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HomeMy WebLinkAbout0080 BLUE HERON DRIVE - Health 80 Blue Hcron Drive, Osterville A = 117 - 010 F 1 j No. 4210 1/3 BCR IAVU Udalqo( a ESSELTE 10%0 0 0 0 0 Mr a- M nod 5v4` ``� coj 4A- 2i cw a4,al 09 5e t s: i 7T' ..... ' * L1Q 5j,Qj!L ID 6 VA IT (!PO ra. - 114 till Awn �: r V f 1 rf E a p. a n..... x _. - ..-.. . s. .. �:. a .., .e -. � �. ... _♦_ ..-. '. - - �.. --., .....,_ham''. TOWN OF BARNSTABLE LC CATION SEWAGE# VIU;AGE05/,r tip ASSESSOR'S MAP&PARCEI/J -0/ INSTALLER'S NAME&PHONE NO. cr (5 C LR) 93- 3 -?nV60 SEPTIC TANK CAPACITY (6CD6 frcp l LEACHING FACILITY.(type) s�j —5-6p 6-4 ize) ,33 rS NO.OF BEDROOMS OWNER vS PERMIT DATE: COMPLIANCE DATE: Separation Distance Between e: 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 Z, No. aw6 — / Fee y � ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -- Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS � 01ppYication for 10 r 6pstem Construction Permit ro Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ndividual Components Locati AjWress or�Lot,No „tee �/) sI Own 's N n�e Add e sd TeTj1,,_ 4 Assessor's ap/Parcel j �� � �� / •""" Installer's Name Add ess,a T -r- Desi is Name Address d T c w —� - , b: Z 1.77 T�pe of Building: Dwelling No.of Bedrooms Lot Size D../ G sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requir ) gpd Design flow provided gpd Plan Date Number of sheets Revision D to Title k-/ � i /5 Size of Septic Tank COO eXb-�(W? Type of S.A.S. eUj C Description of Soil / Nature of R airs 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 Env'ro ental Code and not to place the system in operation until a Certificate o Compliance has been issued by this Boar o alth. Sig ed Date �167D Application Approved by Date oFY: Application Disapproved by Date for the following reasons Permit No. :�C) Date Issued d l No. Fee PI! l C ~ THE COMMON.WEALTROF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN-OF-BARNSTABLE, MASSACHUSETTS . 01pplitation for *pstrm Construction 30Prmit , Application for a Permit to Construct( ) Repair-"( Upgrade( ) Abandon(: ) ❑Complete System ndwidual Components LocatigjkA dress or Lot No s/ I y Own e Ad e s,andT� 97` ✓Y�/ 1 ��QCJ`! f+� l Assessors a /ParcelQ ' Install 'sNamP addeess-andTel_Na__ Designer's Name,Address dTe j4 -•a �o Type of Building: 4 U 1° l r G I e-r r n)r c �, e/ over Dwelling No.of Bedrooms �' Lot Size 1 / sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r r Design Flow(min.requir d) , gpd Design flow provided 5� gpd Plan Date 8 w Number of sheets Revision Date Title Size of Septic Tank COO Type of S.A.S. Description of Soil _ Nature of R airs or Alterations(Answer when a pIicable) Date last inspected: r. "F i,� Agreement: ' 1,41�l /7 The undersigned agrees to ensuree con9tructton and m�intgnance of the afore described on-site sewage disposal system in fig' accordance with the provisions of Title 5•of the Enviro ent d Code and not to place the system in ope rat ion until a Certificate of j�,i"� Compliance has been issued by this B4aro alth.Si ed M, ( '. Date t t ,: s t a 7 � Application Approved by :-:,'� J r Date Application Disapproved by "' as 177 t ...r�/DDate IL PL� for the following reasons i l3SSIIY..Fff ` d / f 7 s Permit No. d gg f i `(�Date ssued t k ----------------------------------------------- -":)t ' t ---—-- - f-- ------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded U/) Abandoned( )by_W4U1VL1 at E )1 �Z1V has been constructed in^accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 01 d C7 1/dated W Installer Designer � '�(� 1 #bedrooms Approved desi ow gpd The issuance of thi pe it shall not be construed as a guarantee that, system will ctio design Date 1 q t` .. � Inspector _tea_:.�� ...:- .,-...._ _,..,._ __,_. _z„, ----- ----- --------------- --------------- ----' -=' ------------- Fee /(Ja THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTHP.IVISION- BARNSTABLE, MASSACHUSETTS Disposal *pstrm ConstrUttioernlit Permission is hereby granted to Construct( ) Repair( ) Up-grr-adder�, ) Abandon( ) System located at OD 1;wC, �� t/�LI r and as described in the above Application for Disposal System Construction Permit. The applicant.reco gnized hisser duty to comply with Title 5 and the following local provisions or special conditions. ' i _ Provided:Constructio must b completed within three years of the date of this pe t. Date ? / 1' Approved by �"_A - = � Town of Barnstable ME Regulatory Services Richard V. Scali, Interim Director • BARNSfABLE. 163 � Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification.Form (D Date: Q 2i ®1 Sewage Permit# Assessor's Map\Parcel Z�/C Designer: Installer: ( ! . C Address: I ��� Address: ,d�rl�V W On , was issued a p ermif to install a (date) (installer) septic system at C? based on a design drawn by —,� (address) cJ �� dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (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 I ' 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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in.cIF, nliance with the terms of the IAA approv tters (if applicable) 4gs ..�% ti r �. pAVID y c. ( s ler's Signature) MASON LT41 ! v _ No.1066 a �S'INITAII\V' (Designer ignature) (Affix Desi 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. QAsepticTesigner Certification Form Rev 8-14-13.doc �.= Town of Barnstable P# '/ � Department of Regulatory Services.�nxatnarn Public Health Division Date JG 1679. �� 200 Main Street,Hyannis MA 02601 fib MP'�A 7C Date Scheduled Time rr Fee Pd. (/��� V10 �.a .a Soil Suitability Assessmentfor Sew le Dis osalA,, Performed By: /AY(� �'Cb�J Witnessed By: LOCATION GENERAL INFORMATION Location Address rely )/�!] j)� �Jy(`�A` Owner's Name It�M� •-^4� L���///��` Address Assessor's Map/Parcel: I l-j I'(� U t �'� Engineer's Nam V'l NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I m _� Ir'++e$ar Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater i DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: 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 Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# Time at 9" Depth of Perc J� Time at 6" Start Pre-soak Time @ / Time(9"-6") End Pre-soak / Rate MmAnch � Ce.. L rt 11AJ, Site Suitability Assessment: Site Passed_�� Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTIC\PERCFORM.DOC US f ( DEEP OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. e� Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) ottling (Structure,Stones,Boulders. Consistent %Gravel 14 /® C. yc p *qd " DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Mao: Above 500 year flood boundary No_ Yes Within 500 year boundary No Within 100 year flood boundary No_/ Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio terial exist in all areas observed throughout the area proposed for the soil ab rption system? If not,what is the depth f n [orally occurring pe ious material? Certification Q I certify that on l� ` (date)I have passed the sod evaluator examination approved by the Department of Enviro ef rotection that the above analysis was perform by me consistent with the re u' ining,expean perie a escribed in 310 CMR 15.017 m� Signa � Date 0 r Q:\SEPTIC\PERCFORM.DOC j GUILE WOOD July 3, 2008 Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Re: 80 Blue Heron Drive, Osterville, MA Dear Board Members: Approximately 25 years ago.I visited the Jones family at their 80 Blue Heron Drive home in Ostervillp, MA. I hereby attest to the fact that the house was at that time used as a four (4)bedroom domicile. Thank you. Sincerely yo , ow Guile Wood �0 ONWULTH OF MASSACHUSETT3� On thifs.,;3.,.dar or U - �1..� rtte, Ihe.Hmtl rrrgr!ud notsry p il , personalty eppeSW - f .� ,.--.... 0my"to me through stig 'r,0ry evideece of idQffiifi�tidn.w7tich were JJf'rf( .2 r �L:+9(.�C,_ (LD)to be fhe Person(s)whose;s:r*(s)Ware tigned on the preceding] Or attached document.and adknowaedged to me that hatshelthey signed fl trbluntaray for iti a blod-purpose:and Ao swore or affirmed to me Md = . tlncontenta of the documerhareuuRful aM accurate totfte beat of AYlff6(/fAekkr0 p 2mObelief �ac& iFxp,ratiat Date• l�fC. , Z� 01•��. .' GUILE WOOD 1 r,�•. July 18, 2008 Town of Barnstable ' r Board of Health 200 Main Street = Hyannis, MA 02601 . 1 1 �� rJ Re: 80 Blue Heron Drive, Osterville,MA l J � r AFFIDAVIT I, Guile Wood, visited and cared for the Jones family at their residence at 80 Blue Heron Drive in Osterville, MA twenty five years ago. Because I was frequently present in the home, I had opportunities to observe that four bedrooms existed. The fourth bedroom is what is now the first floor den area. r Date: Guile Wood COtiw"ACNIr ,ALTN OK tAASSACHUSr_•TTS �� On tAi.��.-•�a •' erso.'r..Iy appeared "j . �© ,.,tivtat to me thror3h satisfactory ' •• 1.V�'i �'?i9 l'+�•—+- .:e'i if • �)c:C!:in9 evidence of uSenta. ' r (i.D.)to be the 7ersort:i wttr, .. •it"• or atld+criC�'d�ttent,at,d al.t�u�•�`y` to mo that t:eis;ceiiney siynad it votuntarihto its�r'.e�•p:'ooso."`'d'7ao sr•'e or;ttirmed to me that +y' tho conlg t+'s t rc_'29ct+jw�'t are;�c+Mw• sccuratc.o the SI Of ii.belita m my reset.0• l �v r r hWhBffthetf'lino�c4 NOW, ��� r_ r� rpua - iR { ..., ». ,. v {!F . � t ,, � �. . „� ..� - . � �. - r e V �� � '�� �b w ��"� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. 80 Blue Heron Drive Os_terville, AM 02655 Owner's Name: James Jones Jr. Trust Owner's Address: ` y R Date of Inspection: March 29, 2006 r) Name of Inspector: (Please Print) James M. Ford p Company Name: James M. Ford ? Mailing Address: P.O.Box 49 N 7> Osterville,MA 02655-0049 a c3 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT ` r- c� rn I certify that I have personally inspected the sewage'disposal system at this address and that the info ation 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. Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: April 3 2066. The system inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions'at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the.future under the same or different conditions of use. Title 5 Inspection.Form 6/15/1000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Blue Heron Drive Osterville. MA Owner: James Jones Jr. Trust Date of Inspection: March 29, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A.metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box'is leveled or replaced ND explain: The system required pumping more:than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: . 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Blue Heron Drive _ Osterville. AM Owner: Janes Jones Jr. Trust Date of Inspection: March 29. 2006 . C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system. is failing to protect public health,safety or the environment. 1. System will.pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a.surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2 System will fail.unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply: The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile.organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other. failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: 80 Blue Heron Drive Osterville.MA: Owner: James Jones Jr. Trust Date of Inspection: March 29: 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion.of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia ' nitrogen and nitrate nitrogen is equal to.or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant.threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 80 Blue Heron Drive Osterv_ille, MA Owner: James Jones Jr. Trust Date of Inspection: March 29. 2006 Check if the following have been done: You must indicate"yes"or"no as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board,of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No Existing information. For,example,a plan at the Board of Health. ✓ _ Determined in the.field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]: 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 80 Blue Heron Drive Osterville, MA Owner: James Jones Jr. Trust Date of Inspection: March 29, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms,(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): N/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title.5 system(yes or no): Water meter readings,if available: Last date of occupancy/use:. OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ; Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 1011197-tier ds built card Were sewage odors.detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Blue Heron Drive Osterville. MA Owner: James Jones Jr. Trust Date of Inspection: March 29, 2006 BUILDING SEWER(locate on site plan): Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line_ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 24" Material of construction: ✓ concrete metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle.condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liauid level was even with the outlet invert There did not appear to be any signs o leakage The outlet cover was 12 'below zrade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete ._metal _fiberglass ;_polyethylene _other (explain): Dimensions: Scum thickness:. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Blue Heron Drive Osterville, MA Owner: James Jones Jr: Trust Date of Inspection: March 29, 2006 TIGHT or,HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: -gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-Box was level. There were no signs ofsolids PUMP CHAMBER: None (locate on site plan) Pumps in working order{yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber;condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Blue Heron Drive Osterville, MA Owner: James Jones Jr. Trust Date of Inspection: March 29, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 5 Cultec 330's- 12'x 17'(per as built card) leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The Cultecs were dry. There did not appear to be any signs of failure Used camera to inspect Cultecs CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 f Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Blue Heron Drive Osterville, MA Owner: Janes Jones Jr. Trust Date of Inspection: March 29, 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100 feet. Locate where public water supply enters the building. y� �r ronT d A � o �a :o 3 � y 113 3`f 110 3 3 ace y/ y 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Blue Heron Drive. Osterville. MA Owner: James Jones Jr. Trust Date of Inspection: March 29, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12 +/- feet Please indicate(check)all methods used to.determine the high groundwater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topoF-rgphic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed:USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the neaps were showing approximately 12'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future.. There have been no warranties or guarantees, either expressed, written or implied,relating to the system;the inspection and/or this.report. 11 TOWN OF BARNSTABLE Li�CATION 1-V� ern SEWAGE #9 _� + VILLAGE C�S(�e-t'V`t(t a ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. B 1 1 Qi.CC LSD 2 SEPTIC TANK CAPACITY LEACHING FACILrN: (type) Cy ��e C��3OS (size)q= NO.OF BEDROOMS_ _`` t: BUILDER OR OWNER_ �AMeS` <}ONCJ -PERMITDATE:Z— "1:z COMPLIANCE DATE: C T. Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility; Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Fir aQ ab 6 oU-cl 38 46 g� s s,; TOWN OF BARNSTABLE LOCATION S6 �IUL Hn eir `Dr. SEWAGE# 91 3.0 VILLAGE 09-1Mt16- ASSESSOR'S MAP&PARCEL Q/0 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY S 0 d LEACHING FACILITY:(type) C V'�t,C 33 0 lS (size) y= /a NO.OF BEDROOMS 3 OWNER A/Vl�„$ .)n(]d.S J r PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Z-A SPE 6 4wi 0 L GA�l�S A Srrdli a r O O y t13 3Y aoLi 3F 3 ace y/ �/ 3/ No. 7- 3 a , Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYiratiou for �Digaar *p!tem Cow6truction Vermtt Application for a Permit to Construct( )Repair K )Upgrade( )Abandon( ) ❑Complete System EJ Individual Components Location Address or Lot No. 810 V/v-F weror voe Owner's Name,Address and Tel.No. Assessor's Map/Parcel OS pp Installl+er's Name,Address,and Tel.No. L(C�_8_-9640 Designer's Name,Address and Tel.No. CQ2(jvn �fiMP vs c [S © AC't�. Type of Building: fA as 0 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alt rations(Answer when applicable) C D i91. P f�e � I-1S/r ho X `- MCOZZEC 33O 1 — lnl 1 r i SIC— 318f STD 7e Cac,C"-r" f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed �t��_`�_= 'k�sr"�Gv�� /� Date c, Application Approved by Date '�—11-�t 7 Application Disapproved for the Hlowijng reasons Permit No. 7s Date Issued x� �=`.:-• 1 �, 9� _wee ,�. � w .';'m'. -7 ,� 10 1 _�-- No. - S •.,...J .n Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN-OF BARNSTABLE., MASSACHUSETTS i for.;DigpofSal *p5tem Con.5truction Permit Applic 'on for-a Pemvt to Construct( )Repair K Upgrade( �)Abandon( ) O Complete System. ❑Individual Components Locatio Address o T r Lot No. yp�on �ie. . Owner's Name,Address and Tel_No. Assessor's MapMarcel �S , f r 80 L'lUC Herv,. tore.— Q S Installer's Name,Address,and Tel.No. t-(a a^5(�4, Designer's Name,Address and Tel.No. C702o�� 3�m �s Type of Building: _ Dwelling No.of Bedrooms L_o ,S-ze� 1 i i �? sq. ft. Garbage Grinder( ) Other Type of Building s No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow galons per day. Calculated daily flow gallons. Plan Date Nu b�l of sheets Revision Date I _•` •. Title s Size of Septic Tank - Type of S.A.S. . Description of Soil n Nature of Repairs or Alt rations(Answer en appl,'cable) 4/ e '' /1,1500 6191 P Z,- 75d Dis/^ fox — li cC Ors /� �` s !IC- 3/g 's7z17c CQ(,r • i,„. O Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issIlSo by this Board of Health. . Signed i � /df�� � Date XIX"14 19 S i Application Approved by Date - /i- C/ Application Disapproved for the o lowing reasons •- S l# x �' Permit No. rI 7 53 Date Issued' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( V'�Upgraded( ) Abandoned( by at 80 �/Zc 010,7 oelvc Q.ST has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 Z.35 7�> dated Installer GdkD6n �GA1DV3 Designer The issuance of this permit shall not be construed as a guarantee that the system will.function as designed. Date )f) l 1ri -T Inspector C� { N. / 7 ———-----�—_ --------- �-A ----------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ligogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Aba�ndon( ) System located at 80 :Vvc. 111-1-On le, QSTwi and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: `7 - // -% Approved by 1 .S r — - 4 ' • , t CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, -;0 2n 0 hereby certify that the application for disposal works construction permit signed by me dated Jv� ,.l n�7 , concerning the property located at 80��u � fz — Os t�r� �� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. I SIGNED : DATE: �� LICENS D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i• 3 i � \ �`1 1 I i �� � \\` \\ I \� I ��. ,� � � ,,, \, �� _ \ 4�� .� �. -----. TOWN OF BARNSTABLE LtxATION l)O U e. R, _ SEWAGE # VILLAGE S t V�t ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ' I " 330 �(si ) ,CIIITY: (type) � 4 LEACHNG FA NO.OF BEDROOMS BUILDER OR OWNER �P► c,c'1" [—Ot — PERMITDATE: 7"' q7 COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility, Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by ' Q � o .9h �al)r) ��� n w � O a� oo) N �- N 00 C,� N N co r---4 O aO PLAYROOM El BEDROOM 4 MECHANICAL BATH W WINE CELLAR o z I z 5W 51nIR5 UP O L1N D I NG RMi V1 W r� O � 00 W EXI5TING BASEMENT FLOOR PLAN SCALE: DRAWN BY: CBH t " DATE: 10/1/15 y V 1 u v Oa� oN � ^/ 00 00 00 cn r-- O EX15T.DINING ROOM EX15T.LIVING ROOM O LANDING ❑ ❑ EX15T.KITCHEN OEXIST.MASTER BATH EX15T.TWO CAR GARAGE ® EXIST.MASTER B/R O C/1 � EXI5T.WIC O w EX15T.DEN OPEN ABOVEO// ,,,�/ 5TAIR5 UP V • � ® LANDING FOYER f--r CD 00 w EXI5TING FIR5T FLOOR PLAN SCALE: 1/8" = 1'-01 1 DRAWN BY: CBH DATE: 1011115 O a o � � oc) 0� ►"`y N N N p °° in 0 L/) r- O c' x O EX15T.ROOF DECK LANDING 5TAIR5 DN. Z EX15T.BEDROOM 2 O EX15T.LOFT EX15T.BEDROOM 3 5TAIR5 DN. ® CHIMNEY RAILING IW Q O EX15T.BATH O w OPEN TO BELOW WW Q W � p F-� W LANDING 00 O a PROPOSED SECOND FLOOR ADDITION K3 SCALE: 1/8" = 1'-011 DRAWN BY: CBH DATE: 1011115 f �a Blue Hero ."� ri e Osterville, Ma. . Zr oovv,• a a � E" v E-------------- Z 6) T CA(L / � L 101k) 'Roo" Iz' ` e �pvuvRY 13AT H IV �y GL 2 Y i' 14 W ,...- � 1'Yn ��$ ,Rj.,Os ((( 1j� 5, pec f IeoR. ic - sG� CLOSET Ci . WET Bart f 31 PRO P05 END ' G�• EN TRY 8� _ _First Floor Scale:V,'=l foot ` ` S Ju 0 41f S 80 Blue Heron Drive OSterville Ma. 9 ; 1q, ---�; NE Slit Dr I I 4 3 TOR PK G'9 aDO`M. " I Loft 0 s _ HE R, s � ' Chtiuevk �`- V C�• ti`• ` r 9� �PJ ATH L 4�I1 --- ; '.New"R' ! • � ��.-•.-.�„�,�;;,,_ � lnoRn FfC •� Second Floor Scale:'/,'=I foot i , w � N oo �-q O 00 N 00 N N 00 In O x O PLAYROOM BEDROOM 4 a O BATh W O WINE CELLAR o z w 5TAIR5 UP O LANDING C/ z O w 00 EXI5TING BASEMENT FLOOR PLAN SCALE: 1/8vi _ p_Ovi DRAWN BY: CBH DATE: 10/1/ C W >� j N 00 O (U 00 N N (�� •C� N 00 00 vs m 4.-a EX15T.DINING ROOM EX15T. LIVING ROOM O O LANDING EX15T. KITCHEN EX15T. MASTER BATH EX15T.TWO CAR GARAGE w z PLO a ® o EXIST. MASTER B/R p EX15T.WIC O EX15T.DEN OPEN ABOVE C) 5TAIR5 UP W v ® LANDING FOYER �--� 00 W EXI5TING FIR5T FLOOR PLAN SCALE: DRAWN BY OOCBH DATE: 1011115 W >� j N 00 cq - O oo00 fsl N N 17-I Oz1" PROPOSED ADDITION rTl ,r„� 'I � ^� C� 00 00 .- PC O�TEDs vs cn r-- 1 v' EX15T. ROOF DECK PROPOSED GYM v O LANDING PPOPOS BATE—fl <<C 5TAIR5 DN. EX15T.BEDROOM 2 EX15T. LOFT EX15T.BEDROOM 3 Q H STAIRS DN. ® RAILING CHIMNEY EX15T.BATH W O OPEN O fs, TO BELOW z Q � O W U x W LANDING Q a W o a °° O a PROPOSED SECOND FLOOR ADDITION SCALE: /OO,, DRAWN BY: CBH DATE: 1011115 QO' ASSESSORS MAP : S -// TEST HOLE LOGS 4- PARCEL: /� I) The installation shall carttt;)l� with Title V and Town of ""bard or z FLOOD ZONE: SOIL EVALUATOR., I l lealth Regulations. Qv�cl�2p � - - - -REFERENCE: WITNESS : 2) The installer shall verify the location of utilities, sewer inverts and septic - - �-� Gam^ /5-7/ DATE:- `Z components prior to installation and setting base elevations. PERCOLATION R TE: 2,W( I 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first bTQ — - -- - C5 ._._- .. _. �Ua � 6 Y p p P g P'' l(_.__ .._ ___.__._ y 16 y. Iq two feet out of the d-box to the icaehin shall be level. g TH- 1 TH-2 4) This plan is not to be utilized for property line determination nor any other i purpose other than the proposed system installation. A 0 5) All septic components must meet Title V specifications. V 6) Parking shall not be constructed over H 10 septic components. (� ; n 7) The property is bounded by property corners and property lines. j , C�Ej77 ailGr`f/ � � /� 8) The property owner shall review design considerations to approve of total LOCATION MAP �--- W � design flow and number of bedrooms to be considered for design. Receipt -7-7 — ---; - of payment for the plan and installation based on the plan shall be deemed JZ uU approval of the design flow by the owner. v - C 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall [ �71 be removed along with contaminated soil and replaced with clean sand.per Title V specs. 10�S stem components to be 10 feet from water line. Sewer !fines crossing Y P g the water line shall be sleeved with 4 inch SCE 140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. \X, title} SEPT I C SYSTEM DESIGN 1 l) 1f a garbage grinder exists it is to be removed and is the responsibility of the \ owner to ensure such. } Ede or PoWneet FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such Sti i 1 exists. I fir, , p c ' - AqD GAL/DAY 13)Tne installer shall verity the location, quantity and elevation of the sewer BEDROOMS AT 110 GAL/DAY/BEDROOM lines exitinp, the dwelling"rior to the installation. .,. I 1 w' SEPTIC TANK 14)"Phis plan is representative only that a system can fit on a property meeting \ Title V requirements. � GAL/DAY x 2 DAYS GAL \\ \ \ `• �'�� % 0 0 r USE I GALLON SEPTIC TANK E?� TI�►alGe- \ SOIL ABSORPTION SYSTEM •\ \ .Ali l _ O - 4P1; n�,yr,. , DAVI - �7 �7 2 \ \ �•� . t � '' - _ _---� - _-- - '�------ - SIDE AREA. �� �� � -i- 12�� X n g \ 1 ,�$ '•I - ' l.r--- BOTTOM AREA: , �3�� ,�1 X Qt-7 'e31 0 N 1 6 A ' \ / - SEPT I C SYSTEM SECTION 1----A Sri LATUM k (oil �� , 1 1 t ��•• ,own (14 X38.5'� h.3_q ! !�j.b� T r �, / �u ` t �� st s •r �' b D- O 17 0 1000 GAL I'1� I + i 1 �I �- 13115 � 1 �tl SEPTIC TANK - 745 ........... 31TE AND SEWAGE PLAN L 0 C A T 1 ON : U' ) 'a1V 61 ,�• -417PREPARED FOR : '200 gyp , >y S ALE• L0 DAV I D• B . MASON R`a DATE:. 01� DBC ENVIRONMENTAL DE31GNS .� DATE HEALTH AGENT EAST SANDWICH . MA G Z ( 508 ) 833- 2177