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HomeMy WebLinkAbout0355 BRIDGE STREET - Health 355 0 S4r ill-n 055- 003 4 4 I I I SMEAD KEEPING YOU ORGANIZED No. 12134 2-153LGN SFORESTRY USTAINABLE� bIW RECYCLED IN CONTENT10%AMk FIM CMified Rb.r Sourcing POST-C= www.efiDroprr,m,otg 8"129D MADE W USA GET ORGANIZED AT SMEAUM No.- ---�- ` Fee-- — -lJ--c BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicat ion-*r Melt CongtructionAermit Application is hereby made for a permit to Construct (t j, Alter ( ), or Repair ( )an individual Well at: 'ASS �/t 3ja 65NtUi L t-u Location — Address Assessors Map and Parcel /) — Owner Address / 6 Installer — Driller Address Type of Building Dwelling--------------------------------------------------------- Other - Type of Building ------ No. of Persons----------_-_----- i� Type of Well—Y—-=L---------- — --- - Capacity--- - ---——- -- --— Purpose of Well-�iL _hj Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed - —---——-- — J �'Y�/f — n / date Application Approved Byly date Application Disapproved for the following reasons: ------ --_ --- ------—------------------—------- ----------------------- date Permit No. ` L — _— Issued---''— -/ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO C-41FIFY, That the Individual Well Constructed ( '7, Altered ( ), or Repaired ( ) ---------------------— -- ---- — J/ Installer at 3S S �v sr: dS�`r y, -----____-- ----- —_-_—-- -- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection �p Regulation as described in the application for Well Construction Permit No/`,/4, -%'O` Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- Inspector------—- - —----------- i No.-l'-'----= f --f Fee-- ------- ti BOARD, OF HEALTH 4 TO N7 OF BAR=NSTABLE.. 2 1 w. pplic tion fi.t Wrlr con!o t �t errrtit Application is hereby made fora permit to,Construct ( /f Alter ( ),,or Repair ( )an individual Well at: 3SS 13�� � S7 0.5�c -- - — Location 'Addres .x� a� wt ,Assessorsavlap and'Pazcel �^ L v o� S r, S J4� Ji`C l pf i ' --- �' 3 5 �S r S T �— — - --- - Owner ---_� Address - CSC(_1 J O [�----'-- ----------- ! Installer _ Driller k Type of Building Dwelling ---- ------ Other - Type'-.of Building,--.-------- No. of Persons-'— - - -— --- �( Type of Well_y ='- F - -- -- Capacity - - ---— 1 Pu ose of Well v �. (, rp {-- t' r Agreement \\\ The undersigned`:agrees to.install the'aforede'scnbe,d.'individual'well'in accordance with the provisions of The i r 'Town.of'Barnstable bard of Healt Private Well Protection Regulation The undersigned further ag ees not to place the well,,in op,ration-until a- ertificate.of Compliance hag.been issued by 'the Board'of Health. ; Signed `� --- G� — -- —— -- _ - date Application Approved By _— date' Application Disapproved.for''the_following reasons .t �a date - Permit No, - _ Issued -- ------/"p - —----- I G date �b►,r. eat:.46aaya+r�+�►aK+etiaesti�..�a±:.�•woas6a:•ioirataa?i4eee:a��ea.�esessea: eata3aew�a:asaasae:ems+mraga�ataaa�fi•,:Psw*a�is�a�e.4vroet.?i9marma.�:,wryoeraca.asar.?��v4s.�.�� f BOARD OF HEALTH TOWN OF BARNSTABLE - �Certifirate Of comCiuce THIS,IS TO.0 IFY, That the Individual Well:Constructed''(' Altered ( ), or Repaired ( ) CI �GrvrV9 by---- -=-----�(-- — --- --•------ -----$ ------------------------- ----- Installer at 3SS i3�� Sl dSTc�y; has been installed in *accordance with the provisions'of.the Town of Barnstable Board o Health Private 1Ne11 Protection k Regulation as'-.described in the"application-for Well ConstructionPermit No '�R----- 'O� Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION.SATISFACTORY: t DATE ---- - . •, `" =- �` — Inspector..-- -----_— - ---------------=— -- !o.W�T.e+�WiOi'i.�GobRiNl29iM oeiKP�!sl�Le , s ie4'1ieMdNa)iRae�ma�aea9a4a9a4fa4a�ali4'iiKQ�ieawi�GQw9i1!i}1yl�4aea9oa�KmaLila^o^i4fi'ItiH_a�'�'y3 ir�iTi?im�i"aP.a�i?isiiVss. Sa WaP'RiT' BOARD OF HEALTH . TOWN OF BARNSI�'AB;LE Well Contruct ion Permt t No:.--- -- n Fee Permission is hereby granted_ ID A J - to Construct (✓), Alter ( , ); or R' air ( :Y. an Individ 1 Well at: -No. S . !��`.i�— — - - --- - - - — - Street I as shown o� the application for a Well Construction.Permit r t No. Dated S ;,, Board of Health DATE f Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 355 BRIDGE ST Property Address COPELAND ' Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. 'Inspector: . onlythe tab key Y to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. ,DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. 'Certification I certify that 1 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 pursua Section"-3 Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑CaRz Is ❑ Needs Further Evaluation by the Local Approving Authority ' 1/14/13 Inspector' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. l ****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. _ 3 t5ins-11/10 Title 5 al 1 action Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 355 BRIDGE ST , Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. Cityfrown 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: SEPTIC TANK AND D-BOX WERE OPENED AND FOUND TO BE IN WORKING ORDER AT TIME OF INSPECTION. NO OBSERVATION PORTS WERE FOUND ON S.A.S SO IT WAS NOT OPENED 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 exMtration 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth.&Massachusetts w a Title 5 Official Inspection+for'M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , ,M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name 4 information is - MA , 1/14/13 . required for OSTERVILLE ° every page. Cityfrown L State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont) ° Observation of sewage backup or break out or high static water level in the distribution box due j to broken or obstructed pipe(s) or due to a broken, settled or,unevendistribution'box. System will pass inspection if(With approval of Board of Health): broken pipe(s)are:replaced "`❑,Y ❑ N ❑ rND (Explain below): - ❑ obstruction is"removed ❑ Y.'',❑; N ❑---ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ,❑ N ❑ ND (ExplaAn 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)-, ❑a broken pipe(s)are7replaced ❑ Y ❑ N ❑_ND(Explain below): ; ❑ a °;obstruction is removed ❑ -Y ❑ 'N • ❑T ND'(Explain below): x s C) Further Evaluation.,is Required by the Board of Health: k ❑: Conditions`exist which require further evaluation'by the Board of Health in order.to determine if the system_is failing to protect`public, ealth, 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 " 6ins•11/10 , ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•'Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r M Syey`ew 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. Cityfrown State ', Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the-Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ - The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply wel(. ❑ 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: w You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® r 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 town overloaded or clogged SAS or cesspool, El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. Cityrrown State Zip Code. Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed of a`f3EP certified laboratory,for fecal coliform bacteria indicates absent'and*the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd: For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ . ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a'nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��M a 355 BRIDGE ST Property Address COPELAND Owner Owner's Name. information is required for OSTERVILLE MA 1/14/13 every page. CitylTown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR'15.203 (for example: 110 gpd x,#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage_Disposal System Form -Not for Voluntary Assessments ,M 355 BRIDGE ST Property Address - COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. City/Town State Zip Code Date of Inspection D. System Information . Description: ACCORDING TO'AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON.SEPTIC TANK D- BOX AND 14 INFILTRATORS Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑- Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail 2012----------290 2011---------282 GPD HOUSE ALSO HAS AN IRRIGATION SYSTEM Sump pump? ❑ Yes ❑ No Last date of occupancy: JAN 2013 Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203)` ' Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.):. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑'Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every 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: BOARD OF HEALTH AUG 2012 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r „ Approximate age of all components, date installed (if known)and source of information: ACCORDING TO AS BUILT SYSTEM INSTALLED IN 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade; feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): _ Depth below grade: feet Material of construction: ®,concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 AS PER AS-BUILT Sludge depth: LIGHT HEAVIEST AT INLET END OF TANK t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments cGM , 355 BRIDGE ST •• - Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle O„ , 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 How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK LOOKED FINE AT TIME OF INSPECTION AND WAS PUMPED IN AUGUST OF 2012 Grease Trap(locate on site plan): j 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete . ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: ' gallons Design Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date' Comments(condition of alarm and float switches, etc.): ' Attach copy of.current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any , evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE ADJUSTABLE SPEED LEVELS PRESENT SOME SIGNS OF CORROSION IN D-BOX BOX FUNCTIONING PROPERLY AT TIME OF INSPECTION 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.): 4 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ' NO OBSERVATION PORTS FOUND t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE " MA 1/14/13 every page. City(rown State Zip Code . " Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 14 ® leaching chambers number: INFILTRATORS ❑ 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.): NO SIGNS OF FAILURE IN AREA OF S.A.S WE WERE NOT ABLE TO OPEN DUE TO THE FACT THAT THERE WERE NO OBSERVATION PORTS 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-11/10 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 355 BRIDGE ST 5 Property Address COPELAND r — Owner Owner's Name information is required for OSTERVILLE MA ; ' 1/14/13 - . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.), Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 2 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«11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System«Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 71, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 355 BRIDGE ST Property Address . - COPELAND M Owner Owner's Name information is e required for OSTERVILLE MA 1/14/13 every page. Cirylrown 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: , 0 hand-sketch`in the area below 5: ® drawing attached separately a • , -a 4. t5ins•11/10 2; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. CitylTown 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 waterAT LEAST 4 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: 1995 CODE Before filing this Inspection Report, please see Report Completeness•Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M , 355 BRIDGE ST Property Address COPELAND Owner Owner's Name information is required for OSTERVILLE MA 1/14/13 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist " ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ' ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 1 r' TOWN OF BARNSTABLE LOCATION L61 IZ e% Zaj a S SEWAGE#q%!N(6?I yII,LAGE (Ya'te�yille ASSES//SOR's HEAP&LOTDg3-0sA00' INSTALLER'S NAME&PHONE NO. Yli SEPTIC TANK CAPACITY I . LEACHING FACILITY:( ) 1n���'faPns�cS (size)17 xS0 NO.OF BEDROOMS BUILDER OR OWNER {4�. ►d2 � PERMITDATE: T-/0-7-5 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 Fumished by I Aq -K S l ZS ya - t http://www.town.bamstable.ma.us/Assessing/I Mdisplay.asp?mappar=093058003&seq=1' ' 1/14/2013 4 , Page: CERTIFICATE OF ANALYSIS s Barnstable County Health.Laboratory Report Prepared For: Report Dated: 08/23/2002 Order Number: G0216948 Ralph C.Copeland / 355 Bridge Street Osterville, MA 02655 Laboratory ID#: 0216948-01 Description: Water-Drinldng Water Sample#: 16948 Sampling Location: 355 Bridge Street,Osterville Collected: 08/21/2002 u Collected by: Ralph Copela Received: 08/21/2002 Test Parameters ITEM RESULT UNITS MCL Method# Tested LAB:Metals Iron 5.4 mg1L SM 3111B 08/23/2002 Note: Based on the results of the parameters tested,the water is suitable for drinking but may present aesthetic problems(taste, odor,staining)due to Iron. Approved By: (Lab Director) - 8�a3loa. d ,_.... ... _. _ rYv 3 f,yx - �+"�'•�� lab � +„� � a 6 Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 , TOWN OF BARNSTABLE LOCATION GR I Z 12�a SEWAGE# VILLAGE ASSESSOR'S MAP & LOT )"-OS'F-00 INSTALLER'S NAME&PHONE NO.<.�Je SEPTIC TANK CAPACITY 1660 2!tL • LEACHING FACILITY: (type) Vq�'n���TcLPn"t,.S (size) 12,4 ® NO.OF BEDROOMS BUILDER OR OWNER1a�5'itv, st�S PERMTTDATE: F-14-7S 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 t � z.. .5 Z1 15 -� / MAP U PGA ev 9 L4;'fMEE,T.OMMONWEALTH OF MASSACHUSET'TS BOAR® OF HEALTH T �q..........OF......... ..A..f.�lS ......... AVVIIrtt#ion for Diapns�al orks C�nntitrurtinn Prrutit Application is hereby made for a Permit to Construct ( 4or Repair ( ) an Individual Sewage Disposal System at: ................__.... 1---......... ............................................ - -- ....3.................................. Location,Address or Lot No. .....................- T-� > . 4vrixet- � Address W Installer Address Type of Building Size Lot................... meet U Dwelling—No. of Bedrooms...............�-_--•_____--__-_---_---Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .._ ------------------------- W Design Flow............. ........ _..___. ____.gallons per person per day. Total daily flow.:._...____...._____.. __... _.__ WSeptic Tank—Liquid'capa ty.� ..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.._../_-___-_.- Total Length.............. Total leaching area...... _PO.sq. ft. Seepage Pit No---------_--------- iameter________-_-_-___--__ Depth below inlet.................... Total leaching area............_.....sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by__•---_- ..�ry ._�._...A.._......... Date___�..�--7. ....... `�a Test Pit No. 1......7---_minutes per inch Depth of Test Pit.....I ........ Depth to ground water....... -V--_--__-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------••---•- ----------------- • •--- ---------- •----....-•----•----...---......................................................... Description of Soil..............-rl......13✓,-----�:--sI�&..../C:�__________- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ...............................-...............................-........................................................................................................................=............... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Coy has een issued by e board of health. Si ned .... ..... •" "�' -te ApplicationApproved By ..................... ..... ............................................................ ----�...--- ------------------ i Dare 4 f Application Disapproved for the following reasons: .-..------ ...................... Date t r Permit No. -------A• -�A-6---21---_---_--------- Issued ---- P /(-) �'� '� 1''` Dare I I / No................_....... Fss........................... . �.THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .............. ..........................OF Appliratilan for Dhipaii al WorkiiTomtrurtion ranfit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: h f -----...-•••-...........%? r� r--. _v.. .. �'?�� /_;��.,�t� -----------------------•............. -f .................................. - -- - ^ Location.-Address or Lot No. �.:�./..;rz��' ��£'���err � fr,t � _�v,•.�__fe.�/�%�•,�. owner �l' Address W Installer Address / UType of Building 4 / Size Lot...................... ..Sq:-feet Dwelling—No. of Bedrooms...............�__^._--___------_.---___-__•Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers — P� YP g ---------•-------•---------- P ( ) Cafeteria ( ) Pa Other fixtures --- -------------------------------•----- r:..... W Design Flow....................... ____ allons er erson er da Total dail flow_______.._.._._...___S`"7` _..__gallons. ----•g P P P Y Y --- 9 Setic Tank—Liquid ca ac}t -11/�_. allons Length................ Width---------------- Diameter-_- •_______- De/� �th................ Disposalarea Trench�No. Width___... _ Total Length � Total leachin-- _cs___.2sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( < Dosing tank ( ) , 7 a Percolation Test Results Performed by.. .. .............•---..:_�=......------ Date_-_._'��_--" ' Z`-- ------. 1-4 Test Pit No. I......;�E .minutes per inch Depth of Test Pit....... e---_____- Depth to ground water------ _/_..._.... (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 --•----•----------- ---------•-•--•---•---•--•= •--........•--------.............-----._...---........................................................ 0 Description of Soil.____.__._._<�_-.a.....49A.-DA............ /1...�--- . �t . •----•----------------------•---•---------------------------------------------------------------•------•--------------------------•-•-•--•--.......................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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. Signed ... ........ ............................................................................ . ..... ........................................ Dare ApplicationApproved By ----------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- Da te Application Disapproved for the following reasons: .. ----------------- ------...--------------------------------------------....--. ...........------- .. .. .............................................................. .. .... .. ........ ..................................................................................................... .................... ..-- Date PermitNo- ---------------------------------- ------- ------------ --- Issued .........------------------------......----------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 101V ... .. OF ...... ..17AJ5i_11 ;Lam_................. CCertifirate of (ILI'omplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( )�or Repaired ( ) by .............. .--.............................------.---............---. ......------------------------------------------- Installer at - ------------------------------ ---------------........_................................................................ . --...---------.............--------------------........ . .---------- -- ......................--- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated -----------------------........................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------------------------------------------------------------------------------------------- Inspector ....---------------------..........---------------------------------............................. M. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEE........................ in Disposal Workii Taaniirnrtian rrani# Permission is hereby granted.............................................................................. •-------------•------•-------------.... .....--- to Construct ( 1`) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No------_--_------- Dated.......................................... ------.....•••-•-----•-••---•--•---•--••-----•---••--•--•-------••••----•-••••••--•-••................._ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I S14EET i5 t.1GLE/AA FAM IL`( 4--��. PI-A", .04 i -BA44 ' �AILy �.o w = L 4.x no u,44o LOT �5 �LIDGO � g st uS� 1500 �.• 4 •t-i . 4 L�AG11lLJl, cyst To Lvoe* Paz, ti!x Ji0 /t 4- WF1Cp'LAW" tA TAOV- 4fru cAroN AMA =O'D• «. �; .... a4o GPD a-► oA 5 SF �tL o r= -DISPOSAL. FiC-�-D -- ,t�uc�ro�+ AM SrtEwALL AM4= o 13oTtoM Ao" s rZ xso =&W s F m ••IDpU. ASMA P &coisF _ ! �—°J'_ 3.... 3a FEMT0►J E Pm7zoLATww 2k1'r; s ftD SOIL 4LA05 '� OF PETER SULLIVAN WHAM N0.29733 �p ; CIVIL M7 or u s 2 � Lsdu4. �� g 8,Z � � �•6 t5oo � $ �. � . 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Z 03 • Q,-N /DBE t , - _ 2IH�241 : f OF f ' O ,} 1 o f t /►�� 3 aPIM smIvm F Y + I• a . — - ryw { t NO w ZONING SUMMARY ZONING DISTRICT: RF-1 DISTRICT MIN. LOT SIZE 43,560 SF* Brid9e MIN. LOT FRONTAGE 20' MIN. LOT WIDTH 125' MIN. FRONT SETBACK 30' Locus 7J17est. a MIN. SIDE SETBACK 15' I1 BD MIN. REAR SETBACK 15' ay -o *SITE IS LOCATED WITHIN RESOURCE 3 �; PROTECTION OVERLAY DISTRICT (87,120 SF Indian MIN.) Trail 0 ENTIRE SITE IS WITHIN FLOODZONE AE EL. 12 (PANEL 25001CO757J EFF 7/16/14) (LAND SUBJECT TO COASTAL STORM FLOWAGE) Street 7 04 CD VERTICAL DATUM NAVD '88 or! LOCUS MAP SCALE 1"=2000't WETLAND FLAGGED BY BRAD HALL of BLH 7.10 ASSESSORS MAP 93 PARCEL 58-003 ENVIRONMENTAL CONSULTING EDGE OF pP`�• \ 7.00 .99 / \7.22 / \ \ 6 "X7 29C�P9 LOT 12 LCP 41663C / \ 1.00 AC 7.61 \ 53 \ x785 / \�v / \ 7.93 Q� x7.77 \ \ x1/.89 G-01 \ ..8.09 / 8.11 8.44 MAP 93 PARCEL 58-2 -ye-8•04 \ N/F GLENN HARTRANFT x 8.61 C/O HAZEL DURAND i o� V• ^q� 9.52 i FIRST FL. \ w i ^ x 9.75 PORCH ,F9.Bg-- .04 i = = EL. 11.1' �(8.92 % 1 \p,`°^Aop i X 9.11 EXIST. DWELL. 8 FIRST FL. EL. 11.7' X-_X / X \ X PROP. POOL F NCF� 8.7 i MAP 93 PARCEL 58-4 6.85 �// 9.58 < N/F PAUL AND MARY SMITH X X X _ x 69 SEPTIC TANK / PROP. POOL FENCE - 1 r----� 6.6T- 8 FLAG. WALK X x 9.1 �� �� °F 6.53 DECK 1 L 1 e V� 1 191 x 9.92 ; / �� o° BENCHMARK: USE DECK N .87 `I QQ x 9.48 ELEVATION AT 11.2' 5.6308 9-i PROP. 18x 36 PATIO i Q \ E 1 POOL � 1 i MA MADE PONDS 1 1s,?• �� WITH NNECTOR SLUICE ( BE 84 x ---"_-_- PROP. WORK LIMIT LINE OF REMOVED) x 55 9z \ ,, 4-"' \ S6 RHODODE ONS STAKED SILT FENCE (NOTE: TO BE 6.07 \ TEMPORARILY � \ RE-LOCATED DURING x 7.37 REMOVAL OF DISEASED 477.31 \ PINES AND PLANTING NATURAL AREA �) WITH NEW TREES) (TO REMAIN) MAP 93 PARCEL 58-8 N/F MADELYN & JAMES REYNOLDS, TR. MJR NOMINEE TRUST `s F PROP. WORK LIMIT LINE OF PROPOSED POOL FENCE OF BLACK STAKED SILT FENCE CHAIN LINK TO BE INSTALLED ALONG r'�o 50' BUFFER IN AREA SHOWN. a's, NATURAL REA POOL FENCE TO BE INSTALLED AS #2 90 (TO REMAI PER STATE AND LOCAL REGULATIONS. , PROVIDE ALARMS AND #1 3• SELF-LATCHING GATES AS REQUIRED. ISOLATE VEGETATED N X WETLAND # 6 #4 2.91 NATURAL AREA (TO REMAIN) / SITE PLAN / OF 355 BRIDGE STREET OSTERVILLE PREPARED FOR off 508-362-4541 s JOHN & KAREN SEAL fax 508-362-9880 qcy downcape.com © DANIEL �s Flo A j . -\ FEBRUARY 1, 2016 down cape enghiffrift f MC. I ���� A N Nc) 49180 civil engineers A°,ESS\�� Scale:1"= 20' land surveyors R �yo , 939 Main Street ( Rte 6A) 1ACO(a YARMOUTHPORT MA 02675 13ATE DANIEL A. OJALA, P. .S. 0 10 20 30 40 50 FEET 15-367