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HomeMy WebLinkAbout0063 BRIAR PATCH ROAD - Health �'� 4IlR � Zi , �� 63 BR FATCH ROAD STERVILLE A= 143 -035 / t' TOWN OF BARNSTABLE LOCATION C2 M C.,(- W<�\ SEWAGE#2p ZI — ®4 VILLAGE C� . \�ASSESSOR'S MAP&PARCEL r /U3 INSTALLER'S NAME&PHONE NO. � � � SEPTIC TANK CAPACITY LEACHING FACILITY:(type)COCCP OOU (size) NO.OF BEDROOMS OWNER PERMIT DATE: ���2���! COMPLIANCE DATE: i a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within_ 300 feet of leaching facility) %e t Feet FURNISHED BY 4 Al .3b b3s 1� �� f 48 ALi o —Lk No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes plication for Disposal Epstein Construction Vermit Application for a Permit to Construct( ) Repair(4pgrade( ) Abandon'( ) ❑Complete System ['Individual Components Location Address or Lot No. GZ Qrl CY, Gl.� er's Name,Address,and Tel.No. Assessor's Map/Parcel `�4 0 3 © V� r mil/ M� �f<lt^ G k or taIW1� 's Nam Address,and el.No Designer's Name,Address,and Tel.No. cv i bl� AA 1A �c aq o0l0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria.( ) Other Fixtures Design Flow(min.required) AZ gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs orAlterations(Answer when applicable) kG.(v e )(t ����`� ` Q �t sjr W A0 n 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 Board of Health. Signed Date 1L4 2.L— Application Approved by Date { ZZ Z Application Disapproved by Date for the following reasons Permit No. Date Issued '� M -� 1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS' Enteted'incomputer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippfication for Misposhl *pstetn Construction Permit Application for a Permit to Construct( ) Repair(t / grade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. Q)Z Qr\ G,( OCA t,in NIF awner's Name,Address,and Tel.No. 0 Assessor's Ma /Parcel QVI r installer's Nam Address,an i TeLN`a0�� Designer's Name,Address,and Tel.No. cv c•cr y -e&r tAyc-,r,e,c. Z ®0 6Ci � " ,Type of Building: Dwelling No.of Bedrooms ` ` Lot Size sq.ft. Garbage Grinder r - Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) Al A- gpd Design flow provided a/ll gpd Plan Date Number of sheets Revision Date w Title Size of Septic Tank Type of S.A.S. Description of Soil d Nature of Repairs or Alterations(Answer when applicable) Q qj,\�r_t o ? Y �k c�-�. �-� p tl c. t\ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the EnvironmentalCode and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. } ' t Signed �, x - _ Date Application Approved by . -- `- Date . Application Disapproved by - �-" Date for the following reasons Permit No. Z -C'� (P Date`Issued t y' -------------------------------------------- r- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) 4 v. _ - Abandoned( )by ff at C Z Q,( C",i- Pr{rV, Q d ti�crti 1 k-k_has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -10;I.,64 dated Installer • c-n- M _.,^V Designer / #bedrooms /y ! Approved design flow A gpd r - The issuance of this permit shall not be construed as a guarantee that the system will function asidesigned p . Date ( I•;-IV 1-I Inspector �••�"'�'�,�,�'� (+�� 1 :V 1 y v� - -•-- ------- ---- --- - - -------- �`.No. r(� � 17 i� Fee t THE COMMONWEALTH OF MASSACHUSETTS �,7 4 �( PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ' j 6 Misposal *pstem Construction permit Permission is hereb granted to Construct( ) (Repair(� 1 Upgrade( )t Abandon( ) System located at r r r �r t C�. �Cl ��E f tQ 1 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. Provided:Construction must be completed within three years of the date of this permit. Date 1 Approved by f -. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required ge. for every Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. Inspector Information 51 l filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not. S M Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane �—,► Company Address Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smionestitle5.com License Number B. Certification I certify that:I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/22/2021 Inspector's Signature m Date The system inspector shall.submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5hW.doc-rev.MUM 8 Title 5 Olfidal hispection Form:Sutsuface Sewage Disposal System-Page 1 of 18 r Commonwealth'&Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every page. Cityrrown state Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 property located at 63 Briar Patch Rd Osterville is served by a Title V septic system consisting of the system gallon recast leach it. Although y a 1000 gallon septic tank, distribution box and a 1000 p p g inspection this report does not guarantee was found to be in prope r workingcondition at the time of pe po g future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ! ❑ Y ❑ N ❑ ND(Explain below): i I s t5insp.doc•rev.7l W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd _ Property Address Maureen Curley-Giordano Owner Owner's Name information is required for every Osteryille Ma 02655 1/22/2021 page Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): t ❑ 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): i 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist whichre further evaluation b the Board of Health in order to determine if require y the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Y f t5insp.doe•rev.7/2612018 Title 5 official lrgxmdon Form:Subsurface Sewage Disposal System•Page 3 of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd " Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 V2212021 required for every State Zip Code Date of Inspection paw City/Town C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other. } 4) System Failure Criteria Applicable to All Systems: You must Indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due.to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the gro nd or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.M2612018 Tide 5 Ofridal inspection Forth:Subsurface Sewage Disrwsai System.Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form r Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0 ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ED Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within'50 feet of a private water supply well_ ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria in absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be. necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a s 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 CA. I 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 t5hsp doc,rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every page. Cltyyrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department 6. You mustindicate"yes"or"no"for each of the following for all inspections: Yes No J ❑ 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 El ® this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ 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?, ® El information 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)] t5insp.doc•rev.7126=18 Title 5 Official inspection Forth:Subsurface Selvage Disposal System•Page 6 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owners Name information is Osterville Ma 02655 1/22/2021 required for every page. Cityfrown state Zip Code Date of Inspection D. System Information 1. 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 gpd Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes,discharges to: Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 3. Sump pump? El Yes ® No 12/2020 Last date of occupancy: Date C t5hw^p.doo-rev.7128=18 Title 5 Official Inspection Form:Suhsiaface Sewage Disposal System-Page 7 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osteryille Ma 02655 1/22/2021 required for every Gityfrown state Zip Code Date of Inspection page. D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: S' 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: r Last date of occupancy/use: Date other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No 'If yes,volume pumped: gallons I How was quantity pumped determined? Reason for pumping: { t5insp.doc•rev.7/2&W18 Tdle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every page. Cityrrown State Zip Code Date of inspection D. System Information (cunt.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑, Shared system(yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and in d from system owner co maintenance contract(to be obtained )and a PY of latest e , y inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (if known)and source of information: original system installed 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2 Depth below grade: feet l Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Joints in good condition, no leakage, vented through roof. ., t5insp.doc•rev.Memis Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 s I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every state Zip Code Date of Inspection page CttylTown D. System Information (cont.) 6. Septic Tank(locate on site plan): 1.5 Depth below grade: feet Material of,construction: concrete. ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 gallons Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3` _ 2,1 Scum thickness I Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle Opened covers and took How were dimensions determined? measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank does not need to be pumped now but should be done soon again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. i t5lnsp.doc•rev.7/2M018 Tdle 6 Official Inspection form:Subsurface Sewage Disposal System Page 10 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano -- Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every state Zip Code Date of Inspection page Cityrrown D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.728@018 Title 5 official Inspection Form:subsurtace Sewage Disposal System•Page 11 of 18 i 0 Commonwealth of Massachusetts Official Title 5 Offic Inspection Form Sewage Disposal System Form-Not for Voluntary Assessments Subsurface Se y 9 P 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is Osterville Ma 02655 1/22/2021 required for every page City/Town gate Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): on Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Distribution box replaced for inspection permit#2021-016 j t5insp.doc-rev.7126Y1618 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley Giordano Owner Owner's Name Information is Osterville Ma 02655 1 22/2021 required for every state Zip Code -dateof Inspection page. CitylTown D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No* Alarms in working order: Yes ❑ No* Comments(note condition of pump chamber,-condition of pumps and ap urtenances,etc.): *If pumps or alarms are not in working order, system is a conditional pa s. 11. Soil Absorption System(SAS)(locate'on site plan, excavation not req ired): If SAS not located, explain why: V Type 1x1000 gals ® leaching pits number: r ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: t5insp.doc-rev.UM018 Title 5 Official Inspection Form:Subsurface Sew go Disposal System Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is required for every Osterville Ma 02655 1/22/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.). 11. Soil Absorption System(SAS)(cont.) . Comments(note condition of sail, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach pit was found with standing water 16'below inlet invert and a stain line 7" higher. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer r Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doe•rev.712SM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd F VV Property Address Maureen Curley-Giordano Owner Owner's Name information required for every Osterville Ma 02655 1/22/2021 page. Citylrown State Zip Code Date of Inspedon D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): zF t5insp.doc-rev.MOB=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information required for every osterville Ma 02655 1/22/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information,(cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I�t K 15, 10 a 2-4 j f�2 /0 Z I L Z 3 C 3 `1 t5trrrp.doe•rev.7/162018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information is required for every Osterville Ma 02655 1/22/2021 page. Cdylrown state Zip Code Date of Inspection D. System Information (cone.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126=18 Title 5 Official Inspection Form:SubsWace Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ;- Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63 Briar Patch Rd Property Address Maureen Curley-Giordano Owner Owner's Name information Is required for every Osterville Ma 02655 1/22/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B.Certification: Signed&Dated and 1,2, 3, or checked C.Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/287018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 } ,-- TOWN OF PARNSTABLE f 'LOCATION Br/,A(- r W Ik SEWAGE # '93 - 9 E�6 / `VILLAGE 0 S7try, [Le- ASSESSOR'S MAP & LOT 1y3 3J INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY GA I' LEACHING FACILITY: (type) Pi L X ' (size) t 3 NO. OF BEDROOMS BUILDER OR OWNER OV),S MA✓►/1 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by �/1 Tpt y 1 on F0/ Ai - a� acp � k ,a (33- Aq- » a 1 y lOCA TION SEWAGE PERMIT NO. �OVILL A 6 E 0-5—) 1 fit➢ ►L1:,t- A7:: t �-3 035 (�INSTA LLER'S NAME d ADDRESS «t UILDE R OR OWNER DA T E PERMIT ISSUED a� DAT E COMPLIANCE ISSUED �� Vj 10 U-S�- < . �f 4 - w,.