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Home My WebLink About0044 BLOSSOM AVENUE - Health 44 Blossom Av1enueq '', Pr , g y�r 1 u a3 ': o -/2 �- M Commonwealth of Mlassachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom'Rpedd O n Property Address ^' Marc_& Patricia Lepain Owner Owner's Name ti' information is Osterville Ma 02655 1/30/2020 required for every page, City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Im out When* fillingng out forms A. Inspector Information 11-13SIC on the computer, use only the tab Sean M. JoneS key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name - key. 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmaii.com, SI4522 sean@smjonestitle5.com License Number } B. Certification I certify that: I am a DEP approved system Inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails - 1/30/2020 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5msp.doc-rev.71AMI8 Title 5 Official Insprmion Form:Subsurface Sewage Disposal System•Page 1 of 18 i n Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owner's Name Information is required for every Osterville Ma 02655 1/30/2020 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 44 Blossom Rd Osterville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 1 500 gallon leaching chamber. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for`yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doe-rev.7126=18 Tale 5 Official Inspection Fomr subsurface Sewage Disposal$*am-Page 2 of 18 � Commonwealth of Massachusetts Title 5 official Inspection Form ri Subsurface Sewage Disposal System Form-Not for Voluntary Assessments +' 44 Blossom Road Property Address Marc&Patricia Lepain Owner Owner's Name information is required for every Osterville Ma 02655 1/30/2020 page. _ Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cunt.); ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): _ ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation Is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.MA120/8 Title 5 Official inspection Form;Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 4 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owner's Name information is Osterville Ma 02655 1/30/2020 required for every City/Tawn State zip Code Date of In page. C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must, be attached to this form. c. Other: 4) 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 15insp doc•rev.T12812p18 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road Property Address _ _........� ...,....... Marc& Patricia Lepain Owner Owner's Name is requireedd for every Osterville Ma 02655 1/30/2020 required page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® 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. r Any portion of a cesspool or privy is within a Zone 1 of a public water supply. ® well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) , ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.00c-rev.7f UM18 Titie 5 Offtciai inspection Fort;Subsurface Sewage Disposal System•page 5 of 1S Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road Property Address Marc& Patricia Lepain ---- owner Owner's Name Information is Osterville Ma 02655 1/30/2020 Pgered for every CitylTown State Zlp Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for an inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part o this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)J 15insp.dae•rev 7126018 Title S Qfti6al Inspadien form Suha,rfaea Sewage nivpasal System•Page 6 of 18 Commonwealth of Massachusetts - - Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments R 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owner's Name information is required for every Osterville Ma 02655 1/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: -Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes Z No Seasonaluse? ❑ Yes ® No . Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: current Date t5insp,doc•rev,71=018 Title 6 Official lnspaction form Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments g` 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owner's Name information is Osterville Ma 02655 1/30/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): . - - -- Gallons per day(g pd) Basis of design flow(seats/persons/sq.ft., etc.): -- ------- ---- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: --- -- Industrial waste holding tank present? ❑ Yes ❑ No 1' Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: gate Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No S If yes, volume pumped: gallons How was quantity pumped determined? -- --_ __.._. ..—.___......._.. Reason for pumping: --- t5insp.doc•rev.7r2812018 Title 5 Ofrrcial Inspection Form:Subsurface Sewage Disposal System•Page a of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owners Name information is Osterville Ma 02655 1/30/2020 required for every .__._._...__..,...�..,....._._ ___.. page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system installed 8/2008 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 _--— „- feet Material of construction: ❑-cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. tShsp.doc•rev.M812018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road "Y Property Address Marc& Patricia Lepain Owner Owner's Flame Information is required for every Osterville Ma 02655 1/30/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: _..-.._-.-- Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 0"----- T, Distance from top of scum to top of outlet tee or baffle __...-.._.__...._......................._._._ Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took _measurements _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. l5insp.doc•rev.712M18 Tilts 5 official inspection Form:Subsurface Sewage Olsposel System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owner's Name information is required for every Osterville Ma 02655 1/30/2020 ..— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: - gallons per day onspAcc•rev.W2812018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owner's Name Information is Osterville Ma 02655 1/30/2020 required for every Page. CkY Rown State Zip Code Date of Inspection D. System Information (coot.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. Wnsp,doe-rev,7/26/2018 Tine 5 gficial inspection Form Subcurf000 taowage Di:posal 6y3tam•Page 12 of 18 �., Commonwealth of Massachusetts Title 5 Official Inspection Form _._ E;i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road_ Property Address Marc& Patricia Lepain _ Owner Owner's Name information is Osterville Ma 02655 1/30/2020 required for every City/Ttmrn page. State Zip Code Date of Inspection D. System Information (coot.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No. Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):. *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 1 16.5x13'x2*. ❑ leaching galleries number: ❑ leaching trenches number, length: - � -- ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp,doc•rev.71AM18 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts • ' {m- _- Title 5 official Inspection Form ^- sewage Disposal System Form-Not for Voluntary Assessments Subsurface Sew g p y ry {� �. 44 Blossom Road .�...�.__.._._..._.._..._._. Property Address Marc& Patricia Lepain Owner Owner's Name information is required for every Osterville Ma 02655 1/30/2020 — page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching facility consists of a single leach chamber surrounded by crushed stone 16.5'xl3'x2'. No signs of past overloading, soil dry above and around was dry with no indications of past saturation. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert ____. ___.____.._...... .................._.......... Depth of solids layer -- - — Depth of scum layer --- -- - --- Dimensions of cesspool - --- Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 18' Commonwealth of Massachusetts _- - Title 5 Official Inspection Form _ r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " '. 44 Blossom Road Property Address Marc&Patricia Lepain Owner Owner's Name information is Osterville Ma 02655 1/30/2020 required for every page.-} Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 13. Privy(locate on site plan): Materials of construction: --- -- - - Dimensions, Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Adam t5insp.doc•rev.7rAM18 Title 5 Official inspection Form:Subsurtaw Sewage Dispose!System-Page 1s of is Commonwealth of Massachusetts " Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments y 44 Blossom Road ._..__ Property Address Marc& Patricia Lepain Owner owner's Name Information Is Osterville Ma 02655 1/30/2020 required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Gf� Al 2 t jw i; � �( AZ 7- I f't3 �� o 0 3Y t5lnsp,doc•tev.7/2612018 Title 5 Official Inspection Form:5uosu"aw Sewage Disposal System•Page 16 of 18 .� Commonwealth of Massachusetts =- NO Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments r 44 Blossom Road Property Address Marc& Patricia Lepain Owner Owners Name information is Osterville Ma 02655 1/30/2020 required for every page:--_ DoRown State Zip Code Date of Inspection D. System information (cont.) 15. Site Exam: ❑ Check Slope Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5inspAoc•rev.71M018 Title 5 official Inspection Form`Subsurface Sewage Disposal System-Page 17 of 18 ;6. h of Massachusetts Commonwealth , E ` Title 5 Official Inspection Form _ d Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Blossom Road Property Address _..__ _......._._._ .__ Marc&Patricia Lepain Owner Owner's Name ^ Information isrequi Osterville Ma 02655 1/30/2020 ppaagered for every City/Town p State Zip Code Date of Inspection E. Report Completeness Checklist =y k Complete all applicable sections of this form inclusive of: ® A. Inspector information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15, Explanation of estimated depth to high groundwater included 15insp,doc•rev.71261ZD18 Title 5 Official Inspection Farm;Subsurface Sewage Disposal System•Page 18 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 BLOSSOM AVE .; Property Address FACEY Owner Owner's Name - information is required for OSTERVILLE MA 2-20-16 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key p to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-20-16 Inspe is 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 office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �01;d- VJ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M �t 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. 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 Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name ` information is required for OSTERVILLE MA 2-20-16 every page. City/town State Zip Code Date of Inspection B. Certification (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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further,Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM '<0 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ .The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 da flow Y t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2per Number of bedrooms(actual): 2 per ( ) asbuilt assessing DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 1 500 GALLON CHAMBER Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? -❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2014----------109 2015--------—137GPD SYSTEM NOT DESIGNED FOR GARBAGE DISPOSAL Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-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 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is OSTERVILLE MA 2-20-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): CURRENTLY OCCUPIED ONLY PART TIME 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 ❑ 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 . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 8-4-08 Were sewage odors,detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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: 1.5 p g feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: LIGHT/MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT 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? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING UPON TRANSFER AND THEN EVERY 2-3 YRS DEPENDING ON USE. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: p Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 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 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 44 BLOSSOM AVE . Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE. I i I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 1 ❑ 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.): CHAMBER WAS OPENED AND DRY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of*groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every 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.): 4 t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where puMc water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 BLOSSOM AVE Property Address FACEY Owner Owner's Name information is required for OSTERVILLE MA 2-20-16 every page. Cityrrown 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: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 44 BLOSSOM AVE Y" Property Address ` FACEY Owner Owner's Name information is r OSTERVILLE - MA 2-20-16 required for ` '"•' - every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,_or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t5ins•3/13 ' Assessing As-Built Cards Page 2 of 2 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar--1 18122&seq=1 2/24/2016 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION ^'Y Av SEWAGE# Ook- /y VILLAGE Q£1try ASSESSOR'S MAP&PARCEL f%k-12 z INSTALLERS NAME&PHONE NO. G fl,Ik Go,r7; SEPTIC TANK CAPACITY 9-01, LEACHING FACILITY.(type) i�a.,phi✓ (size) o?X J.7 F3 x /G_f NO.OF BEDROOMS a OWNER / ,,'I PERMIT DATE: 7 3 O-08- COMPLIANCE DATE: rJb 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 L_ t/r•�r w- 7 `O #yy ,A �? d /7' a 3 om 3 as' 30 y 3y' 3S 3-- http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=118122&seq=1 2/24/2016 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town 3/9/12 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 A. General Information forms on the ` computer,use 1. Inspector. my the tab key I to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE, MA 02632 City mown State Zip Code 508-420-4534 .S 14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/9/12 Inspectors' ignature Date ' The system inspector shall submit a copy of this inspection.report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report onlydescribes 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. tsins•09/08 I ' d Title 5 Official Insp 'o orm:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owners Name information is required for OSTERVILLE MA every page. Cit Date of 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: LEACHING CHAMBER WAS OPENED AND WAS FOUND TO BE DRY WITH NO SIGNS OF FAILURE AT TIME OF INSPECTION 13) 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Properly Address PARKER Owner Owner's Name information is required for OSTERVILLE MA 3/9/12 every page. City mown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town State Zip Code Date Date of of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety'and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: J You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA 3/9/12 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-. 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is OSTERVILLE required for MA 3/9/12 every page. City/Town 9 State Zip Code Date of Inspection C. Checklist Chec k if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection on Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town 3/9/12 State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON SEPTIC TANK D- BOX AND ONE 500 GALLON CHAMBER Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ' ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2010-----112 GPD 2011----90GPD Sump pump? ❑ Yes ❑ No � Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) ' Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disp osal,posal System Form Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town State Zip Code Date Date of 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts AM. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.•y` 44 BLOSSOM AVE Properly Address PARKER Owner Owner's Name information is OSTERVILLE required for MA 3/9/12 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.)) Approximate age of all components, date installed (if known)and source of information: SYSTEM INSTALLED IN AUGUST OF 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: LIGHT t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M <`'y 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is OSTERVILLE required for MA 3/9/12 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): WOODEN POLE Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: . Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Anamm. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every3/9/12 C'page. To p g � State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain): Dimensions. Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments sments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town 3/9/12 p Code Date of Inspection D. System Information (cunt.) State Zi Distribution Box(if present must be opened) (locate on site plan): Depth of Liquid level above outlet invert off Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts U13 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA every page. CitylTown 3/9/12 State Zip Code Date of Inspection D. System Information (Cont. Type: ❑ leaching pits number: ® leaching chambers number: 1 ❑ 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.): CHAMBER WAS OPENED AND WAS FOUND TO BE DRY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE 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 r Indication of groundwater inflow El Yes ❑ No t5ins•09/08 i Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal 9 p System Form- Not for Voluntary Assessments 44 BLOSSOM AVE Property Address PARKER Owner information is Owner's Name required for OSTERVILLE MA every page. City/Town 3/9/12 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: Dimen sions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is required for OSTERVILLE MA 3/9/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M '< 44 BLOSSOM AVE Property Address PARKER Owner Owner's Name information is OSTERVILLE required for MA 3/9/12 every page. Cltyrrown 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: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: } t Before filing this Inspection Report, please see Report Completeness p p Hess Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 44 BLOSSOM AVE Property Address PARKER Owner information is Owner's Name required for OSTERVILLE MA every page. d7dy/Town 3/9/12 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE LOCATION `1`-/ I�ss p.,-, �� SEWAGE#o?Oo� VJLLAGE—2znr,y;_/�� ASSESSOR'S MAP&c PARCEL INSTALLERS NAME&c PHONE NO. 7 SEPTIC TANK CAPACITY _ ..._1 SppH LEACHING FACILITY:(type) geha,,.,h��,. (size) NO.OF BEDROOMS _ OWNER !- PERMIT DATE: '] O- 08- 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 _........----�,. �d I 1 12 a !7 a 3 3 as" 3©" ttp://town.bamstable.ma.us/Assessing/IIMdisplay.asp?mappai=118122&seq=1 3/9/2012 L TOWN OF BARNSTABLE LOCATION L� wSSOdri w� SEWAGE 00e--3 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. ,i_ G fh /`�v Gvs7 SEPTIC TANK CAPACITY /"a LEACHING FACILITY:.(type) 1r a:,-A"h ry� (size) x [G. NO.OF BEDROOMS a OWNER PERMIT DATE COMPLIANCE DATE: C/8 Separation Distance Between the: a'Miximum 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 \d Yfo. G. a i�A a3 3 as' go ® 30 -- .t - —r _�I �sy -.. `�•`-' �`.r, ."—'1'..t'�r. ."�fe..,, y."w..�"'.'6""`3:i:^`,�s"i ^<L;`.c..,,.1�.'Q.Yr'V',r,,.�„ •.t•r�}-, No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH NVISI®N - TOWN OF BARNSTABLE, MASSACHUSETTS Ye Application for Mi5po5ar *pgtem Cottgtructfon Permit Application for a Permit to Cons`ruct( ) Repair(V( Upgrade(-O/Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. wner's Name,Addres and Tel.N Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's N8TEPfftN Jn fiblNToE AND ASSOCL4,TES J 6 194 ItV C"` )9' 42 CANTERBURY LANE �19 o)r 13 f H 111S. 407-1021-/S I EAST FALMOUTH MASSACHUSETTS 02636 Type of Building: r°g V.7E `'!5r 9 508/540.2534 wel"t No.of Bedrooms �� Lot Size �} sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.r quired) `'L-�jp gpd Design flow provided Z�7 gpd Plan Date r Number of sheets / Revision Date Title r� '� fA.A1714 LA..JAt is Size of.Septic Tank Type of S.A.S. Description of Soil :5 j-R— � 5DI.L, L, 6 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Baagd of Health. Signe Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. —3 Date Issued � V� No., —3) 'x''r�-_�"w� ` • Fee �v f✓ 1 "9c. ii T- E COiMMONWEALTH OF MASSACHUSETTS, E Entered in computer: Yes ; F, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,.MASi,$ACHUSETTS 2ppticatiow for Miopoal �§p!gtem CCon5truction Permit ~ .; Application for a Permit to Construct( ). Repair 4 Upgrade O Abandon O ❑.Complete System Individual Components Location Address or Lot No. 'NA Owner's Name,Address, nd Tel. o. r Assessor's Map/Parcel \\ j-2•'� �°�' 'oW fl�J� i'L„� , Instaalller's Name,Address,and Tel No. Designer's N flEN Ji1c11?bE A\D ASSOCLA.TES CAN ANE �m^ ` 42 OSx 33 9 EAST FALMOUTH.MASSACHUSETTS 02536 Type of Building: Y_° Y.79��Y 508/540-2534 wel in No.of Bedrooms t.,. Lot Sizes sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) .. Other Fixtures Design FIOw'(min.required) '�a'ZD gpd Design flow provided gpd s �J Plan Date u�,_.rL �"�, - 9 Number of sheets Revision Date �.{ Title -."'SY=_.� T i �e �.•� \7Gf�t?. �' '.. �yu t 0 5LL,p 1,j Al is Size of,Septic Tank Type of S.A.S. Description of Sdil N� � t�A+ D��— L.•oG{ Nature of Repairs or Alterations(Answer when applicable) } Date last inspected: s Agreement: ► "' —, The.undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in t accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by its Board of ealth. - Signe Date Application Approved by l� r - — : Date Application:Disapproved by: Y Date for the following reasons wr � 1 � a Permit No. !7�'� !� 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 J, C. at 4`-11-/ 13/o s'So m A✓4 l 0 S/"r v haspbeenncconstruc.ed i accordance /� 4 with the provisions of Title 5 and the for Disposal System Construction Permit No. _ ' dated -7 Installer T 6, A" X/� Designer #bedrooms oZ Approved design flow "r/1 A gpd U The is of�thi pe m' sh not be construed as a guarantee that the system v39�7nj odesigned Date �•/ P_M' 7,/, Inspector � No. ��'_' " Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Ii!6pont �&pgtem CCon5tructiopermit " Permission is hereby granted to Construct ( ) Repair ( ; , ) Upgrade ( ) Abandon ( ) System located at `7iyl Q/o tso� jq vQ , t7 tTry '�� and as described in the above Application f'or Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construc�ti n rrius pleted within three years of the date:) this permit. Date �/� Approved by .y Town of:Barnstable r Two. Regulatory Services Thomas F.Geiler,-Director • •nBxsrns�, MAS& Public Health Division =639. .• p'�►�'�°° Thomas McKean;Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 - Fax: 508-790=6304 Installer&Designer Certification Form Date: f3 0 b g ;;Sewage Permit# L(p0g- 3/(. Assessor's Map\Parcel ,,f 9-`T & Designer: Installer: STEPHEN J.DONTE AND ASSOCIATES Address: 42 CANTERBURY LANE Address:. ,7 ig CHUSETTS 02536 508/540-2534 ,(/fC+/�f6 v,S /�,�1,�.�rA Oaf 5'�•, On 30,0k was issued a permit to install a - (date) (installer) septic system at Orb <3 La jzc,a•�l� (Avg C�3� based on'a design drawn by --address �. . dated '(des er I ce ify that the septic system referenced above was installed substantially according to: the esign, which may include minor approved changes such as lateral relocation'of the istribution 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. ' �tH OF�y aj ®AAA • �� rs9c ��*��H pF h1�S�� a� CHRiSTINE yG J� G\ST44 tl- �hG F IRNENY V, PHEN taller s Signature) ;." e STE o. o ®. � ) N 92b tet:: � � J DOYI.E �. SAMITAR�I� O,:-S (Designer's Rodtdrey (Affix Designer's Stamp Here 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 BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc AsBuilt Page 1 of 1 . TOWN OF BARNSTABLE LOCATION _.VLz/"/ SEWAGE# Opk VILLAGE Pry ��2 ASSESSOR'S MAP&PARCEL -j.27- INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) R;< 1a.,83 x j6_i- NO.OF BEDROOMS OWNER PERMIT DATE: 7- 3 O-Ok- COMPLIANCE DATE: lJb 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 r _0 #Ny A L3 H (' G0.` J3/ ar' 110 as' 3o, 3 P-:" htt //iss 12/intranet/ ro data/ rebuilt.as x.ma ar=118122&se =l 7/16 2015 f P� q p P p p � pp q— �'N. - r —_ �_." I Sk 23073 Pw75 �40683 4gt Print Form 07-30-200B DEED RESTRICTION Whereas STEVEN J.FLINT&LEANNE B. FLINT (owner's name) of (address) is the owner of 44 BLOSSOM AVENUE (address) located at OSTERVILLE MA herein after referred to as PARCEL I and being shown on a plan of land entitled "Subdivsion of Land in NO PLAN MA Property of F---� ' et al, duly recorded at the Barnstable County Registry of Deeds in Deed Book and Page Deeds in plan book 9664 and Page 137 or on Land Court Plan number WHEREAS, STEVEN J.FLINT&LEANNE B.FLINT as the owner of said tot has (owner's name) agreed withthe Town of Barnstable Board of Health to a restriction as to the number of bedrooms whch can be included in a disposal works construction permit In compliance with 310 CMR any home built on said lot as apre-condition to obtaining po p p 15.000 State Environmental Code,Title V,Minimum Requirements for the Subsurface disposal of Sanitary Sewage; WHEREAS the Town of Bamstable Board of Health,as a pre-condition to granting a disposal works constriction permit for a septic system in compliance with 310 CMR 15.200,State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage,and authorizing the issuance of a building permit for the construction of a single family home on this property,Is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put o record with the Barnstable County registry of Deeds by recording this document, 0 Bk 23073 Pg 76 #40683 NOW,THEREFORE STEVEN J.FLINT&LEANNE B.FLINT (owner's name) does hereby place the following restriction on his above-referenced land in accordance with his agreement with the Town of Bambstable Boiard of Health,which restriction shall run with the land and be binding on all successors In title: 1. BLOSSOM AVENUE may have constructed upon the lot a house containing (address) no more than I` bedrooms STEVEN J.FLINT&LEANNE B.FLINT (owner's name) agrees that this shall be a permanent deed restriction affecting 44 BLOSSOM AVE located in OSTERVILLE MA,and being shown on the plan recorded in (town) PlanBook'FOPLAN and Page r Or on Land Court Plan i For title of PARCEL I see the following deed: Book 9664 and Page 1377 Or on Land Court Certificate of Title No. Executed as a sealed document day of �— (month) (year) Owners Signature Owners Signature Owners Signature COMMONWEALTH OF MASSACHUSETTS ,sg ' (' 30 O g (date) ext Then personally appeared the above-named �� -►� �� ( o are n Q �1... known to me to be the person who executed the foregoing Instrument and acknowledged to be the same to be n t` L free act and deed before me, 7crc� �J otary Public My commission expires: (date) —` TARA L.JORDAN RE I TR OF DE DS Marypdit A TRUE COPY,ATTEST COMMON►IKYN OF My CG1m tssian Expw JOHN F.MEADE,REGISTER Town of Barnstable P# dye' Department of Regulatory Services s' MRNSU Public Health Division DateNAM 200 ain Street,Hyannis MA 02601 Date Scheduled Time Fee Pd. n y • Soil Suitability Assessment for Sewage Disposal Performed By: �UV Lc/ Witnessed By: 77bi-4&A 0 cti/LP1��' LOCATION& GENERAL INFORMATION Location Address A,� , �u y Owner's Name Address l 0 Assessor's Map/ParceL �. (�j 't,"Z Engineer's Name sJV� NEW CONSTRUCTION REPAIR Telephone# � 0 I Land Use �i-�9'L � y;(y lL_ Slopes(gb) G. 5 Surface Stones O Distances from: Open Water Body T� I ft Possible Wet Area ft Drinking Water Well y t6 J ft Drainage Way ft Property Line ) I 0 ft Other ft I_ SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) �i L) +J fo)1 3 r __J FTI CV1 t i 00 `l Parent material(geologic) � Depth to Bedrock f Depth to Oroundwater. Standing Water in Hole: Weeping from Pit Face a '— 1 + Estimated Seasonal High Oroundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: 1--�N!vz„�J-!�t ' Depth Observed standing in obs.hole: __ ___In. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment 'ft. Index Well# Reading Date: Index Well level�..a.... Adj,&ctor„�... ,r Adj.Groundwater Level,,,p PERCOLATION TEST Ditto 1-61_. Thne ID„�o Observation Hole# Time at 4" Depth of Pero Time at B", 1v: 0(7 Start Pre-soak Time @ Time(9" f End Pre-soaker /Z . � ) Rate MinJlnch Site Suitability Assessment: S' Passed Site Failed: Additional'Testing Needed(YIN) + Original: Public'Health Division,.- Observation Hole Data To Be Completed on Back---------- r ***If percolation testis to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. , Q:tSEPTIMERCFORM.DOC' DEEP.OBSERVATION HOLE LOG Hole# Depth.from Soil Horizon Soil Texture .Soil Color Soil. ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. 1 consistency. Gravel) Y "N t-i k t 11 tLr4+1�)t V Ob ti� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistengy. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistengy. O e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. o ' a r • ac Flood Insurance Rate May: Above 500 year flood boundary No_ Yes within 500 year boundary No= Yes Within 100 year flood boundary No— Yes Death of Naturally Occurring Pervious Ma terial Does at least four feet of naturally occurring p ervlou material exist in all areas observed throughout the. for the soil absorption area proposed rption system? If not,what is the depth of naturally occurring pervi us material? ..._. Certification I certify that on f (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,ex ertise and experience described in 310 CMR 15.017. Date Signature , Q:\.SBPTIC�PERCFORM.DOC LOCATION SEWAGE PERMIT NO. VILLAGE INS.TA LL R'S NA E & ADDRESS B .0 I*L�D E R OR OWNER DATE PERMIT ISSUED c DATE COMPLIANCE ISSUED r - - � 2 / � /000 4 � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A.w,17. ..................OF... ..e............................................... Applirution for Disposal Works Tonstratrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: / ..�?..... ��.. - vs /........................................................... -- Locat - ddress.,[_ or Lot No. Owner Address /� W G/lam lK -Y-•-•-•....................�� ......._.. e ....._.._ . ..... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................. .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Dia titer................ Depth................ Disposal Trench—No..................... Width.................... Total Length................. Tot r:':eachma area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... TotaI'`l'eaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date-'-••................................. Test Pit No. 1................minutes per inch- Depth of Test Pit.................... Depth'to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground'water......_................. --------••-•-----------------------•-----•----------------..........------------•---••---.....-•-•••......................................................... 0 Description of Soil.................................................................,.................................-•----------------•--......------------------.........------------. V ---------------------------•---------•--•-•---•.._......---•--.......------•-------..........--------•-=-----••--:;--......•----•-----------------•----••-•--- -- --•-•-•-•---•-•••-------•--•------ ----------------------------------------=------------------------------;------------------------------------------------------------ - UNature of Repairs or Alterations—Answer when applicab e_--_---__/1------ ._ �—L ------------�- ---- --- ......7.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Lem in accordance with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the boarA of health. Signed h% ' ._.._ � __... A 1 .'. .. �� ate Application Approved By----------l.r-.)4 --•-- ._... .!�1�1/.1. - l� t-_.7.7.... Date Application Disapproved for the following reasons:............................................................................... -••---•---------------------------------•-------....-----•--•------------........----------------•--•-•---•--•------------------------------••-----------•--•-•-----•-------------•-----•----•-...._.... Date Permit No......................................................... �i' --- Issued -.�----• --•..................... Date U7rA/ �. No......................... Fss.............................. .� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -...................oF....... r 41f....-----------------........-•----.._._......•. Appliration for Disposal Works Tonitrurtion rranijt Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at .............. -- -- --------------------- ........ ....!..-�� ...--------------------._........-•------............._ - Coca ddre or Lot No. Owner Address ---- .._------ ------ ---- ---- Installer Address Type of Building Size Lot............................Sq.- feet V Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .. ----_. -----------------------••--•• -----•---•-••••---- ............................................................. Design Flow_____________________________ __gallons per person per day. Total daily flow________ gal WSeptic Tank—Liquid capacity___.__._____gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area........______.._..sq. ft. Seepage Pit No------------------- Diameter.................... Depth below inlet____________________ Total leaching area...................sq. ft.,. Z Other Distribution box ( ) Dosing tank ( ) Ri aPercolation Test Results Performed by__________________________________________________________________________ Datg`_---_______-----------------_---_--_---- ,� Test Pit No. L_______________minutes per inch Depth of Test Pit___._________::..... Depth to ground water........................ G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----•-------•--•-----------•--•••••----•----------•---••••--------------------------------•---...•.---•-•• -•--••-•-•---------••••-•••••--••--••---....•-- P4 / x Description of Soil -.----------------------•-•------•--•------------- V ..__.._..••••----•----------•••-•-•-•--.._..--•-----••---•-••----•••--...••.................................................•----------•---•••-----f---•------•---•-••---•-------••--•••-----•--•-------- W -----------------------------------------••---.._._..--•---•--------•------------------•----•-------------_----- -- ,� UNature of Repairs or Alterations—Answer when applicable� ,� �' ______�_� "9 a__l'__._. •-•------------------------•------------------------------•-------------------------•-•- . ••--- --••----- ..................................................... Agreement: 'p The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITILS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss by the boakd of health. Signe __. ---• - 1 ........... ........... t'^ //'''�'� ate Application Approved B '" .. (rf44 Date Application Disapproved for the following reasons_........................................... ...._....-•---•------•------...--•-•-•...................•--•--•-•-------------------........--------•----•-•-- ............-••-•----•---•---•--------------------•----------••--•------•-••-••-_..._ ' Date Permit No......................................................... Issued_....... ------ - Z .................. Date THE COMMONWEALTH OF MASSACHUSETTS .� BOARD F HEALTH 1l ...................OF ...........? ......... Tntifirab of TompliFanrr THIS ERTIF , That.the Individual stem Sewage Disposal S- co nstructed" or Repaired g P �' _( ) P bY----------- .-•••. Installer at....f-}� -•• - ......................... .............................. -•-••----•-•--._.....___---•--• ----•-------------------------- has been installed .accordance with the provisions of T M r of The State Sanitaryki� das described in the _application for Disposal Works Construction Permit No. ..___ ................. - ,da.ted_ __ _______ ______________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WNI L FUNCTION SATISFACTORY �j DATE ;l� 7 , Inspectgr :" �`� es�G ..`. .... 2y 4X�R( +•3.I '-1'�°1"' u-• .,J:� ✓ ��}� 1 it ��'S�'Y 4l' h�iCj. �L 01� Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............0F..f.w •--40�-_:.........., ............................................. No......................... FE>a ...................... Disposal r T tra ion rranit Permission i) hereby anted_;,: e VY . to Constr ct or an Ind jdual S a isposal System Street as shown on the application for Disposal Works Construction P No.___ Dated_._..................................�`77 --•••-•- Board of•health DATE. 7 7 .......................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS L— � E N C� OSHUA �p POND `ob EXIS:TING UTILITY POLE SAM Z POND �- G EXISTING :GAS SERVICE LINE = W —' EXISTING WATER SERVICE LINE X EXISTING SPOT GRADE 41.4 PARCEL 122 4,638f SF E I �P SON S Rp o 40.8 BM: SPIKE _ MAIN EL. 40.72' PROPOSED I °SSO DATUM: GIS± x 1500 GAL. PARCEL 122 40.7 4 638t SF 0P 6 SEPTIC TANK I ��5� _ O f G 110.87 x PARKING 9�F x - P TPI 40.4 AREA w PROPOSED 40.7 �' 7� Q I POLE LOCUS MAP CHAMBER S.A.S. , rnz p�g 16.5'x 12.83' 1 3 . TO'- 44 x wo: a ASSESSORS MAP 118: PARCEL 122 H G 0. SE # 41.3 2 BED0, LOCUS ADDRESS. EXISTING BURIED GAS LINEScio SHALL BE RELOCATED AS REQUIRED 1°'�° 16.5' 24.7 n wo o I v #44 BLOSSOM AVE, OSTERVILLE J �. i-: z 0o I SH ED i: Q � DEED REFERENCE- 9664-137 G N. _ _ X I w 40.5 ER ` 2 `� 40. _ o l _j o ... w E �o PT r > i 2 FIRM PANEL.' 250001 0016 D Uf SHED � Q { o MAP REVISED•. DULY 2, 1992 x: 97.72 40.5 L_ J � ZONING DISTRICT• RC EXISTING CESSPOOLS TO BE PUMPED AND OVERLAY DISTRICT. WP & ROPD AND FILLED �w OF BUILDING : TACKS P# 11922 CHRIs INE FROjVT - 20'B FA IRNE Y & REAR - _ u N . .� _ _ SOIL DATA:: : No. 926 � SIDE IQ' TEST DATE: 09-21-07 w® � SHEET 1 OF 2 _. Ff,/S7�(l . SOIL EVALUATOR:: S. DOYLE �!�r n Tw UPGRADE T /�D �y n�r PLAN �T �r T ^ �T n WITNESSED BY: DONNA MIORANDI SgHITARI�`N a.7L'1- TIC (JP(.;Tl11�D PLA !/ O LA V1/ TEST PIT #1 TEST .PIT #2 _ _.. . .... PERC <2 M/INCH PERC <2 M/INCH_ _. . . 7-2 -o� P repare.d For• a BLOSSOM 7� AVENUE 7�7 7 EL. 40.7' : .0,,. EL. 40.T 0„ ►►► -4 #44 L7LO�J ®1�1 f�L �L�1 CJ A SL 10YR 3/2 :. A' SL 10YR 3/2 •o= `sr�'�F� �0 . In - _ 8 8, 8 S'p P"F �' � Os ter Ville .111a ssa ch use t t, B" LS 10YR 5/6 LS 10YR 5/6 OYL .... EL..37.95 33" EL. 37.95 33" .--.. � � a,�� m Scale: 1" 20' Date: July 22; 2008 MED _ MED. �►� '�D S�:F� a Prepareday.' TO: pERC (� 40" TO vs :. Stephen Doyle -- ► n J an Associates GRAPHIC SCALE FINE_ _ FINE _. �,� � � .. 42 Lane E. Falmouth, SAND C SAND zo a terTele hone.• :508. 540-2534MA �� . Can02536 10.. 20 40 80 p 2.5Y 6/4 2.5Y 6/4 EL. 2s.T 144" EL. 28.7' 144, NO G/WATER OR NO G/WATER OR ( IN ET FE ) REDOXIMORPHIC FEATURES R.EDOXIMORPHIC FEATURES 1 inch = 20 ft.. _ . . _ N0. DATE DESCRIPTION. : B:Y . . T- - FIN. FLOOR EL. 41.1' A� JL l/ 's 1 'V1L _, _ 0 _ ' JL _L ��JL !l 'A �'V V ,JL-.�, FINISHED GRADE EL. 40.5'f 111111171111 6„ 6„ 1/8" TO 1/2" DOUBLE WASHED STONE ® 3" THICK OR GEOTEXTILE FABRIC z w 20" RISER 20" FINISHED GRADE EL. 40.5'f FINISHED GRADE EL. 40.7'f INv EL Dia. Dia. IIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIII s" IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIllllIIIIIII Q ._ 15 HORIZONTAL RISER . : m 3® _ RISER .... . 80, N0. BREAKOUT E _ 1. 37. Z OOL 10" Mina 14":Min. INV EL a a a o o El. INV EL INV EL Min. 6'` INV EL INV EL 36:97' 4s"-- -4s" 37.52 Sum 8.5' 37. 77 Below Flow Line c ! 12.$3° --�{ 37.42 37.22 Liquid Level 48" 3/4" TO 1=1/2'' 6 Stone DOUBLE WASHED STONE 34 4. 24., DISTRIBUTION BOX 16.5 a •: o ' 48"� 48„s PROPOSED 1500 GALLON TANK 5�" PROPOSED CHAMBER TRENCH _ = _. NUMBER OF TRENCHES - ONE Tees shall be constructed of Schedule 40 PVC and shall extend: a BOTTOM OF DEEP OBSERVATION HO;E EL. 28:7' NUMBER OF UNITS = ONE _. . minimum of 6" above the flow line of the septic tank and be on SE EA CH END N0 GROUND WAIER..OR . the: centerline of the septic tank located directly under: the REDOXIMORPHIC FEATURES :OBSERVED clean-out manhole. PRECAST REINFORCED :CONCRETE DISTRIBUTION BOX PROPOSED LEACH::TRENCH - VIEW Install on a le vel :base..The inlet pipe elevation shall:be no less than 2 nor more than 3" _ INSTALL:ONE 500 GALLON :UNIT. Minimum. wall thickness - 2:':. WITH F N above the: invert elevation of:the outlet pipe..:: WI FOUR Minimum: inside dimension = 12" Septic tank shall be installed level and true to grade on a level, RATEENDSF ANDUA AT SIDES WASHED Outlet inverts shall:be equal to each other and at STONE stable base that hasbeen mechanically compacted and :on which 2 minimum below: nlet invert. 6 of crushed stone has been placed to ensure stability and The distribution lines .from the distribution box shall all have to prevent settling. equal inverts as determined by flooding the distribution box to Septic tank shall.have a minimum cover of 9" the height of the distribution line invert after all lines ha ve Design Data.` Two 20" manholes with readily removable impermeable covers of:durable material shall be provided with access ports. : been sealed in place. The outlet tee shall be equipped with gas baffle. Invert adjustments shall be made by filling with durable and Two Bedrooms =: 2 X 110 gpd 220 gpd Required Flow nondeformable.material permanently fastened.. to the line or No Garbage Disposal Allowed reconstructing the lines until all inverts are of equal elevation. Use. Chamber .Design 16.5'L x 12.83'W x-2' Eff/Depth GENERAL CONSTRUCTION NOTES - [16.5 + 16.5: + 12.83 + 12.83] x 2.0 =-117 sf 1. All the worlfmanship and materials shall conform to D.E:P Title 5 16.5 x 12.83 = 211 .sf and the Town of Barnstable rules and regulations for :the subsurface: 328 x 0. 74 =. 242 GPD To tat Design Flow. . . . disposal of sewage.. - 2. Access ports over tank tees shall be accessible within 6" of finish grade. ��0�g��s� SHEET 2 OF 2 3. All components of the sanitary system shall be capable of ®' q�ti CHRISTINE. G withstandin H-10 loadin unless the are under or within 10 ft g g Y o fAIRNENY �, SEPTIC UPGRADE' PLAN OF LAND of drives or parking. H-20 loading shall be used under or within U No sa6 10 ft of drives or parking unless noted.:: :Plastic equals may be Prepared For. used in lieu of all.precast units. GISTEti SANI:LARia��. #� BLOSSOM 1`� : d�E1�l (J 1� 4. The excavator/contractor shall call dig safe and verify the louation Of all site utilities prior :to any exca va tion, and shall be responsible :for all matters relating toelectric easements. _.. .. In 5.- Sewer pipes shall be 4 Schedule 40 PVC laid a t a min. -0,02 slope. 7 -Z p p p Oster°rrlll e, Ala ssa ch zzse t is 6. An masonryunits used to brie covers to grade shall be -- ® mortared in plae. g g _ ®a` �or 'us °� Scale: As Shown Date. July 22 2008 7. Finish gsade shall have a minimum slope of 0.02 ft per foot. ^� PSG , s Prepared By.- Ln STEFHEN 8. Existing system components -if any- shall be abandoned ; Stephen J. Doyle and Associates DO P Y per Title 5 requirements. ; � 42 Canterbury Lane, E. Falmouth, hfA 02536 :9. The exca va tor/con tractor shall be responsible to contact o , ;;•?_e e Telephone: 508/540-2534 Doyle Associates 24 hours prior to any required inspections. °►�� uF� �� g� v _1 � M a �1L ® � 10. All components shall be marked with magnetic tape or p comparable . ..means in order to locate them once buried 11, 36 max cover over system components.... NO. : DATE DESCRIPTION. : \R\ OSTERVILLE MICAH a _ I o2 POND „PARCEL ID: I Q JOSHLIA 118/72 I I POND Li L' LOCUS 98' DEED) 44 BLOSSOM AVE.' I> I z �� _ .1 I o' i j w PARCEL ID: I GAS 118/1,22 ILL Q �NtiO / / / AREA 0.1 ACRE SEPTIC SYSTEM w uPov PER TIE CARD I �_ LOCUS MAP__ Z I '-� I / / / p PLAN REF: SEE NOTE; ABUTTING PLANS: 1° J _ _ --� ►1 44: I I -� 97/17, 313/99, 331/41 & 626/34 I, 1 I / m. TITLE REF: 29542/_246 I. : . I_. W PARCEL ID: MAP 118 LOT 122 b Q J' ' ' I EXISTING I I p ZONING: "RC" SETBACKS: 20'F-10'S-10'R \ .'.'. i . _. . . . . . I (.1 I / DWELLING / I I F-- WIND EXPOSURE: "B" : J \ L ::'.'.'.'.'. . . L J FLOOD ZONE: "X" \ m , (ON SLAB) / I }- COMMUNITY PANEL: 25001CO544J DATED:07/16/14 / /20.0 <C �. \ . _ • I •o a - - � I .' N ' W PROPOSED oo / ,; ,;� ,- , / i I CERTIFIED PLOT .PLAN ADDITION p �^ oNC. PILES) , I FOR ADDITION a \ (ON C21.6 0 . s : ( p LOCATED AT: W a 18.0 0 9.4' w _ S� i I� J GRAVEL,DRIVE QI 20 10.3' w 44 BLOSSOM .AVENUE 10 11.3; I - - -- -=- o1 r. OSTERVILLE, -MA. - - - a,s a - - - W (DEED) I � ' ( k` I PARCEL ID: 94 0 oI r w CO PREPARED FOR MARC A. & PATRICIA A PARCEL ID: L E P A I N 118/73 t� of .k4S SCALE: 1"=10' 1p4o PARCEL ID: EDWARD y°s 118/74 NOVEMBER 22, 2016' a A• STONE N NO.289 MacDougall Surveying W 8c Associates - .' ' GRAPHIC SCALE Q P. O. Box 2428 10 0 5 10 20 40 o Mashpee, Ma. 02649 Y PH. �508�419-1086 22.5 NOTE: THE LOT LINES SHOWN WERE DERIVED BY DEED O fax 508419-1087 DIMENSIONS, ABUTTING PLANS AND EXISTING ( IN FEET ) m email: ' MARKERS. AN INSTRUMENT SURVEY SUITABLE FOR macdougallsurvey®comcast.net CREATING A RECORDABLE PLAN IS RECOMMENDED. 1 inch = 10 ft. SHEET 1 OF 1 J 1884 T,r rr'' 12 III 111222 12 1122 12 ]� _S 7 �7 ]— . - .. , f �Fm I I' I LS EEEEEEEEEE=-� NEWMASTERBEDROOM ADDITION , f PROPOSED REAR ELEVATION EXISTING REAR ELEVATION PROPOSED FRONT(DRIVEWAY)ELEVATION EXISTING FRONT(DRIVEWAY)ELEVATION y ASPHALT ROOF SHINGLES TOMATCH ISTING - - - GENERAL NOTES:�- =-- -�- "- - - < 1.USE"TYV KOR EQUIVALENT ON ROOF AND SIDEWALLS �. -- ---- - - --- - - -- - - - 2.ALL DIMENSIONS TO BE VERIFIED PRIOR TO CONSTRUCTION- __- MOST NOTABLY THE LOCATION OF SUBSURFACE SEWER PIPE TO EXISTING TANK GUTTERS AND DOWNSPOUTS TO BE PROVIDED WHERE REQUIRED. 4 PRO IDE LASHING ABOVE ALL WINDOWS AND DOORS. -- - -- - - - --J -r -T:-`' 6 VENT ATTIC SPACE TO MEET STATE DE REQUIREMENTS. 7 ALL CONCRETE TO BE A MINIMUM OF 2500 PSI STRENGTH AT 30 DAYS 8.OWNER AND CONTRACTOR SHALL ASSUME ALL RESPONSIBILITY FOR CONSTRUCTION AND r I CONFORMANCE WITH ALL STATE AND LOCAL RULES AND REGULATIONS. ! n i_ .. w- �"". '_ to CORNER .. •. .4_.-... —rt i�- ..Li -BOARD AND ' • .' r 1' "• J T mn cnRG INSULATION NOTE: EwST.NG • FLOORS ABOVE UNHEATED AND BELOW HEATED SPACE-9"R-30 FIBERGLASS - INSULATION OR BETTER. _ - _- - • FLAT CEILINGS ABOVE HEATED AND BELOW UNHEATED SPACE-12"R-38 FIBERGLASS INSULATION OR BETTER. WHITE OEDAR SHINGLES iO MATCH-STING • EXTERIOR WALLS ABUTTING HEATED SPACE-5.5"R-21 FIBERGLASS INSULATION OR BETTER. NEW HALL ADDITION NEWMASTER BEDROOM SUITE II I ' PROPOSED RIGHT ELEVATION c w BED T .J. I, i EXISTING HOUSE MASTER BEDROOM SUITEB HALLWAY ADDITION I PROPOSED LEFT ELEVATION EXISTING LEFT ELEVATION A ,„ ELEVATIONS GREYWING DESIGN DATE: NOVl'-O'6 PROJECT:LEPAINSOMARESIDENCE 44 BLOSSOM AYE..OSTERVILLE,MA _ SCALE: 1/4-=1'-0' PREPARED FOR SCOTT PEACOCK 131 QUAKER MEETINGHOUSE ROAD,EAST SANDWICH,MA 02537 ® 2016GMywingOeSig,50888"a86 www.greywing.com (508)888-0886 """"`•"""" PROJECTNO:G161020 SHEET: A1OF2 25-Y - __________________I__--_ '________--.a=_______ NAILING SCHEDULE "a.aom„W, rro,SP, "aa aPaerre -----` --- --- �alra paua __..--_____ j_--_�____--__-_- -.._- ROOF FRAME: I- ------_-- BLOCKING TO RAFTER(T—AILED) 2.6tl 2-I 21. cacB Intl -1 BOARD TO RAFTER(END-NMLED) 318tlDtl exn en0 WALL FRAME: EXISTING KITCHEN EXISTING -I---- TOP PLATES AT INTERSECTIONS(FACE.NMLED) d-IfiE 318tl el dnu I BATH __..______________ 1 -_____________ -------- HEADER ST HEADECEFACE-O) 2.16E 2-IBtl 24•D,c. ' HEADER TO HEApEP(FACE-NMLED) 10a 18a IB'o.c.alo�p eE9oa ___ FLOOR FRAME' _ JOIST TO HILL,TOP PLATE OR GIRDER(TOE-NAILED) d-Btl A1W porjeiel ---- --_-_-�---------'-_-- ------ BLOCKIN 1,01SILLORTOPALEDI PLATE ROE-NMLED) ]-16E BLOC KING TO JOISTRTOP AILED) 2JW 2-IDQ eacn entl _ _-------------- --------- --_--- LEDGER EDGER BEAM OR GIRDER TO BEAM(IFAGE-NAILED) }18tl 4-IfiE aacn lout jOIST ON O RIM JOIST TO JOIST END-NMLED) I IxtrjXm, S 318tl 4.1fp `p _-..____________ _________�- RIM JOIST TO HILL OR TOP PLATE ITOENAILEDI 2-i6E }1BE Per loot W ----------------------- ROOF SHEATHING: EXISTING ------- - RABLE ENDWALO.C.OR LESSNOO SK f00 6-etl9a 8- Id }T. -- -------------------_--_----______ GABLE ENDWAlL RJ1KE(NO OVERHANG or w/STRUCT.WTLOONERS) 1Qa 6'etl8o 1 B'Feltl ENTRY ------ - CEILING SHEATHING: EXISTING LIVING ROOM __.._-- -_-____I_______________..__ GYPSUM WALLBOARD SE coolers - T etl9a 10'6eltl __--- WALL SHEATHING: --- ---------------I-------- -- --- P—OOD OR OSBW/STUDS Q24.O.O OR LENS Btl tOE 6•III lY 9e1tl tlY—LAIUM WALLBOARD 5tl cooks - ]•etl9e 1a new 1 FLOOR SHEATHING: -OR LESS ----- - PLYWOOD OR OSB GREATER THAN 180 6'ee9e t-6nW 1 B'otl0o 8'BCIE STEPS EXISTING DOWN I FOUNDATION—� _ n N WALL __. _______________I_____-_-_______..__------ 2x6 O.G RH n x / —® HEAOEF2 SCH EOULE rDaIPUNT v ABOVE __ a LENG H ABOVE U MNMUM 'up u PORTn IA -EOFHEaDER Max. 2ENG"H N - e _____________i- _______ _.. s 3 2-2X6H 6 1H MA%,x-0 30 II A i a ---- - i Ho -- 2xs RAFTE0.5 LOCATION OF SONOTUBES TO / \�. / I ®16-O.C. - - y BE ADJUSTED TO ACCOMODATE EXISTING' SUBSURFACE SEPTIC SECTION B ""BEDROOM2 �' OUTFLOW PIPE LOCATION- CENTER MAX.SEPARATION 6'-fi' 4 RIDGE BOARD- - - - - \✓ ) IIr ----- i------ D f III 2ARAFFERH @tfi•G.c ' III. i— _{-. 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OVER OD IX K•OVER 1(1'EXTERIOR 'P PLYWOOD w OSB OVER 2"x6'x 7'-4-STUDS - PL ATEOSTUD WALLt BOTTOM - 9"F.G.RJp PE 2+Bs®16.O.a. J DECK 9•F.G.R30 INsuL, BLOCK ABOVE BEAMS Bls'o.c.� ATTACHMENT DETAIL �. EXISTING�., IrvHUL. EXISTING GRADE I 2.8 P T,JOISTS®16'°C. (� GRADE- - NOT TO SCALE A r ._._.'.....!'i.::.........�....:.,. ._T.._..........._.._..1I .I I. - ]-P.T. W000 BEPM e P0.0VIDE 1YOCONC,FILLED ' TERMITE BONOTUBE TO MIN— SHIELD = 4 '-0"BELOW GRADE WITH BEAM ANCHOR PLAN SECTION AND SCHEDULES GREYWING DESIGN GATE: NOV 3020tfi PROJECT:LEPAINSOMAN., 44 BLOSSOM AVE.,OSTERVILLE,MA 7'-O"SECTION B SCALE: 1/A"a T-0' 1 V-6"SECTION A PREPARED FOR SCOTT PEACOCK 131 QUAKER MEETINGHOUSE ROAD,EAST SANDWICH,MA 02537 0 2016Gre ing Design 508685.0886 www.greywing.com (SOB)SSS-OBSB >'..a..W"" ""�"'w""'"•'""""'�' PROJECT NO:G161 G20 SHEET: A�OF2