. (H20 LOAD) 4D.4� `►► �+� 4!!5 �, ��iiOF y rz� � P���oTruSs�EGENERAL .CONSTRUCTION NOTES � E � r pHENmaterials shall conform to RE.P Title 5 GsTE 1. All the workrnanshlp and FAII;NEN J. and the Town of Barnstable rules and regulations for the subsurface c, p0YE 10 ► cP No-926 �� disposal of sewage. PROPOSED �, o -�o �F �o i #375`9 2 At least one access port over tank tees shall be accessible 1500 GALLON a QISTER : o F s°yoQ o GRAPHIC SCALE within 6" of finish grade,e, with any remaining access ports bro ugh t SEPTIC TANK S SA tad ► N S , g M20 LOAD vs - 1a 20 �w as to within 6" of finish grade. ( ° 3 All components of the sanitary system shall be capable of m' it ZG -'a4 withstanding H-10 loading unless they are under or within 10 ft - �2 ob of drives or parking. H-20 loading shall be used under or within UU1� 4i' . REF. DEED- 21562 - 115 ( IN FEET } 10 ft of drives or parking unless noted. Plastic equals may be �' _- , 8 - A.ssEssoRs MAP 117 PARCEL 51 I inch = 20 ft used in lieu of all precast units. �. NG pY1€� .4 FEMA DATA. ZONE 'C"" 4. The excavator/contractor shall call dig safe and verify the location ��; 1 �42 FIRM PANEL 250001 0016 D of all site utilities prior to any excavation, and shall be responsible for r MAP REVISED• JULY e 1892 relating to electric easements. all matters 'SITE .�..�D SEPTIC PLAN g" -c 5. Sewer pipes shall be 4 Schedule 40 PVC laid at a min. 0.02 slope. ZONING DISTRICT RC 6. Any masonry units used to bring covers to grade shall be 0VERLAY DISTRICT` WP & ROPD Prepared For.- mortared in place. BUILDING SETBACKS, 7. Finish grade shall ha ve a minimum slope of 0. 02 ft per foot. FRONT - 20' c BLOSSOM t� Li NU 8. .Abandon old septic system. SIDE & RE�fR !o' In 44 2' LOT COVER BY STRUCTURES' 9. The exca va for/contractor shall be responsible to check all grades EMSTING COVER = 119 ] and elevations and to contact Doyle Associates of any discepancies, PROPOS PROPOSED LOT COVER = 197 Q,S'L�E'�"VI���, aS`See�I LI,SE' tS prior to construction. �IitY ExISTINo BEDROOMS = Scale: 1" = 20' a te: December 26, 2006 10 All water lines located closer than 10' feet from sewage components PROPOSED BEDROOMS = 4 shall be sleeved in schedule 40 PVC. Demotes Existing Pa pared By.Spvt me va tion (Tpp) r Stephen f wale and Associates HEALTH AGENT: D. DESMAIRIS RS TEST DATE: 12-15-06 R�d�' ll t 42 Canterbury e, E. Falmouth, 111A02536 SOIL EVALUATOR: S. DOYLE P# 11543 EX,gWG I Telephon : 5081540-2534 TH #1 EL. 40.4' TH #2 EL. 40.4' TH #3 EL. 40.4' TH #4 EL. 40.4' pR►VE° B_Z O C .ki PERC <2 MIN/INCH PERC <2 MIN/INCH PERC <2 MIN/INCH PERC <2 MIN/INCH Q.Oa �eIIt ~42.80' -- "PggelTl A SL 10YR 3/2 0.. A SL 10YR 3/2 0 A SL 10YR 3/2 0 A SL 10YR 3/2CB 4?63' 8„ 8" 1 8" of 8,. �±wedge 0913'46 � B LS 1 OYR 5 6 B LS, 10YR 5 6 B LS I-, 5/6 B LS 1 OYR 5/6 42.97' EL. 37.4' 36" EL. 3T'4' 36 EL. 37.4' 36" EL. 37.4' 36" A -VE; MED. PERC 60" MED. MED, PERC 63" MED. PERC 63" 0 0 C FINETOSAND 2.5Y 7/4 C FINETOSAND 2.5Y 7/4 C FINETSSAND 2.5Y 7/4 C FINETOSAND 2.5Y 7/4 P--�" Util/Pole 132" 132" 132" 132" f �. l� DESCRIPTION EL. 29.4' (NO WATER) EL. 29.4' (NO WATER) EL. 29.4' (NO WATER) EL. 29.4' (NO WATER)