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HomeMy WebLinkAbout0030 BRIDGE STREET - Health 36 Bridge Street, Osterville A=116-007 I r 7 TO'WROF BA NSTABLE� �ldr - IP15TP,3�LERis NAiIx dt ODIE N, Sfi]�'I'iC TA11 CAIPAC�TY 4 � LACIItl�iG II.T'I"Y' fa) ptUII:1C►EI8 G)At AV+It~Tlap l�El g'T�bA'1t : CC�PrP�IPd�C�>X�ATE, Sopbratiot}�)xtwar�: et i*i Olt- Maximum Adjusted GrputeJwatet Table to the Battoly%bx X,eachtn�laat<ihtY r P�tvBa '1ntir�upplj►Vic: a��ct i�tx►sltia C�acautyf cmy�r:19s xis t OWN.0 ori-W in:�tl0 feet af�lencEut►�fnG��}') cc�9 Lti�i c�fi VN�t9a�►d and LOikd n lands .-- s+Dt{aiit'�QQ Ic.et l eucl�ftig�mcilicy 1FuralEiy b P 3 - ' a3`�`�' 9 � TOWN OFAB' 1.00p�`if�ON. v 'LA�:t; v ll e ss ss0a�s &;L T. IPdSTfL1.Ett'S N Bt ONE .777776 T�IQ s�a�c T�ai�i�c��crrx: L CI itNG PACILI'Jf } N© ( FEpR04NdS }3UI11�1EId OR 0 � .. _ . ion: . I3stweeiz t�e� i"ees Niaxttinum Adjustor!G��autAdw�tet T�GIe�tiac�attom:dt X,eachm�t�sci lity ' PrWjjB ' lq,L,t r Supply VfG�I s �c3 Y~en hin lac t�► a�►y�rriis exisi' �troe. ata s�tG or;:wlt�in�(lA feat aQ ionchirt�i'�G�t}�) ^-w' Ecl r;c��11U t and an d"lLeac�tl acclity�YF a�y wet{and5 exist � �F66 t+i4thrq'�QQ(eCIO$.tcuLi T g cy} 1 7 C rz�q e a � C13 y � l7` r fllv - 00 �L Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Fora, EI Subsurface Sewage Disposal System Form Not for Voluntary Assessments �� " !✓ 30 Bridge St (System 1 of 2 Front System) Property Address - -g N.7 Robert Moran Owner Owner's Name information is Osterville MA 02655 9-19-17 X required for every �• page. City/Town State Zip Code Date of Inspection had 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. A. General Information (54 .1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Service , Company Name P.O. Box 73 k Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification ,h , 1 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 FurtherfEv by the Local Approving Authority • 9-19'17 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 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 =nN, 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 V / Commonwealth of Massachusetts lay Title 5 Official Inspection Form f ' �I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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: System is in good working order with no sign of failure. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts a .a Title 5 Official Inspection Form ' 'i�l Subsurface Sewage Disposal System Form Not for.Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) _ a Property Address Robert Moran Owner Owner's Name .. information is Osterville - ' _ MA 02655 9-19-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if :pumps/alarms are repaired: °'` V B) System Conditionally Passes (cont.): El 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 �y❑ 'ND (Explain below): ❑ obstruction is'removed ' z ❑ 'Y ' ❑ N '-0 ND (Explain below): El distribution box is leveled or replaced 0 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 A❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N El ND (Explain below): C) Further Evaluation is;Required by the Board of•Health:„). .: 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 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:doc•rev.6/16, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts lay Title 5 Official Inspection Form :y1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is Osteryille MA 02655 9-19-17 required for every 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts f Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) d Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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, E 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`ll'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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Al „ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is Osteryille MA 02655 9-19-17 required for every 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): 5 Number of bedrooms (actual): 6 Total lpropertyr DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora., �-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El 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)): a. Detail 7A Sump pump? r ❑ Yes ® No Last date of occupancy: n„ 2017 Date Commercial/Industrial Flow Conditions: Type of Establishment: r 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.doc_•rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts r. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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: N/A 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts , Title 5 Official lnspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is Osterville MA 02655 9-19-17 required for every - page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 ► Were sewage odors detected when arriving at the site? + ❑ Yes ® No Building Sewer(locate on site plan): f 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain):' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: t 12"feet Material of construction: x ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 1 Commonwealth of Massachusetts a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t_ ! 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every osterville MA 02655 9-19-17 page. City/Town 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 20" Scum thickness 1" 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 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osteryille MA 02655 9-19-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) f Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: A • i Capacity: gallons ' Design Flow: , , - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract copy Is(required). co attached? El Yes El No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of,17 Po Ys - 9 Commonwealth of Massachusetts a�l Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town 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.): Good condition with water at working level and no sign of back-up from field. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 • Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is + required for every Osterville MA 02655 - 9-19-17 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: , El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: a , ' 1-1® leaching fields number, dimensions: 5x50 ❑ 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.): Leach field in good working order with no sign of back-up into d-box or surrounding stone. t Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction • Indication of groundwater inflow ❑ Yes ❑ No t5ins.dcc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts aa Title 5 Official Inspection Form { i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1'of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmepts - 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ' b ® hand-sketch in the area below ❑ drawing attached separately 4kr3 - ,5-1 w r +r ■ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts a} F Title 5 Official Inspection Form Subsurface OSewage Disposal System Form -Not for Voluntary Assessments a� 30 Bridge St (System 1 of 2 Front System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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: 10, feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts f� Title 5 Official . Inspection Form �W-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 1 of 2 Front System) Property Address -- - Robert Moran Owner Owner's Name information is required for every Osterville MA 02655' 9-19-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 00�- Commonwealth of Massachusetts :a= Title 5 Official Inspection Form I , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rri . F � 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran C0 Owner Owner's Name information is ,y required for every Osterville MA 02655 9-19-17 , page. City/Town State Zip Code Date of Inspection K' 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. A. General Information 1. Inspector:. Shawn Mcelroy Name of Inspector ' Upper Cape Septic Service Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification d I certify that I have personally inspected the sewage disposal system at this address and that the information reported,below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: 1 ' .gy ® Passes, , ❑ Conditionally Passes ❑ Fails. .. t❑ Needs Further EvaluatiqaAWhe Local Approving Authority ' 9-19-17 Inspector's Signature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of IHealth 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 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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every osterville MA 02655 9-19-17 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: System is in good working order with no sign of failure. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I __ r - ' Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � hV as, 30 Bridge St (System 2 of 2 Back System) f Property Address Robert Moran Owner Owner's Name information is required for every Osterville > MA 02655 9-19-17 page. City/Town - State Zip Code Date of Inspection B. Certification (cont.) 4 ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): 4_ El 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 0 ND (Explain below): r ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): A- , ' f ❑ 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 Lis removed ❑ Y ❑ N ❑ ND (Explain below): C) f urther 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts ` v'I Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins,doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I ` Commonwealth of Massachusetts :a= Title 5 Official Inspection Form 1 f. f. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r.. 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is Osterville MA 02655 9-19-17. required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) t 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. El ® 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. J. 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 � - i ❑ _❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts � Title 5 Official Inspection Form '�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �I 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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): 1 Number of bedrooms (actual): 6-Total for property DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts - ,a=1 Title 5 Official Inspection Fora Subsurface Sewage Disposal System.Form Not for Voluntary Assessments • ' 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville t MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? + ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) .w 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: 2017; Date Commercial/Industrial Flow Conditions: ti� •, Type of Establishment: Design flow;(based:on 310 CMR 15.203): fr Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): _ > Grease trap present? gk. ❑ Yes T❑ No I Industrial waste holding tank present? + ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �l I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): F General Information Pumping Records: Source of information: N/A 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts iaa Title 5 Official Inspection Fora a, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is Cisterville - MA 02655 9-19-17 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source,of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): , Depth below grade: 24"feet Material of construction: , ❑ cast iron ® 40 PVC ❑ other-(explain): y Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 1 g Depth below grade: feet Material of construction: f, ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years- Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" III t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts ^4 Title 5 Official Inspection Form l-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments es` 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town 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 20" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 6" I Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F a=1 fv Title 5 Official Inspection Form �'f4 Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments IY 30 Bridge St (System 2 of 2 Back System) Property Address - Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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 ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: w, Capacity: gallons, Design Flow: ;�,. :, gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �V, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osteryille MA 02655 9-19-17 page. City/Town 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.): Good condition with water at working level and no sign of back-up from field. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts (,� Title 5 Official Inspection Form -III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-flodiffusers ❑ 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.): Flodiffuser field in good working order with no sign of back-up into d-box or surrounding stone. 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 I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 , Commonwealth of Massachusetts :a Title 5 Official Inspection Form �. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions j Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts :- :a� ; Title 5 Official-Inspection Form } . I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) , Property Address Robert Moran ' Owner Owner's Name information is required for every Ostervflle MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r.: Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at feast 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 33 IV 67 t5ins.doc-rev.6/16, _ s, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts �a} Title 5 Official Inspection Form �+ 111-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 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: 10, feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Y 9 If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts =i Epp Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bridge St (System 2 of 2 Back System) Property Address ,. Robert Moran Owner Owner's Name information is required for every Osterville MA 02655 9-19-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file • - d ' t s♦ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17.of 17 TOWN OF BARNSTABLE ` �' 00/ LOG,+TION 30 SEWAGE # `1-7 VIII AGE � y'��Z ASSESSOR'S " & LOT b Ada 7 INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY .EACHING FACILITY: (type) tAR►c�`��� �!c��� (size) Jr➢C NO.OF BEDROOMS "BUILDER OR OWNER PERMITDATE: ` ` _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 001 2 yo '► � �C... Vic, �s tvZ� y� No. Fee/ ,0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Diopool *pgtem Cori.5truction Permit Application for a Permit to Construct(V)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -#..j O &Z I 60 6: �S T Owner's Name,Address and Tel.No. Z Z� 0 S T€!2 V i Li-F )e6 BCP2T /4 ag4A-1 Assessor's Map/Parcel //6/ ,7 y Installer's Name,Address,and Tel.No. 7 3 0 p 5 Designer's Name,Address and Tel.No. Z — F/31 JoF_ b10 i6tio �3�4x-teWC Disc Type of Building: Dwelling No.of Bedrooms S� t' Lot Size 01(0- '?y7 sq. ft. Garbage Grinder(A'14 Other Type of Building��✓1.4A _ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5� P1,4� ei gallons per day. Calculated daily flow gallons. Plan Date G v (9 — —7 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil aA _2 Nature of Repairs or Alterations(Answer when ap licable) T I s AJ 6 Svsrc (1q-10 ff 0 aE- U59 6 F'02 ,z gr-v,0-000,S 40C 7_ v 4 E 0s0 c V VW 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 Environmen Code and not to place the system in operation until a Certifi- cate of Compliance has bee issue y t ' Board of Health Signed Date l X h 5 Application Approved by Date E���7 Application Disapproved for the9ollowiW reasons Permit No. r Date Issued (`-F 't - •+ma's \ ��r'a"/n No. Sc c Fee/ -0 THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIpprtcatton for, �Dt.5 ogal,-& .5tem Cow6truction Permit Application for a Permit to Construct(✓ )Repair( . )Upgrade( ).Abandon( ) El Complete System. ❑Individual Components Location Address or Lot No.•0 5 0 4 0 T Owner's Name,Address and Tel.No. ?-7( /0 qG G 1TER v IG.L,F_ 2T" Assessor's Map/Parcel Installer's Name,Address,and Tel.No. t�a 3 O p `,� Designer's Name,Address and Tel.No. q z i­ /F/3/ Joc DI C //qaU /34x reR 7 tiY Type of Building: Dwelling No.of Bedrooms S f' Lot Size a tO k�/rj sq.ft. Garbage Grinder(NJ Other Type of BuildingGU -TAa V_ No. of Persons. Showers( ) Cafeteria( ) Other Fixtures Design Flow 566 PL441 gallons per day. Calculated daily flow gallons. Plan Date _ 01 Number of sheets s .Revision Date r Title . Size of Septic Tank Type of S.A.S. Description of Soil r I Nature of Repairs or Alterations(Answer when anDDlicable) g: + THE �X r 5T lit./ 6 5Y5T� C�'�`�Yq U 13r U56 6 Fo2. Z 6.60A00.0 S 40C►4 r—b gad V E 46E !5 0V A� rat- t( Date last inspected: Agreement: { The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 3 in accordance with the provisions of Title 5 of the Environmen 1 Cod su e and not to place the system in operation until a Certifi- cate of Compliance has beerrise y t s Board of Heal Signed Date A Application Approved by Date Jn Application Disapproved for the ollowi g reasons Permit No, / 7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS i i BARNSTABLE, MASSACHUSETTS Certificate of (Compliance" THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed O Repaired( )UpgradedAbandoned( )by /.E at has been constructed�inaccordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No. _t 9 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system ill function as designed. Date Inspector No. - 5 t Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS r lwtgogal 6potem Con!6tructton Permit �t Permission is hereby granted to Construct( )Repair( )_Upgrade�).Abandon -System-locat d 2,t, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be competed within three years of the date of this p. Date: ��" �'� Approved by i. TOWN OF BARNSTABLE n :,:.LOCATION 3D �� SEWAGE # `11 ..,•'VII.LAGE C �eR'U�\l�- ASSESSOR'S MAP & LOT _aa INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY :>.:.; LEACHING FACILITY: (type) .(.fit P A"t'S � l (size) $➢C NO.OF BEDROOMS S f BUILDER OR OWNERkA PERMrrDATE: J I ``1 , �� COMPLIANCE DATE: Separation Distance Between the: ;: ;'Maximum Adjusted Groundwater Table and Bottom of Leaching Facility,.,, Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet :•``Edge of Wetland and Leaching Facility(If any wetlands exist `a within 300 feet of leaching facility) Feet Furnished by + q *,2 �� zh Ll hh ' IVY$ fi V 2� r I •f DATE: _ 5/1 PROPERTY AODRESS: 30 Bride Street Am Mir ,, T9yy � .3 , Osterville,Mass . yFP,T_g5`139 02655 Z On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1500 -gallon septic tank. CD 2. 4-Flow Diffussors 3. 1-Distribution box. Based cn my Inaoectlon, I certify the following conditions: 1 . This is a- title. five septic system. ( 78 Code ) . 2. The .s_eptic system ' is' in proper working order at -the present time. SIGNATURE: G %1 Name J P Macomber Jr... i r ------- Company:_'• P_Macocgber & Son- 'Inc .. ; Address:_-B,;.x_,6g_-____A--__-- Cente�rvilleLMass__024632 ` Phone:___508.�Z_75�.3338------- "-i THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER, & SOS, INC. Tanks-Ceupools-Leechflelds . Pumped & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 77.3-3338 775-6412 . U Commonwealth of Mossachusetts ExecutNe Office of Environmental Affairs Department of Environmental Protection vNUlam F.weld Trudy Coca Arpeo Paul CeUucd s"-"" David S.Struhs LL 6oert+or Cornmsiorw • I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop"Addrees 30 Bridge Street Osterville,Mass . Address or owner..700 Pleasant Street D-leofInsPecuon:5/15/97 (It different) New Bedford,Mass. Nfaeoflndpeotor.J.P.Macomber Jr. 02740 Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 8enterville,Mass . 02632 CERTIFICATION STATEMENT 508-775-3338 I cutdY that I have passonay inspected the"wage disposal system at this address and that the information reported below is trtirs,aocumts and complete as of the time of inspection. Tha laspection was performed based on slay training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: - Conditionauy Passes _ Needs Further Evaluation s�By the Local Approving Authority Falls l k�,L�'�T- pector's Slgaatura: Date: s"ls 7 The System Inspector&hall submit a copy of this lnspedI6 report to the Approving Authority within thirty(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&hall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be seat to the system owner:tied copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check& B. C, or D: A) SYSTEM PASSES: I haw not found Lay information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: / One or more system Components need to be replaced or repaired. The system,upon completion of the replacement or repair,passed inspection. Tndicste Yet,DO,or not determined(Y, N,or ND). Describe basis of determiaatioa in all instances. If" of determined•;explain why not) /0 The septic tank is metal,cracked,structurally unsound,shows substantial inflltratioa or exSltratio immiasat. The a,.or teak failure issystem will pass inspection if the existing septic tank is replaced with&.conforming septic tank as apProved bu the Board of Health. (revised 11/03/95) 1 One winter Street a Boston,Massachusetts 02108 a FAX(617)S56-1049 a Telephone(617)292•5500 0 hlmd on R"Ied Pape suB9URPACE SEWAox b18PoSAL SYSTEM INSPECTION PORM PART A CERTIFICATION(oontlnued) 30 Bridge Street Osterville,Mass . owasn John Bently Date of lwp.otioat 5/1 5/9 7 B)SYSTEM CONDITIONALLY PASSES (oontiawd) �Q 6r.age backup or break mA or ho static water lsvek observed in the distritAW=box is due to brolea or ob w=tad pip-(,) or dw to a broker~settled or uneven distrbAiom boa. Ths system will pus Inspection if(with approval of tha Board of Haalth)o broken pipes)are nplsoad obstruction Is removed distribution bas Is lave or replaced AP The system required pumping man than tour times a year dw to broken or obstru pipe(). The Vow= wal Pau inspection It(with approval of the Board of Health): broken p)pe(s)are replaced obetnutlon b nmowd C) FURTHER EVALUATION 18 REQUIRED BY THE BOARD OF HEALTH, Coaditioas exist which require Mrther evaluation by the Board of Health in order to detarmias it the system is 4ai0i to proc.c: Lha public b"Ith,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENM a C"' L within 60 feet of•surface w SL p�or privy .ear d& Cesspool or privy Is within 60(aetbf a bordering vegetated wetland or a rah marsh 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMIMES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank had soil absorption syetsm mud is within 100 bet to a Surface water supply or trt to a sur400 water supply. The eystam has a septic tank and soh absorption system and Is within a Zone I of a public water supply well I6 The ovum has a septic tank and coil fb.orption system and Is within 60 feet of a private water supply wsl /VO The systsm Dace a septic tank and soil absorption system had In Isar than 100 bet but 60 feet or man from a private water supply w4 ualss a well water aaabsls for oolltorm bacteria and volatile o gaaic oompouade indicates that the .all is &... !}om polhttba from that facility Lad the prewnos of Lmmonla nitrogen and nitrate nitrogen is equal to or lw than 6 ppm 3) OTHER (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddress:30 Bridge Street Osterville,Mass . Owner. John Bently Data of Inspootion5/15/9 7 D) SYSTEM FAIL& I ban dourmiaod that the gsum violates one or more of the following Ullurt criteria as dadaad in 310 CUR 16.303. The basis for this determination is idant'W below. The Board of Health should be Contacted to determine what will be asousary to co:. the iaiturs. Backup of"wage Law facility or system component due to an overloaded or clogpd SAS or owspool. Discharge or ponding of efDuent to the surface of the ground or susfaa 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 Is"than 6"below invert or available volume is less than 1/2 day Dow. !� 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 foot of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public wall. Any portion of a cesspool or privy is within 60 feet of a private water ea➢➢ly well. Any portion of a cesspool or privy is less than 100 feet but greatar than 60 fact hvm a private water supply wall with no ao=ptablo water quality analysis. If the well has been analysed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 4V The system serves a facility with a design Dow of 10,000 gpd or greater(Large System)and the system is a sigmid— threat to publ heahh and safety and the environment because one or more of tha following Conditions wrist: the system is within 400 feet of a surface drinldag water supply the gets=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 pubb water supply well) The owmar or operator of any such system shall bring the system and f=Wq into i1r11 compliance with the groundwater treatment program requirements:of 314 CUR 6.00 and 6.00. Please consult the local regional oDlos of the Department for Author information.. (revised 11/03M) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propartymdma 30 Bridge Street Osterville,Mass . Owner. John Bently Date of Inspeotlom 5/1 5/9 7 • Check if the&Bowing have been dose: , 9Pnmiping information was requested of the ownar,occupant,and Board of Health. Zone of the aystam components have been pumped for at least two weeks and the during that period. Large vohimeses of water have not been introduoW into the a been receiving normal flow rota, system ro=tjY or as pan of this insp.etioa. ZA,bulk plans have bean obtained mad"amined. Now If they are not availabL with N/A. - The facility or dwelling was inspected for signs of sewage back-up. 1 The system does not receive non-sanitary or industrial waste flow , The site was inspected for sips of breakout. ZAll sYd*m oomponanL, udiag the Soil Absorption System,have been located on the sits. , The septic task manholes were uncpveredl opened,and the interior of the septic tank was ins for=Aition tees,material of ce 1?ected of baIDes or natructlon,diminsloas,depth of liquid,depth of sludge,depth of scum. � ,/The aise and location of the Soil Absorption System on the site has been,determined based on existing information or ./a proximated by non-Intrusive,methods. Ths facility owner(and pants,if dilfwvat from owner)we Surface Disposal System. provided with information on the Proper maintenance of Sub. revi( red 11 03 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAd&v" 30 Bridge Street Osterville,Mass . O vner. John Bently Date of Inspecilow5/15/97 FLOW CONDITIONS RFSIDENTIAL- J Design Ilow-_4jyepi�' Number of bedrooms: Number of currant reLldtnt Garbage grinder(yes or no)._101 Qa Laundry connected to system or no):� Seasonal use(yee or no)mr Water meter reading,it available i iZAP,- 4 4r S% Last date of occupancy:_�/� COMM ERC IAL/I ND USTRLAL Type of establishment:_ A/A Design flow: AIR pIIons/day Grease trap present: (yes or now—A Industrial Waste Holding Tank present:(yes or no)Xh Non•sankary waste discharged to the Title 6 system: (yes or no)lu Water motor reading, if available: ATV Last date of occupancy:— AM—OTHER (Describe) 1)A Last date of occupancy: A)IQ GENERAL INFORMATION PUMPING RECORDS and sogrce of rmation: AAAQ System pumped ex part of inspection: (yes or no) If yea,volume P=P�.��rallons Reason for pumping: _ TYPE_,4F SYSTEM Septic taah/distribution bca/soil absorption system Siagie cesspool . lll� Overflow cesspool �.� Privy Shared system(yes or no) (if yes, attach previous inspection records,if Lay) Other(explain) APP TE FeE of all components, data la.rtalled(if known)cad source of information: l le.ei� Sewage Odom detected when arriving at the site: (yes or no) (revised 11/o3/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 30 Bridge Street Osterville ,Mass . Owner: John Bently Date of Inspection: 5/15/97 SEPTIC TANK:���A' �"'�' �'�� e . (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP_other(explain) Dimensions:,f4 ` r i Sludge depth: Distance from to %Iudge to bottom of outlet tee or baffle:,",f�,L, Scum thickness:A"� Distance from top of scum to top of outlet tee or baff1e:;,7;-A.4_-, Distance from bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level In relation to outlet invert, structural rity, evidence of leakage, etc.) F mmp_septie' .tank e-very 2-3 years : Inlet and 0utlet- t It . Seialic tank of the GREASE TRAP. (locate on site plan) Depth below grade:;v Material of cons(n.onion-' ..oncrete _metal _FRP—other(explain) Dimensions; Scum thickness: �- Distance from top v( scum to top of outlet tee or baffle:_4_2 Distance from bottom nt srun+ to honom of ouuet tee or tsaltle:44 Comments: (recommendation for pumping, condil-nn of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, structural integrity, evidence of leakage, ett.i�_�, (;rAaRP t.rnj i C nnt. =nrp`sent, s I, (revised I/1S/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) p,.p.AyAdd,.a 30 Bridge Street Osterville,Mass . owner. John Bently D&W of Inspection: 5/1 5/9 7 TIGHT OR BOLDING TANX-ffA"- Uoosts an site plan) e Depth below� Material of construction:126crets metal—f RP_otbs upww - Dimensions: A14 Capacity da sallons Deep flow: i iWday Alarm lswl• AJ Comments: (oondition of inlet too,condit, a of alarm and float switches,etc.) _Tight or holing tanks are no -present. DISTRIBUTION BOX: .Z (locate an site plan) Depth of liquid level above outlet invert: Ae Comments: (not*if level and distrilutioa is equal,evidence of solids carryover evidence of lMe knoe into or out of ban,•tc.) Distribution box .is level has to laterals eedin the four ilow i . Sep 11a�ee4cc oog solidscars over: o evidence o .eata e ri ak .a o e distribution box. no repairs neectecL at. l��e PUMP CHAMBER, /K, (locate on sits plan) Pumps in working orden(M or no)__4.),4 Comments: (note condition of pump chamber,condition of pumps and appuftenances,stc.) pump rhambPr lS nn+. nrPCAnt. (revised 11/03/95) i SUSSURPACE SEWAGE DISPOSAL 9YBTEM MSPECTION FORM PART C SYSTEM INFORMATION(000tinuod) 30 Bridge Street Osterville,Mass . Ovosrt John Bently Dats or Iaspeocuaw 5/15/9 7 SOIL ABSORPTION 6YS=(SAS _Z Oocsu an s$s plu6 if possible;euavat vgairv4 but my be appradmatsd by Doodatrnsivs mmhods) e If not determined to be pr "u4.apWw Typ« a 6ulklnt P11"Jed,aumbe::, 6441410r trOMC11A cumber laayth W41%ln j fields,number,d+ = l warno.cesspool ouu+bsr,�' Cam—mats.(note condition of e4 aigum of lydrsulia fauure level of poudir&ooadition of TV tadac6eta.) Madinm Gan(i * No Cigna of h;Ldraulio failure :No _ evel 67 T)on inR: All v6s@%atioN is "^"Mal Nn "epaire nmPrIpa at. t.hA =rF spnt tim CEWPOOLS1 Oast an s84 plan) Nampa and om4watioo: Depth-op of UquW to iabt iavart.. Depth of sa=lyv Dimsad=0 of o�spool: ILataiake of oonasxme ion Indiatioa of pouad.atar: imfl (oeespool must be pumped ss part of inspection) ('.accpr)nl c nra nnt. I)rAE1P.nt. Com-1, (note ooadW=of&4 silos of hydraaki0 Wk m level of poadia&condition of vegetsdoa,etc.) �66C+jaAA�s "'� nnt. rracant. PRIVYs&OAZ Ooaa an sits PUA) HiterkL cf 00a4rudios Depth of wbds:_&& Cam—lf (Dots 0aaditiaa of soil,suns of k v sulie Uure,I"of poadW&condition of v.gdatioa, Privy is not present (rrvisod 11/03/95)• i TOWN OF BARNSTABLE LOC��ON SEWAGE # VILLAGE D S i -? ASSESSOR'S MAP & LOT //4—yo, INSTALLER'S NAME 6r PHONE NO. AQ c N (c w,s 1 SEPTIC TANK CAPACITY. : LEACHING FACILITYAtype)&} 47uSS 6 zs (size) I-2-X X NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER '72 F �i T�E Y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes No 37 5S I - •RRr1f•.f—n'rT/*�.rT•ffnrarrr•nt.nllTrr+.+T.rR.nr.•srrT.R►ITrRRnn tte17i1A•a7fnsT T1T'T.a—n—:..--.r Barnstable IUNN OF BOARD OF HEALTH SUASUIIFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION '� F.�•4PI�T••.•::f—T.1.R�.TTT.T}T1',I.T111"'ITIRifflR'71Trr—.5'1-7RTttrR /�:'�7 VMS .;`"I'T'T•1.— -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 30 Bridge Street Osterville,Mass . ASSESSORS MAP, BLOCK AND PARCEL # 116-007 OWNER' s NAME John Bently PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & S W 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 08 ) 775 33389 FAX ( 508 790 1578 !T CERTIFICATION STATEMENT ° I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true # accurate , and complete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgr_ade , maintenance. and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXXXXXXXXXXXSysteui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con acted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector SignatureZ4Zffdd1dWX& Date 5 15/97 R O[.•."iiR.Zy One copy of this tification must be provided to the OWNER, the BUYER ( where applicable) and the DOARD 08' HEALTH, * If the inspection FAILED, the owner or"'o` erator shall up grade pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in .3.10 CMR 16 . 305 . partd .doc ��� . .-•c�>-. SAC �G woo _ SbyY 3r71 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF E ONM[ENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, 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. ,unc a, 1995 Acting Director of the ' ion of Water Pollution Control 1 4f P„ TOWN OF BARNSTABLE LO&ON SEWAGE # VILLAGE 0,5%,f-2 I/l�l/�? ASSESSOR'S MAP LOT ' INSTALLER'S NAME & PHONE NO. Aec-o •y i 7J:v ��� SEPTIC TANK CAPACITY -.N®Z> dr/o l� 4 kEACHING FACILITY:(type)a5,7, n0f ,PAO"E zs (size) /-2—Y -Z NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER BE 1v T Ile-m Y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �� 11?� VARIANCE GRANTED: Yes No �- 4.� ,37 31 �q .ems ova� A ESS®RS KAP NO/V-2 No.........Y77!C01/? ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diripwiul Hlork,s Towitrnrtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at: , Do -------•---------•--•-•--------•----•-------------------•---•----------------.......••-•-------- 'ofltion-:\ddr•'� or Lot No. - l� ......................,.. - y •--••-- ------------------------------__--------------................................................ Oene„ � % Address a A!?�� �wST . .<S Installer Address Q Type of Building Size Lot............................Sq. feet V DwellingNo. of Bedrooms.-_-_._ ___ -----------Expansion Attic Garbage.Grinder aOther—Type. of Building ____________________________ No.�of persons----------------_----------- Showers ( ) — Cafeteria ( ) d Other fixtures ----------------------------- w Design Flow............................_-__-_-.____--_gallons per person per day. Total daily flow--------------____..........................gallons. 9 Septic Tank—Liquid capacity------------gallons Length----------- Width---------------- Diameter..... .......... Depth................ Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------..:---------- Diameter-------------------- Depth below inlet.................... Total leaching area............._....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......-.................................................................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ......................•-----••-•------------••---•--•-•----------•......------------•--•-•--•---............................................................ 0 x Description of Soil........................................................................................................................................................................ - U .............................................. ------------------._.._...--••••----...•-------------••••••---•-•--•-----------•-----------•--•-------•-----•------•--•-----••--••.......--------•-------- w _ ,F U Nature of airs or trerations—Answer when applicable._ T��-_-- -__------�!.-0. ........................................... - -�owvs "cZ 'o. ....----------------------------------------------------=..- Agreement: t= s The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE S;of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sue y the boar of health. - ................... ......... - -................. �1(... ...�1`+..�...... Dace Application Approved By .............................................--- -- ................................................. ........................................ Application Disapproved for the following reasons: .. ...... .......................................................:............................................................ ............................................................ ...... ...................... . ---- ------------ ............ ..-------- *......... ........ Permit No. .......�....�.........(�..�.................... Issued ...... .:. .....I j .-.l............ Dare...... Da No�. � ` _ C� 7 Fss .�. THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH TOWN OF BARNSTABLE . pphration for Di,Vwial Works Tv'it,it'rurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. .................................................................................................. Address O�cnc Installer ess of a2�y �v...ST �' A-��� -If U TypeDwellingBuilding No. of Bedrooms.......7.1.................................Expansion Attic SizerLot-Garbage Grinder feet, aOther Type of Building ............................ No. of persons---------------------(--.-.)Showers ( ) Cafeteria ( ) 04 Other fixtures ------------------------------------------------•. d -------------------------------- ------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter----- .......... Depth................ x Disposal Trench—No. ..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) est a Percolation Test Pit No'2lsults Minutes per by Depth of Test Pit...................• Depth to ground water---_.................... a T G%4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a' 0 Description of.Soil......................................................................................................... ------------------•---------••--•--•-•--.....-------•-----•-- x w -----------------.: - U Nature of Repairs or Alterations—Answer when applicable.�T,�_._._ ____..__./ _ ���, ...............................................................................................•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE.5 of the State Environmental 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. -- .. Si /nei�y ...................✓' � ... Dare ApplicationApproved By .......... . ....:............................................................._.---...--------------'................... ........................................ Dare i Application Disapproved for the following reasons: ......... .................................................................................... .......... .. ............_` .....--.........._............ .. ........................................ / Date PermitNo. .......�....�.........C..Q .................. Issued ......�.�.:. ... .. ....................... Dat i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE LLPrtifirate of Complianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ! by ffZ ..... .... J _ .__----------------------------------..._-----------_. ......... � I : cr I I, has been installed in accordance with the provisions of TITLE 5 o The State Env' onmental Code .s described in the application for Disposal Works Construction Permit No. .__--- _-._.CO.. dated ......�/ I/........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ DATE..... _..... - __. Inspect(y-,� ....__ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c� L/ _�y 9 TOWN OF BARNSTABLE - No...........-........ FEE 0.......... �r�� �>att�tr�trtilan �rrmit Permission is hereby granted / •C�-------------------- - to Construct ( or Repair (---).,an do ividual Sewage Disposal System ---------------(5 -------- ............... --- Street as shown on the application for Disposal Works Construction Permit No.--1LJ_(a. ___ Dated------11 .�Y Board of Health DATE........ -- / ............................................. FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS �) Cal TIt�1Ce Je-(JTIC SYS-r6Frn i ~ '• • ' 4o be reusc- 4C,r- -two bedrndrv,s A6cvc �areae: t.jrK0 .� �• Pau+- flow c?, �us�rs w }� Z.1 o•f 5�'onC I 1 sldcwcll ^ � rs •' � � � �; '' I S _ ' • o • p'+12 '�x Z I C2o X IZ.r - 304 51 PK NAIL SET i .. • ; `J'1' Z Z 5 EL =s 10.07' 10.1 _,rr:;:;?fY=,, t •^ . S •. Stp4-ic �•a n 1t - I S oC) cJ� 11 a h s CB/DH FOUNDS 10.8 j r� •',' \ / G �� 2) 'PROP >%eO 5t-p-Ic. SYS'Tk:rr1 � ( f1vc bcdiroo✓v1,S -Y"cc"'j .'1ouS G J ,4 �/ \ 6 • o, , r bdrms x I10 �psO/bclrvvl = SS0 ! pFO ne 9a. lo�,�c 5rt,,, er ~ r o o 550 3P� o.-7 4 tjp.1/zv- = 749 SF O / #0 _ • Lca6i,n FicicQ I5'x 50 ' = -750SF e r I US,� ISoO Cjalluv, Se�li7c �an1t }• / _7If p� \ LOCA110N MAP BRB FOUND C SCALE: 1:25,OGOTUIT LE `� ' +l: { �', \ \ MAP 116 PARCEL 7 Ili �S ry ASSESSORS INS 9,3 '11.1 � IM[ 91Nd Isoa r .f•+ PK NAIL SET \ ZONES: /cec1,.S F• /c/ I SIB b 6,(6 o S EL - 11.11' I`I� AQUIFER PROTEC11ON OVERLAY DISTRICT $•� 6�1 • �`�/ IRON PIPE FOUND 1trQ1 .1 1'kr. r4.0 P r \ ZONING DISTRICT: RC Sc he C! MINIMUMS 3D- - ,� ,y AREA 43,560 S. F. 4.8 Tctnl� T �► �'6, ,�'�' � Q '� \ FRONTAGEP. - 20' r WIDTH - 100' i ^ 8^ •�I� G, x 10. y- O \ �''r'"j�," �p� �c J '� ''f j. FRONT DE SETBACK 10' VE� ll� ~ QP t 17 -f C �- \ A REAR SETBACK 10' PLO F Q'� O ,�4 � qp F 10.7 7 ��d •. io a 10.8 x 1 8 a C '� FLOOD ZONE: A13 (EL 11) 6• ti \ � FIRM COMMUNITY PANEL 9.7 10.d ® ,yh' No. 250001 0016 D & 0018 D k \ h / REVISED: JULY 2, 1992 Q / 0.6 4 '�� S \ `i ELEVATION DATUM IS NGVD 10.2 P- 2 ►�cp a+o.,c \V� J L A W N 3� 6" CB/DI•I FOUND %2., Wc.skeat 5+one. \ O�� ,. '� x 10.8 H R U 8 S •2 k < '` _ o x 9.7 F / z S s Zy \ .�'o 10.0 Q m ,, �o� c s►,cw Nd TES 7/1 8.2 { 'i r 1, �xrshn �jo�.sC / 9�,ra�c Shta✓ fa (7G rlGZcc� x 10.3 ,atr /cachin� ��/s+C Dar'ai/ STAKE SET . 10.1 �Ib,�� �, • EL 10.10' i x ZONE , �q"' � vi- �o�cd p sic Jy CB/DH FOUND .� (EL �) '' , a x b.8 7 ' �7.3 /s ccv,�d✓.•� lir, //a��/ica,�/c !v .. 2 O , -C f0/a, hates '" cc+,stsuct�ur, wi t�,I.� n {/vac0/a/ai 7 9 x y / 3. E>trs•hnj se - .?�j7/zr,� /oeahn, rs /0e✓-• iQirr►�iE 0 �� 1� �' x to.s •1 .�` 7.e f-4 44`7, T be /eose� c� 0,7�11 .94'��sF o \ ' � rt� L A Yr it ''10.4 �;�/' �' N�t'It�, a�'. <J R '� \. ,. �' 1-- /oadin9 rla f= ( l nc %if/c �J !� O �� / c .6 18m TREE c tiv ; j'4 x 7.3 x 8.0 PK NAIL SET EL 6.97' �y $ �t,p67/3 7.0 0 / c 7 1�f�,° �,�41�� .r , n.���,�., / 10.4 Z O N E A 1 3 ' S Q / 0 x 10.2 0., 0"q-, % x 0 / { / : r ( ») \ LAWN ,• ,.���o0��o �. 3• t 1. '10.1 � r. rD.�o x el 10 X 10 ? b9' 10.2 ��� 4 ca / Rcmo.rc /Rc,zc 10.1 'f .* 1.�tt L A W N exrs 1-7--1 h�a vse x 10.3 ry F _ ` 0.2 x �� w6.3 � / \ STAKE SETS ' Tp \ S r\ EL 10.26 r d F ,0.0 41 \ P A R C E R • � , �, / x 9. 26, S PO ';04 \ '7 °% / S I T E P L A N AT _ 'x� 1•f F,I \ 030 BRIDGE STREET IRON PIPE F UND DA-r A P- 9009 \ / osrERVILLE Mass. TcS+ b� St�vL Gilson P!•. FOR k R l.O,fr)cssecQ bx ' Scrrn buv�h,.•.q 4 ROBERT MORAN DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Ilorizon Soil Texture Soil Color 1 Soil Other ,r' r^ A !/ •t�l,`�y Surface(in.) (USDA) (Munsell) I Mottling Structure-10 ,Stones,Boulderes. / SCALE: 1 20 JUNE 25t 1997 f•?FvIsED SEPT. Z3 1957 of O-b A Sa c/ I-fd- io VR 513 - BAXTER & NC. 9TEPHEN �•I "-2,4" D .� / Loy.., /u vK G 8' - / NYE,' ALL.YN - 6S o loop' SON o �` Co Z CGRT-►FY T 14AT -THE PROPOSED M2U05G: i 13ARN 812 MAIN STREET I %k z4°_1zo• c s, ./ �.sye � 4 �le� I, o o'�,� p SHowN �t�le�vu COMP -40S WITH -n-Itr SI05L1,�1li OSTERVILLE, MASS., 02655 plLaezrls AND Scrc5AC/r Rc=ou/rrb.n�>ur-s of T <nx 7)WA1 (508)-428-9131 0 A SF'eC1AL FCvo1? ClA2A#e0 20A/C ; 9/Z3193 DEEP OBSERVATION HOLE LOG Hole# 2 ti/e.o �µ OF , Depth from Soil Horizon S(USDA Texture Soil(MuCnslor Soli Olhtr "`�J C �- 1 'M l GRAPHIC SCALE Surface(1n) (USDA) (Munsell) Mottling SWcture,Stones,Douldeses. 0-4 f} So�c/ 1 na,.� /v YQ 5�Z / 4ICA.FO 20 0 10 20 40 do A. WCTER u ro-24 ,Q �wno/ Lenin /0 Y'/Z S B / b021048 Z '-120' C 5.�,</ �a ya 7 g - �h�p ioc G I c u 1 , Z vav ( w FI�LT ) I inch 20 ft 6ffs�is �,n 48u i/c//�qs- Shoe,/c/ �'Jo t 01 Use-c/ 76 BRB FOUND .J 97057 (SITEOI.DWG) , 1 I