HomeMy WebLinkAbout0046 BRIAR PATCH ROAD - Health (2) 46 BRIAR PATCH R COOSTERVILLE
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No. ✓'7 `� Fee
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitatlon for Disposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair k Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
4
Location Add ess or Lot No.*M 1\ I P P01-P RO Owner's Name,Address,and Tel.No. 114
/q3
Assessor's Map/Parcel / b$TC KI/I 0
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Ted i 5 EA 2C� 19A1110 MASd /
Vj
T� L
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building `)W e L L 1 ►/6 No.of Persons 3 Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided (!1 gpd
Plan Date aj Number of sheets Revision Date
�r7
Title
Size of Septic Tank /o OO CA L Type of S.A.S. L 2A L t� C Hap - Q 55D4`CAC4A.
Description of Soil S�_
Nature of Repairy or Alterations(Answer when applicable) 2-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar o He
Signed Date I So
Application Approved by i /, ,_ P,Z.4 Date
L' �
Application Disapproved by Date
for the following reasons
Permit No �� � ��L Date Issued
------------- -- ---------�------------------------_ -___-_-
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,�5
--y
�. -. Fee No.
computer:
THE COMMONWEALTH OF MASSACHUSETTS Entered in com P ..- c�a
-4+ PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE�MASSACHUSETTS es
Zipplitation for MispoSal 6pstem Constrortion Vermit
Application fora Permit to Construct( ) Repair k Upgrade(, ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. t ( �t N PA(L Kt Owner's Name,Address,and Tel.No. C ;
Assessor's Map/Parcel W
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
aR+ 'id�sc
Type of Building:
` t -
Dwellin `No`of Bedrooms`g i 'Lot Size sq:$. Garbage Grinder( )
Other Type of Building 7 14/2 t.L t If f i No.of Persons 3 Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) fj �.' gpd Design flow provided �� gpd
Plan• Date i'/. `( r Number of sheets ' Revision Date
j P
Title
4
Size of Septic Tank /010 0 CA L Type of S.A.S. 1-e.A �' NQ jr O-P a�
Description of Soil i'\A e '7,
1
t.�� yA A t9 g �q -_p. t�l ,y1°� �, �2t..
P + ( applicable) !J`t L- 7�/`�Lrl �' ''� f�i Z,-)
.Nature of Repairs or Alterations Answer when a licable
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 1
l
Compliance has been issued by this Board of He(althe-
�L
Signed Date
-Application Approved by _� ,�a 1 �l1 / "1�t Date
Application Disapprovedby Date
v
for the following reasons,
Permit No. 0„;2 1 '"g Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compfiante
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at �„ iQ.t, t�i �1.-�T,(.� P_,-6 i x� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No 'dated a,I A l:g
Installer •%/;/ 4. '' w [,/ Designer 17 64 1. A IA4n, r
#bedrooms µ _Approved design flow ' gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as,designed.
Date ` ( Inspector A
No. 1~1 -•1��.. ��---------_----- ---=-----•- �-- --- -- -- -- -- -,------ --1 Fee -� -�t%_--°--. .•. .... ,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,-MASSACHUSETTS_
Mispo al 6pstem Construction jermlt '
. Permission is hereby-granted to Construct( ) Repair O Upgrade( ) / Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the'following local provisions or special conditions. y
Provided:Construction must be completed within three years of the date of this permit.
Date Approved by 1 �/� ,a r0
.r K
Town of Barnstable
I"ETO'�ti Regulatory Services
Richard V. Scali,Interim Director
• anarrsrnste.
MASS. Public Health Division
i6gq. �0
'° o►�r" Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790=6304
Installer& Designer Certification Form p�
Date: 6M-Sewage Permit# r' Assessor's Map\Parcel V
Designe Installer.
Address: Address: "�� '���
On Ci l® �� Y'�"" 1� was issued a permit to install a
date (installer)
Wz Vy q N_
septic system at �1 based on a design drawn by
(address) --
_ 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 fo d satisfactory.
I certify that the septic system referenced above was installed with mayor 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. Strip out(if required)was inspected and the soils
were found satisfactory.
LI certify that the system referenced above was construc_;�-_:�;�liance with the terms
of the AA approval-letters (if applicable) �pJ�ti QF1I4,q
DAVID �y
NIASON R;
(Ins ller's Signature) No.1066
• �Q�3TE��
N1 TARS\
(Desig s Signature (Affix Design'r S
n amp 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.
QASeptic\Designer Certification Form Rev 8-14-13.doc
J
Commonwealth of Massachusetts M I ' 3 031
Title 5 Official Inspection Form S T ��,2�
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
46 Briar Patch Road
Property Address
Araksi Arakel an
Owner Owner's Name „w;ff
information is every Cisteryllle ;
re uired for eve Ma. 02655 06/05/2015
page. City/Town State Zip Code date of Inspection
t'�'
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key.
Cape Septic Inspections
� Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
Cityrrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
06/06/2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional 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. e 0
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
LEM-
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is required for every Osterville Ma. 02655 06/05/2015
page. City/Town 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:
This home has a 1000 gallon septic tank a d-box and a precast leaching pit with greater than one foot
of available space at the time of the 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 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
M ,.•°'t 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owners Name
information is required for every Osterville Ma. 02655 06/05/2015
page. Citylrown 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
f
Commonwealth of Massachusetts
F
required for every Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is Osterville Ma. 02655 06/05/2015
page. City/Town 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
❑ Z 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 Y day flow
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 17
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owners Name
information is
required for every OSterville Ma. 02655 06/05/2015
page. City/Town 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
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Briar Patch Road
Property Address
Araksi Arakeiyan
Owner Owner's Name
information is required for every Osterville Ma. 02655 06/05/2015
page. City/Town 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
C4 M ,•�' 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is required for every Osterville Ma. 02655 06/05/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ 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
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Briar Patch Road
Property Address
Araksi Arakel an
Owner Owners Name
information is
required for every Osterville Ma. 02655 06/05/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ 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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' M 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is required for every Osterville Ma. 02655 06/05/2015
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 19"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: 12"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: Standard 1000 gallon septic tank
1
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
*M °' 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owners Name
information is required for every Osterville Ma. 02655 06/05/2015
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
39"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 8„
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Field Instruments
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The septic tank is structuraly sound.) would recommend the new owner have the system put on a
Paint. plan based on the age of the system and the future use.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M •''r 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owners Name
information is
required for every Osterville Ma. 02655 06/05/2015
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:
Material of construction:
❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order:i ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,.•'� 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is required for every Osteryille Ma. 02655 06/05/2015
page. CitylTown 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.):
At the time of the inspection there were no signs of solids carryover or signs of past hydraulic failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is required for every Osteryille Ma. 02655 06/05/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection there were no signs of hydraulic 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
t
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
•� ' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
t. a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owners Name
information is required for every Osterville Ma. 02655 06/05/2015
page. Cityrrown State Zip Code Date of Inspection
I
D. System Information (cont.)
t
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Privy (locate on site plan):
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Materials of construction:
Dimensions
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Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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ins-3/13 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
f "M yoy 46 Briar Patch Road
Property Address
Araksi Arakelyan
Owner Owner's Name
information is Osteryille Ma. 02655 06/05/2015
required for 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 public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately _
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ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Briar Patch Road
M Property Address
Araksi ArakelY an
Owner Owners Name
information is
required for every Osterville Ma. 02655 06/05/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: plus feet
feet
t
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)
I'
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augured a hole at a lower elevation and shot it with a transit to show five plus feet of seperation.
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 46 Briar Patch Road
4 Property Address
Araksi Arakelyan
Owner Owner's Name
Information is Osterville Ma. 02655 06/05/2015 required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
r ® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
t
' ® System Information—Estimated depth to high groundwater
} ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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Septic System Inspection Report
46 Briar Patch Road
Osterville, Massachusetts
RECEIVED
AUG 13 2001
i July 10, 2001 TOWN OF BARNSTABLE
HEALTH DEPT.
Prepared For:
t Christopher Botello
46 Briar Patch Road
Osterville, Massachusetts 02655
Prepared by:
William E. Robinson, Jr. Septic Inspections
43 Tomahawk Drive
Centerville, Massachusetts 02632
COMMONWEALTH OF MASSACHUSETTS
' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
' PART A
CERTIFICATION
' Property Address: 46 Briar Patch Road,Osterville
Owner's Name:Christopher Botello
Owner's Address: Same as above
' Date of Inspection: July 7,2001
Name of Inspector:(please print) William E.Robinson,Jr.
Company Name: William E.Robinson,Jr.Septic Inspections
Mailing Address: 43 Tomahawk Drive
Centerville,MA. 2632
Telephone Number: (508)775-7986
I ' CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
' X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
' Fails
Inspector's Signature: ev Date. July 10, 2001
' 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.
Notes and Comments
' The septic system appeared to be in good functioningcondition on the day of inspection.
Y P
****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.
Page 2 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION (continued)
Property Address: 46 Briar Patch Road,Osterville
Owner: Christopher Botello
Date of Inspection: July 7,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
' A. System Passes:
' X 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: The septic system was found to be in good working condition on the day of inspection.
' B. System Conditionally Passes: N/A
I
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:
1 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:
�I
' Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 Briar Patch Road,Osterville
' Owner:Christopher Boteilo
Date of Inspection: July 7,2001
C. Further Evaluation is Required by the Board of Health: N/A
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 CAM 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
I� 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:
' Page 4 of 11
' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION(continued)
Property Address: 46 Briar Patch Road,Osterville
Owner: Christopher Botello
Date of Inspection: July 7,2001
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
' Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
' — clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
' = X Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
' indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
' No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Y
Large Systems: N/A
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 H 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
fill 15.304. The system owner should contact the appropriate regional office of the Department.
' Page 5 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
' Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
' Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
' Yes No
X Pumping information was provided by the owner,occupant,or Board of Health(Sewage'treatment Plant)
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A) N/A
' X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
' of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
' Yes no
X Existing information.For example,a plan at the Board of Health.
' X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION
' Property Address: 46 Briar Patch Road,Osterville
Owner: Christopher Botello
Date of Inspection: July 7,2001
' 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 gad(assumed)
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): N/A
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd): 1999—32K gals.(87.7 gaWday).2000—95K eats.(260 galsJdav)
Sump pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIAL/INDUSTRIAL N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sq ft,etc.):
Grease trap present(yes or no):_
a 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: No pumping records available Barnstable Sewage Treatment Plant)
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
X Septic tank,distribution box,soil absorption system
_Single cesspool
=Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obt_ained 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:
Sixteen years old(installed in 1984). Information from Board of Health records.
Were sewage odors detected when arriving at the site(yes or no): No
' Page 7 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
Property Address: 46 Briar Patch Road,Osterville
' Owner:Christopher Botello
Date of Inspection: July 7,2001
BUILDING SEWER(locate on site plan)
Depth below grade: 6"
' Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
' No evidence of leakage,all ioints appear to be in good condition on the day of inspection.
SEPTIC TANK: X (locate on site plan)
' Depth below grade: 16"
Material of construction: X concrete_metal_fiberglass polyethylene
_other(explain)
' If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5'x 4'x 5'
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 35"
Scum thickness: %11
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: 12"
How were dimensions determined: Direct Measurement
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): No pumping recommended at this time. Inlet and outlet
' "T's"in good condition,no leaks in the tank observed. No damage to tank noted. Liquid level at outlet
invert.
GREASE TRAP: N/A (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.):
1
Page 8 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
' TIGHT or HOLDING TANK: N/A (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: X (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.):
"D"Box level,no evidence of solids carryover,no evidence of leakage;
PUMP CHAMBER: N/A (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.):
i
it
Page 9 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
' Type
X leaching pits,number: One leaching pit with 2'of stone all around.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
' innovative/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):Soil dry,no signs of hydraulic failure,no ponding,no lush vegetation.
CESSPOOLS: N/A (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: N/A (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.):
t
' Page 10 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 46 Briar Patch Road,Osterville
Owner: Christopher Botello
Date of Inspection: July 7,2001
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.
t
' Please see attached sketch
1
1
1
1
2
' Page 11 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
Property Address: 46 Briar Patch Road,Osterville
' Owner:Christopher Botello
Date of Inspection: July 7,2001
i ' SITE EXAM
Slope: Mostly flat in SAS area
Surface water: Micah Pond is located to the southeast
Check cellar: No water
' Shallow wells: None in area
Estimated depth to ground water 17.4 feet(below the ground surface at the SAS)
' Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
' Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
' X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Seasonal high groundwater was determined by comparing USGS/Cape Cod Commission groundwater data
and Town of Barnstable GIS data to field measurements.
' The surface of the ground at the SAS was estimated from the Barnstable GIS map (June 1992) to be at
elevation 30. The bottom of the deepest cesspool was measured to be approximately 8' below the surface;
therefore,the bottom of the SAS is at elevation 22.
The groundwater elevation beneath the site was estimated from the Barnstable Ground Water Contour and
Road Index Map (June 1992) and found to be at elevation 9. Using the Cape Cod Commission method to
estimate the seasonal high groundwater elevation, the site was found to be within the area of groundwater
indicator well MIW-29(Zone Q. According to the data available from the Cape Cod Commission the June
1992,the adjustment for that well is 3.6' upward. Therefore,the adjusted groundwater is at elevation 12.6.
When subtracted from the SAS bottom(elevation 22) the resultant separation is 9.4' between seasonal high
' groundwater and the SAS bottom.
I
LOCUS MAP & SEPTIC SYSTEM SKETCH
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' Name: COTUIT - Location: 041'38'30.7" N 070°23'00.3" W
Date: 7/9/2001 Caption: Locus Map
Scale: 1 inch equals 2000 feet 46 Briar Patch Road
Osterville, MA.
Septic System Sketch
Briar Patch Road
#46
' 30' 35'
25' 40' 19'
' 72'
"D" Box SAS
Septic Tank
1
William E. Robinson, Jr. Figure 2
Location: 46 Briar Patch Road
Septic Inspections Osterville, MA.
43 Tomahawk Drive Not to Scale
Centerville, Ma 12632 Date. July 7, 2001 Based on Visual observations
� Inspectors Certificate
� I
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1
1
1
1
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C
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W
t'
THE COMMONWEALTH OF MASSACHUSETTS
]DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
William E. Robinson, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of. Chapter 21A of the
General. Laws. Issued by The Department of Environmental Protection°
April 20, 1995
Acting Director of the. ' ' ion of Water Pollution Control
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07/1P/2001 13:41 5083629001 KINLIN GROVER GMA-C PAGE 02
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE.QFFICE OF ENVIRONMENTAJa AFFAms �.
s DEPARTMENT OF' ENVIRONMENTAL PROTECTION
J �® V
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 46 Briar Patch Road,Osterville RECEIVED
Owner's Name:Christopber Botello 1 ZOO'
Date Owner's Address: Same as above 'JUL 1 L
Date of Inspection; July 7,2001 jOWN OF BARNBfiABLF-
Name of Inspector:(please print) William E.Robinson,Jr. liEAITH DEFT
Company Name: William E.Robinson,Jr.Septic Inspections
Mailing Address: 43 Tomahawk Drive
Centerville,MA. 2632
Telephone Number: (508)775-7986
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address,and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of ott site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15-W of Title 5(310 CMR 15.000)�. The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: i&c 9 Date: July 10,2001
The system,inspector shall submit a copy of this inspection,report to the Approving Authority(Omd of.I?ee?'h—
DEF)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd cir 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;U applicable,and the approving
authority.
Notes and Comments
The septic system appeared to be in good functioning condition on the day of inspection.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of.use.
I
07/10/2001 13:41 5083629001 KINLIN GPOVER GMGC PAGE 03
Page 2 of i 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART A
CERTIFICATION (continued)
Property Address: 46 Briar Patch.Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
Inspection Summary: Check A,B,C,D or l;/ALWAYS complete all of Section D
A. System Passes:
X 1. .have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303
or in 310 CNIR 15.304 exist.Any.failure criteria not evaluated are indicated below.
Comments: The septic system was found to be in eoW worldne condition on the day of inspectlon.
B. System Conditionally Passes: N/A
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`snot 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 exhltration or tank failure is imiaainent.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
indicates that the tank is less than 20 g 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.systenn 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:
07/10/2001 13:41- 5083629001 KINLIN GROVER GMAC PAGE 04
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
Ts failing to protect public health,safety or the environment. .
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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)determ'nes that the
system is#bnctioning 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 I 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,perfomed at a DEP certified laboratory,for coli£orm
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
tiro 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:
07/10/2001 13:41 5083629001 KINLIN GRrVER GMAC PAGE 05
Page 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X liquid depth in cesspool is less than 6"below invert or available volume is less than '/:day flow
X Required pumping more than 4 times in the last year NOT_due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well_
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (Phis 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 pol Woa from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15,303,therefore the system fails.The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Large Systems: NIA
To be considered a large system the system most 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 ownu or operator of my 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 tvgional ofTtce of the Department.
07/10/2001 13:41 5033629001 KINLIN GROVER GMAC PAGE 06
Page 5 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 46 Briar Patch Road,Osterville
Owner: Christopher Botello
Date of Inspection: July 7,2001
Check if the following have been.done.You must indicate or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health(sewage Treatment Ptant)
X Were any of the system components pumped out in the previous two weeks?
X T Has the system received normal flows in the previous two week period 7
X Have large volumes of water been introduced to the system recently or as part of this inspection T
X Were as built plans of the system obtained and examined?(If they were not available note as N/A) N/A
X _ Was the facility or dwelling inspected for signs of sewage back up 7
X _ Was the site inspected for signs of break out 7
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depot of sludge and depth of scum?
7f _ 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
i _ X Existing information.For example,a plan at the Board of Health.
X — Det:T. mind in the Field(if any of the failure criteria related to Part C is at issue apYruxunatiou of distance
is unacceptable)P 10 CMR 15.302(3)(b)]
07/1Q1/2001 13: 41 5083629001 KINLIN GROVER GMAC PAGE 07
Page.6 of i 1
OFFICIAL INSPECTION FORM --NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 46 Briar Patch Road,Oster-Mle
Owner: Christopher Botello
Date of Inspection: July 712001
FLOW CONDPTIONS
RESMENTIAL
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¢tad(assumed)
Number of current residents:2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): NIA.
Seasonal use:(yes or no): lrjo
Water meter readings,if available(last 2 years usage(gpd): 1999—32K eab.(87.7 P&W&y162000—"ji gala.(260%ezWd4A
Sump pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIAIANDUSTRIAL N/A
Type of establishment:
Design.flow(based on 310 CMR 15.203), gpd
Basis of design flow(seats/persons/sq ft,etc.):
Grease trap present(yes or no):_
In.dustrial 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: No mmtnina records available Barnstable Sewage Treatment Plant)
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
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool —
Privy
_Shared system(yes or no)(if yes,attach previous inspections 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:
Sixteen years old(lnstplled in,19N. Infonnntion from Board of Health records.
Were sewage odors detected when arriving at the site(yes or tro): NQ
07/1Q/2001 13:41 5083629001 KIhILIN GROVER GMAC PAGE 08
Page 7 of 1]
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
BUILDING SEWER(locate on site plan)
Depth below grade: 6"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: NIA
Comments(on condition of joints,venting,evidence of leakage,etc.):
No evidence of leakage.all ioints apmr to be In good condition o4 the day of inspection.
SEPTIC'TANK: X (locate on site plan)
Depth below grade: 16"
Material of construction: X concrete_metal—fiberglass_polyethylene
_other explain)
If tank is metal list age:^ is age confirmed by a Certificate of Compliance(yes or no):certificate) (attach a copy of
Dimensions: 8.5'x 4'x 5'
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 35"
Scum thickness: '/,"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or;;foe'
How were dimensions d'etcrnained: Direct Me9surement
Comments(gat pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): No Damping recommended at this hM- JWct W optldl
`°T's"in good condition no leaks in the tank observed. No damage to tank noted Liguid level at outlet
invest.
GREASE TRAP: 1/ (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 baffleL
Distance frorn bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(oft pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
r
IL Y
07/10�2001 13:41 5083629001 KINLIN GROVER GMAC PAGE 09
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
III SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: duly 7,2001
TIGHT or HOLDING TANK: N/A (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: _ stallons/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: 2j (if present must be opened)(locate on site playa)
Depth of liquid level above outlet invert: 4"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage unto or out of box,etc.):
"D"Box level,no evidence of solids carryover,no evidence of leakage,
PUMP CHAMBER: N/A (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.):
07/10/2001 13:41 5083629001 KINLIN GROVER GMAC PAGE 10
Page 9 of 1 1
OFFICIAL ]INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection.: July 7,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why.
Type
X leaching pits,number: Qne leaching,pit with 2'of stone all around.
leaching chambers,number:
leaching galleries,number.
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology-
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):Soil dry,no signs of hydraulic failure,no ponding,no lush veeetatio
CESSPOOLS: NIA (cesspool must be pumped as part of inspection)(locate on site plaza)
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: N/A (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.):
07/10/2001 13:41 5083629001 KINLIN GROVER GMAC PAGE 11
Page 10 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address; 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001
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.
Please see attached sketch _
r
07/10/2001 13:41 5083629001 KINLIN GROVER GMAC PAGE 12
Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 Briar Patch Road,Osterville
Owner:Christopher Botello
Date of Inspection: July 7,2001.
SITE EXAM
Slope: Mostly flat in SAS area
Surface water: Micah food is located to the southeast
Check cellar: No water
Shallow wells: Nose in area ,
Estimated depth to ground"water 17.4 feet(below the ground surface at the SAS)
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plazi reviewed:
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)
2C Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Seasonal high groundwater was determined by comparing USGS/Cape Cod Commission groundwater data
and Town of Barnstable GIS data to field measurements.
The surface of the ground at the SAS was estimated from the Barnstable GIS map (June 1992) to be at
elevation 30. The bottom of the deepest cesspool was measured to be approximately 8' below the surface;
therefore,the bottom of the SAS is at elevation 22.
The groundwater elevation beneath the site was estimated from the Barnstable Ground Water Contour and
Road Index Map (June 199M) and found to be at elevation 9. Usiog the Cape Cod Commission method to
estimate the seasonal high, groundwater elevation, the site was found to be witbW the area of groundwater
indicator well MiW-29(Zone 4 According to the data available from the Cape Cod Commission the June
1992,the adjustment for that well is 3.6' upward. Therefore,the adjusted groundwater is at elevation 12.6.
When subtracted :from the SAS bottom(elevation 22) the resultant,separation is 9.4' between seasonal high
groundwater and the SAS bottom.
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00
TIC COMMONWEALTH- OF MASSACHUSETTS s
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A BE IT KNOWN THAT
William E. Robinson, . Jr.
H
Has satisfied the Department's qualifications as required and is hereby
m
authorized to use the title
CERTI ,IED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the
General. Laws. Issued by The Department of Environmental Protection.
n
April 20, 1995 m
Acting Director of she��Ioft of water Pollution Control
W
LOCATION SEWAGE PERMIT NO.
aVILLAGE 1 + 3
® Z -
� v
'V)INSTALLE It'.S NAME i ADDRESS
1 .DUILDEIII OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
:i
a
J10�
O �/
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M A�C(, I
DATA
No..? Tf
{!?' THE OMMONWEALTH OF MASSACHUSETTS l
= OAR® OF HEALTI—I 7
Y•"'r .. .-.L .............OF..........P..A fiL.t�j..r-(- --1�1-..V���.............
ApplirFation for Mivvii al Works Towitrurtion rumt��
Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal !
System at:
......�-�.1.. ... t�l. R.p T�! .. p�gO 'r..................................t �u �. d !JST ¢.M A
I- ation-Address or Lot No.,
.... �' .'.7 !�L ......•-. �7......... Y.A t.1!_.`.L, ,!. 7k
Owner Address
14 W
Installer Address
Type of Building Size Lot.....
-�14�57----Sq. feet
Dwelling—No. of Bedrooms...........3 .......•_ ..........Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building l"-......... No. of persons............................ Showers — Cafeteria
f4 YP g ------- -- P ( ) ( )
a' Other fixtures .................................
Design Flow.....•....._�1..6 ........................gallons per person per day. Total daily flow........ ... .....................gallons.
WSeptic Tank—Liquid capacity.1Qvp...gallons Length-'!�-rP.... Width................ Diameter.-.-..-------.-- Depth................
xDisposal Trench—No............................. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........1---------- Diameter.......... Depth below inlet......?... Total leaching area.1 ._ ...sq. ft.
Z Other Distribution box (✓) Dosing tank
aPercolation Test Results Performed by...... .. .... .. _t. I .67_.�Q. !�_ �;ti15. Date...._ :. _-_........
P�l7 Test Pit No. 1.....�'..-..minutes per inch Dept i of Test Pit------.t'-.-...... Depth to ground water....N�.N. ......
44 p7,01 j Test Pit No. 2....._.�k...minutes per inch Depth of Test Pit-------I.-k........ Depth to ground water-----NP ...
----------------------------•-•- ----------------•-------.....................•-•--...••-•.........................................................
O Description of Soil------------ =7l.`.-.. --••-- !'o_AA P LT ji�v...:�.M4 P
W
(� -----------------------
------------
------------------------------
-------------------------------------------------------------------------------------------------------
------------
----------•---------
W
U Nature of Repairs or Alterations—Answer when applicable...........................:...•---.--.---..----...--•....•...--....-.-.-----------.--.-----•--.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
,the provisions of M i; 5 of the State Sanitary Code— The undersigned further=agrees not to place the system in
operation until a Certificate of Compliance has be ue by e d of health.
is Signed.... . •. • ---•----- ......................... .�.
Date
ApplicationApproved By............. f.... ••- ---------------..................... ........................................
Date
Application Disapproved for the following reason -........................................
....................................................
-•---------------••-•-----....---._.......--••-••-----•-•---•.....-••----
Date
-
PermitNo......................................................... Issued.......................................................
Date
� t
FEs.... .
r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratiun for Uiupu,ial Workii C omtrurtiun Vamit
Application is hereby made for a Permit to Construct (I✓) or Repair ( ) an Individual Sewage Disposal '
System at:
.......��' 1... ..✓.f<--!!1�? i A%f �I 7 Cz� - 1/�f� 17 .L.'_r j� C..._ `.Jl _ �itLC� Fk -lJ,jf\ L n!� R.
.... •--......--- _
Location-Address
' i or Lot No
!I .. i-T� . G ... . Ar
r v.---•------•--L-. -�GL--� _..--.___. . . .. ! .4.......-... ___ -----
Owner Address
W
Installer Address
Q Type of Building Size Lot._____ i_ '.5.7....Sq. feet
Dwelling—No. of Bedrooms____._______�____________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ----- ......... No. of persons____________________________ Showers ( ) — Cafeteria ( )
QOther _fixtures ------------------------------------------------------•--•-•---•--•-•-----•••-•---.._.._.._......-------•-••-•-•-•---••••-•••-•••------••------•-•-•-
W Design Flow................. per person per day. Total daily flow---------_: _________._____._.___gallons.
WSeptic Tank—Liquid capacity_166(j---gallons Length__'?____P__._ Width................ Diameter--------------__ Depth...._------.__..
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
_____ Total leaching area_/�'-_-5_`2s tt� Seepage Pit No..........I---------- Diameter----�.��.__--------- Depth below inlet...... .__.._ g q. " .
Z Other Distribution box (✓) Dosing tank ( )
Percolation Test Results Performed by.Z�T.. - t_ 17 `t=�`.6_vl_k j_�I5 Date---- �3r -wJ�•-----•---.
Test Pit No. I......Z----minutes per inch Dept of Test pit-------12___.___ Depth to ground water_-__N�Gti_l✓ f
Li, 76 1 c Test Pit No. 2..._---2'_.minutesper inch Depth of Test Pit.......22________ Depth to ground water_-____N�_�
-----------------------------------•---....--------------------....------------........_..--•---•---........................................................
0 Description of Soil.............. '?.-•-1L ----- �J =1 �._l�l E L? .r A�-�--I-:- � A N P%
x
W
VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
--••-----•--•-•-•--•-••--••-•------•----•-•--•---••-----••••---•---•-••-------------•--•---.......--•--•-•-••-•----------------------•-------•••-------------•.-----•--------------•---------•-•---•••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed..........................
Date
Application Approved By............. --_ V-- --•-•----------------------••---•-
Date
Application Disapproved for the following reasons- _0'
0'05 -------------------=------------------------•-----------------------•--•••--•--- --•-•--•••---_...._
----•--------------------------•---------...-•-----------•--•------------....--------------•--------------••--••-----•--•-•--•---•-•----•-•••---•••----------------••-•--------•-----•--------•-•.._..--
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F..................................................................___...._...........
Trdifiratr of Touttytiattrr
THIS IS TO CERTIFY, That the ividual �Serte ispsal System constructed ( ) or Repairedby-------------------------------------------------- -------------- -- -_ .......................................................................................
stal ler
at......................................................................................................I-•---•--••---••••••--
has been installed in accordance with the provisions of Tl=` 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated................................................
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTRUED. S A GUARANTEE THAT THE
SYSTEM 16NILL �VN SATFSFACTORY.
DATE----_...Z_> ..................................................... Inspect or..... ... .._....__
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF..............------•-----.. ..........................................
No..._. .. FEE........................
Disposal u4Se
unutrtiun unfit
Permission is hereby granted............... - -----'--------------------
to Construct ( ) r Rena' ( ) an ivi. , � Disposal �st�
at No................ .................1 ¢ }�G �/
Street
as shown on the application for Disposal Works Construction Permit No-----_----_------ Dated..........................................
.�.� 4 Board of Health
DATE.......................=........... .....--- ........✓--•--•--•--
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - -
ro
WAR QTpOW}N OF BARNSTABLE
LOCATION p � A I\ I,atc H RDA OSTSEWAGE# 2—o X 1 — 3 Z IQ
VILLAGE OSfLUI LLB. ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. h h 15
SEPTIC TANK CAPACITY I D O O G,Cj,
LEACHING FACILITY:(type) LeAG u C 444 f� (size) I,3' x I
NO.OF BEDROOMS 13
OWNER I e-�
PERMIT DATE: 10 COMPLIANCE DATE:
0
Separation Distance Between the: N of 2 0 r o
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
0
a 8 -3
o L
L\
3Q .00� ��, 33
o �
t
EXISTING
CELLAR ACCESS
18'
III
to
II
Ilo '
Ilm
II�
EXISTING EXISTING a I I
R.O. 2'-4 /8' x 4'-0 1/2• II o N N BATH BATH I I
AND. CW14 I I w N
113 0 l i EXISTING
II= EXISTING HOUSE. o i I BEDROOM
NEW ONE CAR GARAGE
III _
4 3000 PSI CONCRETE SLAB EXISTING I I
,._,. I i WAD
EXISTING BEAM ABOVE IMPROVED PER FRAMIN LPLAN BEARING WALL —
- -
EXISTING COLUMNS. 6-e'
- - - - - - � - - - � — - - - - - — - - - = — — � - - I — I —`= - - - - - -
-�IXISf1NG BUILT-UP GIRDER BHLOW� I � � — — — Y TON CONC�7E FILLED STEEL TUBE COLUMNS 3 1/2•
L — —BRACED e8" ON CENTER TYPICAL— — I_ - — J �- — -� I ( L — — J
AIR 00 TO GARAGE GIRDER (3) 2X70 BELOW I I BEARING WALL
NEW OOR FROM GARAGE.
V1
: 2
FLUSH STEEL DOOR }
R.O. 2'-4 7/8' X 4'-0 1/2'
AND. CW14 0
EXISTING C H MNEY EXISTING
EXISTING LIVING ROOM I I I BEDROOM
/\
OVERHEAD GARAGE DOOR 4
9' 3' 1'
1._2.. OPE TO Aeove\ —
i
t NEW DECK W/ROOF ABOVE
O O
Araksi` Arakelyan FIRST FLOOR PLAN
Arshak Yeremyan GARAGE ADDITION AND RENOVATION
46 Briar Patch Rd. SCALE: 1/4"- 1'-0" DULY 30, 2004
Osterville, MA 1
2' 4'-3" 3'-11"
R.O. 4'-9" X 4'-0 1/2' R.O. 4'-9" X 4'-0 1/2" 0 2'-4 7/8' X 4' 1/2' I I
AND. CW24. AND. CW24 AND. CW14
2'
NEW BATH I
w I I
® 2'-8"
a I I
N � I
I EXIIISTING ROOM
SISTER EXISTING FLOOR JOIST =a o
W/ADDITIONAL 2'X10' 16 O.C. I I h N I I U
18'-3 1/2" I 7'-5"
wza
Co
as
I LINE OF BEARING WALL BELOW w
J
o ;o
n �
x /
EXISTING ROOM N
STAIR DOWN
00
/ NEW DORMER'
OPEN TO.BELOW
NEW DORMER I I R. 2'-4 7/B'R 14'-0 1
M
a I I 4'-4" 4'-4"
AND. CW14
2'-4 7/8' X 4'-0 1
7—1 4-4— AND. Xxxx
e R.0.4'-4 " X 4'-0 1/2'
Araksi Arakelyan r
Arshak Ye remyan GARAGE ADDITION AND RENOVATION SECOND FLOOR PLAN
46 Briar Patch Rd. SCALE: 1/4"= 1'-0" JULY 30, 2004
Osterville, MA
1) The installation shall comply with the State Environmental code Title V and Town of
ASSESSORS MAP: TEST HOLE LOGS
Board of Health Regulations.
PARCEL: t t�f f ' ! ! 2) The septic system as proposed on this Ian shall not be installed until a licensed town
SOIL EVALUATOR: � P p p
installer receives approval and an installation permit from ttie applicable town.
REFERENCE:
t WITNESS: 3) Prior to installation,the installer shall verify the location of utilities, sewer inverts,
sewer lines and existing septic components nor to installation.
DATE: g P p p
T 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8" per foot. The first 2
t.,n 1 feet out of the distribution box shall f1
�" ? PERCOLATION RATE: - `� o s a I be level. All piping connections to be glued.
19-7 5) This septic design plan is not to be utilized for property line determination or for any
T.H.#1 ELEV. T.H.#2 ELEV. A other purpose other than the proposed septic system installation.
LOCATION MAP 6) All Title V components are to meet Title V specifications.
7) Parking shall be prohibited over Title V components unless components are H2O
loaded.
-- / 8) The existing leaching or cesspools shall be pumped and filled with material per Title V
J ��c abandonment procedures. Leaching and cesspool(s)and contaminated soils within
N�r the proposed SAS shall be removed and replaced with clean sand per Title V
f specifications.
9) Septic components are to be 10'from a water service line. Sewer lines crossing a
water line shall be sleeved with an appropriately sized schedule 40 PVC with ends
p Y
grouted. The water service line or the septic line can be sleeved with the sleeve being
a distance of 20' on both sides of crossing the line.
��• .' ' ': , `� t -iS 10)If a garbage grinder exists in the structure, it is to be removed if the septic system is
GI'� not designed to accommodate a garbage grinder.
- 11)The installer is responsible for care of excavation around all utilities on the property
and protecting the structural integrity SEPTIC SYSTEM DESIGN CALCULATIONS p g of all structures during the installation process
Cam✓ �'• of the septic system.
FLOW ESTIMATE: 12)This plan only represents that a septic system can be installed on the property
meeting
BEDROOMS AT ` GAL/DAY/BDRM = ' GAL/DAY Title V requirements.
4,j} �� SEPTIC TANK: 13)The property owner shall review design criteria to approve the total number of
/ bedrooms and design flow. Installation of the septic system as proposed and receipt
t � _ GAL/DAY BDRM X 2 DAYS = lO GALLONS of payment for the design
GA ONS P Y g shall be deemed�%=.-- _ --- / � approval of the design criteria by the
property owner or agent of.
USE GALLON SEPTIC TANK
14)The validity of this plan shall expire with the expiration of the town installation permit
(GARBAGE GRINDER iS PROHIBITED) issued for this plan or the validity of this plan shall expire on the expiration of the
`� Certificate of Compliance issued for the installation of the proposed system on this
Y �/ �� � SOIL ABSORPTION SYSTEM: Pl y
G i {c plan_
it
SIDEWALL AREA: - f .-� �. JC , = 97
� �(N Oi
BOTTOM AREA: Z �C /Zj J �G 4�7 " =` ��! ajJ f/ f� r� VID
SEPTIC SYSTEM SECTION
BENCHMARK � , r' �W ,�---____ � _--_ -----•..�_ ` u .C)� \�
-� Sb'Z" • TOP OF FOUNDATIONFV _
ELEV.
1 ✓
(DATUM ASSUMED) (*A� #410f 6"STONE BASE
ZSX' )Z, I
H2O D-BOX
6"STONE BASE OR COMPACTED BASE WATER TEST FOR LEVELNESS
GALLONS ;
SEPTIC TANK
C, J�r7 k-� SITE AND SEWAGE PLAN
LOCATION: = ► r--, ;�.,t` l _ ; .i -.�. x� .�
PREPARED: s ,
f
t
SCALE: DATE:
SITE PLAN TYPICAL PROFILE
SCALE — I = -'��� , q ,g NOT TO SCA L E
IB"STD. LT. WGT. C.L MH COVER
7.
4"C 1. PIPE _______. 4 R/r FIBER PIPE TIGHT JOIN TS
OUTLET FLOW LINE I TO F/RS rL EVEL
JOINT �--=� _ 1 l=:__`__
17
c.I. rEE C.1. TEE
S rANDARD PRECAST ---
`' CONCRETE''�60 GAL LON I �9 oO
''-- SEPTIC TANK i
015;rR/BU TION BOX I
8+ TO BE INS r.4L L ED ON I
E VE S 4 BL F BA SE
SEPTIC TANK
TO BE INS TA L L EC ON i
LEVEL , STABLF BASE
LaT //8" TO !/2 ' W4 Mf 0 P£A5TONE
i LEACHING PI T
ALL AROUND FREE OF IRONS FINES
I I \ - AIVP OUS T IN PL ACE BASE TO BE LEVEL
l Jo0 w• '}!. . h��T l t j A ti V_ &R1Ch•8 MORTAR COURES 3/4" TO /-112" WASHED CRUSHED
AS R:7QUIREO rO BRING � STONE ALL 4ROUN0 FREE OF
'� TO GRI'.Dr 24 C.!. MH COVER IRONS, FINES AND DUST iN PL4CF,
�! AND FRAME �L
....................
i
INL EA
8' FLOW LINE
SEC
• ', ` PIPE � , 1. CONCRETE TO BE 4000 PSI 28 DAYS
Za' '� / 2. REINFORCED WITH 6 x E;" N0. 6 GA. W.W.M.
3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER
,.� ,^,u1i.. ! �,a� f o�, �l 3 v I DEPTH REQUIREMENTS.
��t ;'L d `t*•t=' ��>✓icP� �� _ , , OPENING WITH 4 //B ' 4. NUMBER OF PITS REQUIRED bf"'
OUTER DIAMETER !3 I NOTE: EXCAVATE TO ELEVATION Zy'� OR LOWER AS
l`3/4 INSIDE DIAMETER , ``
d\ i j t REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
i PIT REPLACE EXCAVATE" MATERIAL WITH CLEAN
GRAVEL TO DESIGNED GRADE
9 N' 4- m V M//v
EFFECTIVE DlA,iIETER I Z - o
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH I
\ f
^�. � �P -_ WATER T,iIBL E ,
a �1UUY+� ,D,T eL, Ytj , O
.-S q
SC' ;'11 F'ERC. DATA GENERA L NO TES
PE RC. R"TE MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. +
hi A �/.t I L k 4 /a �i5 D(� SEPTIC .TANK, `L'ISTRIBUT!ON BOX , `EACHiNG PITS TO BE STANDAP,
TEST BY: PRECAST REINFORCED CONCRETE UNITS.
�, WITNESSED BY __�v N �.1_ J A L D 01 t pj , JA • ALL. SYSTEM COMPONENTS SHALL_ BE INSTALLED IN ACCORDANCE ' a
}' L o 17 et-37.0 5, #b �� IP`( E�.t►1'`J TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL COPE , . .
$` TEST PIT GR.EL p Z&Il5 P-L�.ODATE ' tC� 14 , fib
MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TE f3T PIT NO.P Z017 TEST PIT NO ' Zlr 1 Gj SANITARY SEWAGE EFFECTIVE I JULY 1977
ANY CHANGES TO THIS PLAN MUST BE APPROVED B'f THE
6 U�:1 R
L E
E Off+ VN` 1 R CT CN , PRIG TO 9ACKFILLING, `-
*3 2 a I AT CUMPL TI t; U i P
" ,r I t�1 i~ AGM. A � - I'1 Nta 4A }.iC> BOARD OF HEALTH SHALL BE NOTIFIEC FOR INSPECTION.
PITCH ALL SEWER LINES I/4" / �=T UNLESS iNDICaTEC.
, * �.� E' o144 OTHERWISE.
owXTld'r.R.
5
BEDROOMS DISPOSAL �G' 1``l�
T' EST. TOTAL !DAILY EFF. GALS.
L EGEND -''.• SEPTIC
TANK_.��'� _ GAL
SIDEAALL 4REA � j?____GAL ./30 FT
/ BOTTCV!'r! AREA I 'p GAL •1SQ. FT S�YYf-�iVE LJI��P N / ^� � /V1
"IXoc EXISTING GRADE LEACHING REQUIRED_. '`'.°``��'_SQ FT PO SA[_ S E
ZONE a �v FiNISHEp GRAt3E ACTUAL LEACHING AREA �oi.=`�SQ.FT. FOR
-- y�
DOMESTIC WATER SOURCE: Al y r ,- - 0 . oo MVERT ELEVATION
PROPERTY LINE r r,~. a v-
PLAN REF`ERENCE: . �'9 Zri� Pt,� ••iY � " ` ��' ,-
4 a •
MEAN HIGH WATER
." SCALE' AS INDICATED DATE.
BENCH Rot t � T -
DATt -;� v ' �` ► v _ _ ?� MARSH WM M ►WARWICK � A 55004TF
f BOX BOI NJRTH gALMOUTH
bfA SSA CHUSET T,"" 02556