HomeMy WebLinkAbout0385 BRIDGE STREET - Health ..
385 BRIDGE STREET, OSTERVILLE-
A 093 058 DO L
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93-oa-oo�If, JoCommonwealth of Massachusetts , - . . . . . - . ..
Title 5 Official Inspection; Form
Subsurface Sewage Disposal System Form -Not for Vol untary'Assessments. .,
385 Bridge St r�l
Property Address
Chip Hartranft
Owner Owner's Name F *;
information is Osterville ✓+ z MA 02655 9-18-15.
required for every
page. City/Town ,t:. - 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.
A. General Information
1. Inspector:
Shawn Mcelroy ... r. ► =,, w-
Name of Inspector `
Upper Cape Septic Services
Company Name
P.O. Box 73 J..1
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have..personally inspected the sewage disposal system at this address and that the
information reported below is true,.accurate and complete,as'of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5 (310 CMR 15'000).The system: - its -
rr
®,,Passes ,, , �, . ; ❑ Conditionally Passes,,,k- t;," Fails
F] '.Needs Further Evaluation by the Local Approving Authority �t
. 9-18-15`
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
40 Vs
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dis�os�f S te/m=Page 1 of 17
Pe 9 P Ys 9
Commonwealth of Massachusetts r
W Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
M 5. 385 Bridge St
Property Address a
Chip Hartranft
Owner Owner's Name
information is required for every Osterville MA 02655 9-1.8-15
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts j .�_ �.; , �, •... {
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not.forVoluntary Assessments j.
4
M 385 Bridge St i +
Property Address
Chip Hartranft rt +
Owner Owner's Name
information is
required for every Osterville A'<{ MA 02655 9-18-15 "
page. City/Town z. State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational_. System will pass with.Board of Health approval if
pumps/alarms are repaired. ' ''
B) System Conditionally Passes (cont.):
ri S :
❑ Observation of sewage backup or break o6t 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
' ass inspection if with approval of Board of Health
❑ broken pipes)are replaced' ❑ Y ''❑ N;•' ❑, ND (Explain below):
❑``nr tobstruction'is removed �IY y.❑ IN�� ❑,ND+(Explain below):
❑ distribution ibox is leveled or replaced '❑'Y ❑ N ❑'ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
El broken pipe(s) are replaced ❑ Y ❑,N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:i),
❑ 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: t' '
., C ..FJ 1. • t,;F•r,. .•r J. ...qo
❑ 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•3I13' , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form j
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
385 Bridge St
Property Address
Chip Hartranft
Owner Owner's Name
information is required for every Osterville . MA 02655 9-18-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) r
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 Y2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts s :
Title 5 Official I nspection . Form ,
Subsurface Sewage Disposal System Form.-Not foryVoluntary Assessments
385 Bridge St +
Property Address
Chip Hartranft k ,
Owner Owner's Name
information is
required for every Osterville i, : 't MA 02655 9-18-15
page. Cityrrown E �. State Zip Code Date of Inspection
B. Certification (cont.)
j Yes ,, No „ st, 1.
❑ ® Required pumping more than.4 times in the last year NoIT due to clogged or
obstructed pipe(s). Number of times pumped: -
r. ❑ ® ,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
" •, f tributary to a'surface wate4r 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.
ET "" ® 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-
'� 'ro ,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. F •t� �; :. f� ,:
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
�f' ❑J- Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13.•- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
385 Bridge St '
Property Address
Chip Hartranft
Owne- Owner's Name
information is required for every Osterville MA 02655 9-18-15
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
® El 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
e 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts ;► :.y. y �:,; . ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
385 Bridge St
Property Address }t
Chip Hartranft
Owner Owner's Name r .,
information is Osterville_ MA 02655 9-18-15
required for every
page. City/Town ., - State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1.
Does residence have a garbage grinder? i ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection t. El Yes ® No
information in this report.) `
Laundry system'inspected? a:= - . Z ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):,- ti -
Detail:
Sump pump?.: + a ,. : .;r , . + r ,.I- ❑ Yes ® No
Last date of occupancy: ,. ._ 9-2015
Date
Commercial/Industrial Flow Conditions: t
Type of Establishment: -
M
Design flow(based on 310,CMR 15.'203): �,N Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap;present? ❑ •Yes ❑ No
Industrial waste holding tank present? . ;,w tr ❑ Yes ❑ No
s
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
h 385 Bridge St
Property Address
Chip Hartranft -
Owner Owner's Name
information is required for every Osterville MA 02655 9-18-15
page. Cityrrown 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: Owner--pumped 8-2014
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:. gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
_ J Title 5 OfficiaU Inspection ,Form
Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments
M 385 Bridge St
Property Address
Chip Hartranft ° r; 's.,►
Owner Owner's Name
information is Cisterville i MA 02655 9-18-15
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:
1996
Were sewage odors detected when arriving at the site? r ❑ Yes ® No
Building Sewer(locate on site plan):.. _-.s,,r , ;• .x ,;, 4 ,
Depth below grade: f F - ' i ,. �, 16"feet
Material of construction:
❑ cast iron ® 46 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): .
8
Depth below grade: .4 ' -feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El-polyethylene ❑ other(explain)
If tank is metal, list age: years '
Is age confirmed by a Certificate of,Compliance7(attach;a-copy of certificate)4t ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth:
12"
t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of.W
Commonwealth of Massachusetts =
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 385 Bridge St
Property Address
Chip Hartranft
Owner Owner's Name
information is required for every Cisterville MA 02655 9-18-15
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 Err
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•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
it
Commonwealth of Massachusetts r;• i
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form.-Not,for Voluntary Assessments
V1 _ 385 Bridge St
Property Address r
Chip Hartranft of
Owner Owner's Name
information is r
required for every Osterville: - _' "' MA 02655 9-18-15
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, eviderice of leakage, etc.):
00
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- a ,
;Design Flow:.. n ;, r 1. - .-
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form Not for Voluntary Assessments .
M 385 Bridge St
Property Address F
Chip Hartranft
Owner Owner's Name
information is required for every Cisterville MA 02655 9-18-15, .
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
1
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 wonting 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts w
_ Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •T r%.t _}.
385 Bridge St - -'
Property Address
Chip Hartranft
Owner Owner's Name + .
information is
required for every Osterville , 'rs MA 02655 9-18-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) �
. Type: , : .. ._ _ _►.,, . . � ��, � . � r a .-t ii�rl�• .,, , 1 � r. ` .
❑ Teaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields .number,dimensions:
Infiltrator 50'x12'
❑ overflow cesspool 5 number:. ._
❑ innovative/alternative system -,
Type/name of technology: ,
r Comments (note'condition of soil, signs of hydraulic failure;,level�of ponding, damp soil, condition of
vegetation, etc.): 1. •
Infiltrator leach 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
t
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Tide 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
385 Bridge St
Property Address
Chip Hartranft
Owner Owner's Name
information is required for every Osterville MA 02655 9-18-15
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.):
3
t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
1
v Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments-- .r n
M 385 Bridge St f
Property Address
Chip Hartranft
Owner Owner's Name -
information is Osterville r s MA 02655 9-18-15 . +
required for every `W �'
page. City/Town State Zip Code Date of Inspection ,
D. System Information (cont.) j; �,'� • °-�. t` ,
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A
—,o
�
.�� 3 1 4
32 ,
t5ins-3/13 , 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
' 385 Bridge St
Property Address
Chip Hartranft
Owner Owner's Name
information is required for every Osterville MA 02655 9-18-15
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:
Original design plans show no groundwater at 10'. Bottom of leach field at 36".
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•313 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
385 Bridge St
Property Address
Chip Hartranft
Owner Owner's Name
information is required for every Osterville MA 02655 9-18-15
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
00
PROPERTY ADDRESS: 3'85 Sgfcl e Street 1998
r� 70"0Fe rj J
Osterville,Mass.
02655 P
On the above date, I Insp-ected the "ptic system at the above address.
This system conalsts of the following:
• . `4
1 . 1 -1500 gallon' septic tank. !
2 . 1 -Distribution box. '+
3 . 1 -50 'x12,' leaching trench with infitrators packed in stone.
Based bn my Ine;cuactlon, 1 certify the following conditions:
4 . This is• a title five septic- system'..",(- 95 Code
5. The tank was installed backwards. Elevations were -changed to
give 20 difference from the inlet to othe outlet of -the tank.
6 ., Pumped. the septic tank, Had heavy solids 'and scum layers. .
7 . The septic system' is ' in proper wdrking order
at the' present time.
SIGNATURE: /
Name J P Macomber Jr_, i ', . ,
-,- -------
Com an J. P.Macoa)ber & Son• 'Ync
P Y�----- -------- • '
Address:_,g _66_____.:�__ _
Cente�rvi1LeAap,;i_02b32 *' • ' '
Phone:__ , --
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
,J'OSEPH P. MACOMBER & SON, INC,
Tank&-Cs&.&pool&-Leachfleld&
Pump+d Z, Instilled '
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632.0066
77.3.3335 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292.5500
r
WILLIAM F.WELD TRUDY COXI
Govcmor Sccrctar.
ARGEO PAUL CELLUCCI DAVID B.STRUR
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission
PART A
CERTIFICATION
Property Address: 385 Bridge Street Osterville Address of Owner:
Date of Inspection: 9/2 4/9 8 Mass. (If different
Name of Inspector: Joseph P.Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc-
MailingAddress: lox 66 Centeryille,Mass. Oa032
Telephone Number: S g 8 :7:15 333-9
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails r
Inspector's Signature: ll Date: �� ` d
The System Inspector s all submit a copy of this inspection 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 shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
:VS,TEM
PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
0 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/twww.ma m
fl net.state. a.us/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 385 Bridge Street Osterville,Mass.
Owner: Shawn Butler
Date of Inspection: 9/24/9 8
e) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(,) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four limes a year due to broken or obstructed pipe(s). The system will pus
inspection U(with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed-
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_A)D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
t) 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 ENVIRONMENTt
2A Cesspool or privy is within SO feet of a surface water
Cesspool or privy is within So feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
.UQ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS Is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system end the SAS is within SO feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the pfesince of ammonia nitrogen and nitrate nitrogen is equal to or
less than S ppm. Method used to determine distance (approximation not valid).
3) OTHER
.LA A
Dag• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropcnyAddress: 385 Bridge Street Osterville,Mass.
Owner: Shawn Butler
Date of Inspection: 9/2 4/9 8 `
D) SYSTEM FAILS:
You must indicate ei✓.er 'Yes' or'No' as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be ccniacted to determine what will be necessary to correa
the failure.
Yes No/
Backup of sewage into facility or system component due to an 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 i the di r)but(on box utet Invert due to an overloaded or clogged SAS or cesspool.
x
Liquid depth ineesspoe)-is less than 6' below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped r-.
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 feet 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 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 SO feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either 'Yes' or`No' as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
(_3 . The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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
_ 40 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Department for further information.
M
(revised 0//3S/37) ➢.y. 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 385 Bridge Street Osterville,Mass..
Owner: Shawn Butler
Date of Inspection: 9/24/9 8
Check if the following have been done: You must indicate either `Yes' or,"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been Introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or Industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, 4*cluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened;and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions:depth of liquid, depth of sludge, depth of scum.
_ The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
�l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 385 Bridge Street Osterville,Mass.
Owner: Shawn Butler
Date of Inspection: 9/2 4/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: S.p. Jbedroom for S.A.S.
Number of bedrooms:
Number of current residents: �-
Garbage grinder (yes or no)::B
Laundry connected to system (yes or no): Va C.
Seasonal use (yes or no):,AM
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump (yes or no):_Q
Last date of occupancy: -/-021 97
COMM ERCIAVINDVSTRIAL:
Type of establish ent: A914
Design flow:�gallons/day
Grease trap present: (yes or no).&
Industrial Waste Holding Tank present: (yes or no)_tLA
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:��-
94
Last date of occupancy: A44
OTHER: (Describe) _AM
Last date of occupancy: /1>
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons 1
Reason for pumping: 6viT� -rc,u.�! �- Sa�l�ls .Cq't�Ps
TYPE OF STEM '
/Septic tank/distribution box/soil absorption system
,149 Single cesspool
_4b Overflow cesspool
Z�/Q Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
_V1_VA Technology etc. Cop of up to date contract?
Other /1>
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)/Ul)
(revised 04/7s/)7) Page S of 10
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:385 Bridge Street Osterville,Mass.
Owner: Shawn Butler
Date of Inspection: 9/2 4/9 8
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material o4c:onstruction: _cast iron Z40PVC other (explain)
Distance from priv a water supply well or suction line /d"7`
Diameter
Comments: k d t on of joints, venting, evidence of leakage, etc.)
Joints appear tight No Fvidence of leakage-System vpntPrl thrnugh
thArhnnec van+-
SEPTIC TANK: 06
//fAli�
(locate on site plan)
rl
Depth below grade:,
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list a/gee 2 Is age confirmed by Certificate of Compliance A Y- Not
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:2
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bown of outl t tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) pump tank annually_; Garbage disposal
is prPSPnt Tnlpt A nntlpt tppG arp in p1ar•p- Thp tank is
c�triiri iir- 1 1 �� find and P.Lawrz pa Qyi d.QWr6 6f- 11aakage.
GREASE TRAP: A
(locate on site plan)
Depth below grade:///9
Material of construction:-4concrete t-f meta 1,4Fiberglass/V2PoIyethylene.L/tother(explain)
Dimensions:
Scum thickness: O_
Distance from top of scum to top of outlet tee or baffle: A/!¢
Distance from bottom of scum to bottom of outlet tee or baffle: y�
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,-etc.)
Grease trap is not present
t:.vttad 01/3S/S7) P&g. 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v
PART C
SYSTEM INFORMATION (continued)
Property Address: 385 Bridge Street Osterville,Mass.
Owner: Shawn Butler
Date of Inspectiont 9/24/98
i
I ..
TIGHT OR HOLDING TANK:440-0 (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:,
Material of construction:40concrete4iA metal,dFiberglassAAPolyethylened/Aother(explain)
N
.84
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order/ Yes:/j, No
Date of previous pumping: _1AN_
Comments:
(condition of inlet ice, condition of alarm and float switches, etc.)
Tight or holdinq tanks are n0 presen .
DISTRIBUTION BOX:,
(locate on site plan)
Depth of liquid level above outlet inven: A
Comments:
(note if level and distribution is equal, evidence of solids car over, evident of leakage i to ors ut,n(box, etc.)
Distribution box has one latera�;No evidence otn soalids
carry nyer;No evidence of leakage into or out or trie
PUMP CHAMBER:,/&(,-
(locate on site plan)
Pumps in'working order: (Yes or No) 4
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appunenances, etc.)
. Pump chamber is not -present.
lr wi..d 01/JS/77) D.O. 7 of 10
SUBSURFACE SEYdACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 385 Bridge Street Osterville,Mass.
Owner: Shawn Butler
Date of Inspection: 9/2 4/9 8
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:, i
leaching chambers, number,
leaching galleries, number: 45
leaching trenches, number-,length: _
leaching fields, number, dimensions:
overflow cesspool, number: 0
Alternative system: pp
Name of Technology: Ld�•
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
pozad n?' T 1 l vegetation i G i it ti nat .
CESSPOOLS: -
(locate on site plan)
Number and configuration: D
Depth-top of liquid to inlet invert:
Depth of solids layer: _
Depth of scum layer: d/
Dimensions of cesspool: �J�9
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as pan of inspection)_
CeS.-;jlnnl G arp nntF prpS®nt
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
esspoo s are not present
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.)
��; G not--r re s en t.
(revised 04/25/37) 2.9. 8 of 10
SUBSURFACE SE%','AGE OISPOS.',l. SYSTEM INSPECTION FORM
PART C
SYS EM INFORMATION lcontinuod)
Progmy Address: 385 Bridge Street Osterville,Mass.
Inspection:of 0411 Shawn Butler
O+u of
9/24/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two Permanent reference s landmarks or benchmarks
locate all wells within 100' Uocate where public water supply comes into house)
S\k\
1
tr.•i�•� oc/as/sal 1'.c• a or so
SU8SURFACE SEWAGE DISPC;)-,t SYSTEM INSPECTION FORM
C
SYSTEM INFOR..; .rION (continued)
Property Address: 385 Bridge Street Osterville,Mass
Owner: Shawn Butler
Date of Inspection:9/2 4/9 8
r
Depth to Groundwater Feet
Pleax indicate all the methods used to determine H;gh Groundwatw Elevation:
Obtained from Design Plans on record
Obs ation of Site bunin to
erry, bser/.,(ion hole, basenu.nl'sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
—zCheck local excavators, installers
Use USGS Data
Describe in your own.words how you established th,- High GrounJw,rcrElevation. (Must be completed)
Used Gaherty &Miller Model
12/16/98
ts.vs..d 04/33/!7) . r.9.. 1001 10
nr*.—n.•rs�'rs— rnrmr•nss.rrrnnr.nmtrnss-�+rri�rrr�rnrn fssrnv srtr�eatmn �'r-r•r•T-�r.:��:..�-.r••�
t TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACE SEWAGE DISPOSAL .SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
�. �:-•rn-r••.-...—r,..��.-rnmrm-rr.rn rwrrssra+r�en-v�n•r rnvrnv��r.rwr•'�ow�.e�+annsnw•os� rnn n•e.atr..rs*�•rrr..rr....•.rrrr-•r,---.r—..A
•-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 385 Bridge Street Osterville,Mass. '
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Shawn Butl-er
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Ina-.e
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Tours or City State LIP
COMPANY TELEPHONE ( 508 ) 775- - 3338 FAX ( 508 ) 790 _ 1 578
A
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 upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
Systeui PASSED t
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 16 . 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 tcted has found that the system fails to
protect the public health and the environment in accordance with Title
6 , 310 CMR 16 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature 41 1 Date jL-1;"L�
Onb copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF RZALTII.
* If the inspection FAILED, the owner or"*operator shall upgrade ' the aystem
within o'ne ;year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 306 .
partd .doc
c<
W
� IY7
THE C ONiMONWEALTH OF MA SSACHUSETTS
)DEPARTIMEN`I' OF E ONMENTAL PROTECTION ON
BE IT KNOWN THAT
R�
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and i q s hereby ..
authorized to use the title
CERTERED TITLE S 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_
Junc a. 1"5
Act;ng Dimctor of the on u( Wztcr Pollution Control'j
v
a .
�-_. Fps.....l Q 0.........
No....2:
THE COMMONWEALTH OF MASSACHUSETTS
_ BOAR® OF HEALTH T
................1-Q 4.---....OF........X44,.SST.d -&....-----.....--------------........----------
Appliratioo for Disposal Works Tonotruriiou Vamit
Application is hereby made for a Permit to Construct ( ,-t!j or Repair ( ) an Individual Sewage Disposal
System at
••--•-..�.W.kjtPA .. 1 -'`'y'1 L�:.! C/G!�1'' ......................................... ......................................
Location-Address or Lot No.
.��...:.�._s_. -----------
d6tivrtCr � Address
a ........................••..............•-----------••-------........----•-------------•--•••_.._ ......-----•-•--------•••--...:_.....--------•-•----------........ •-
Installer Address
{�
Q Type of Building Size Lot____....../.:.!tL ._..s�-fEet
U
.., Dwelling—No. of Bedrooms..................
..........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -____---.
d ---- --- --
W Design Flow........................S'.�_�_.- gallons per person per day. Total daily flow......................._. _..-..._--.•....gallons.
WSeptic Tank—Liquid capacity.IrD ..gallons Length................ Width................ Diameter---------------- Degth................
x Disposal Trench—No._-__.�............. Width... 14-......... Total Length.......5,2...... Total leaching area...... '..sq. ft.
Seepage Pit No.-•-____.---_-_--_-. Piameter.................... Depth below inlet....._.............. Total leaching area..................sq. ft.
z Other Distribution box ( ✓ Dosing tank ( )
Percolation Test Results Performed by..... ---4;C7M .. .................... Date.............................
............. . 7.
Test Pit No. I-----'Z minutes per inch Depth of Test Pit-----.1JP....... Depth to ground water;........R,- -__- --
Test Pit No. 2................minutes per inch. Depth of Test:Pit.................... Depth to ground water........................
---- .............�•--------- ------------------ ---------•------•------------•--••-•-----•--------•-•--•------------------------
Description of Soil g--- ....... e.
A
----------
----------------------------
.....
•-••-•-------------•----..-_............••------•-•------•----------•--••-•--•-•--••--•-••-•••----••---:-_.....•-----------------••-••--•-•-•-------••---• ---••-. .
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
- 4
-----------------------------------------------------------•-----------------------....................:----------------------------------•-----------------........-•--••-••-•-......-•----..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Envir nmental Code—The undersigned further agrees not to'place the
system in operation until a Certificate of Com i nce s pn issued by th oard of health.Signe .... ............ . .. ........... ...
.. /..��
------------------- ..........
Application Approved By --------- ---- --- J =J o tf D y�.S
Application Disapproved for the following reasons: ............ ........................ ................... . ..............:..:... ................... ........ ........
.......................................------------- -------------------------------- ----------------------------------------------------------------------..................................--------- ----------- ---------------------
n� � � pate
Permit No. -------- 9 ...... �v --..... Issued ...................c�....�1 3
Dace
------------------------
No------------------------- Fim$..............................
T9i COMMONWEALTH OF MASSACHUSETTS'
BOARD OF HEALTH
.r.W:' ........OF.................................. ..
Appliration for Diipnaal Workii Tongtrnrtiun amit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: /
t.�rTLt. I " Z.
L
................__..._:-..............-.--.-ocation---..--Ad------dress--. ................
!5f 45 J1J't< -f't!!/ �.r� v; c� /" �. G t.4:c.
......................i.....•............... .j............................... ------------------..........................Address-----...--•---••...........................
W _
Installer Address -7 4L,
� feet Type of Building Size Lot............:.............S q-"
U Dwelling—No. of Bedrooms............................. .. _Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures _ ___________________
d --------•-------------•----•-----------------------------------------•------------------------•--- .....................
W Design Flow.........................�.�%.............gallons per person per day. Total daily flow.........._...._..._._...�74.414"0......gallons.
Septic Tank—Liquid capacity.!. !a..gallons Length................ Width........_....... Diameter---------------- Depth................
Disposal Trench—No. ------............. Width._.C?n......... 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
Percolation Test Results Performed by...... �%!-_.`..�:,-�'...-----h't._= Date !• �d..
-•---- --•----------------- ------------------------
Test Pit No. I____.. �.+ -"'minutes per inch Depth. of Test Pit......t� '_._._... Depth to ground water......... '... ' _..
G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil.................... 1_ A, " A 4--.._.. ��,...c7�C_.
.«..........................................f�_-___.J_:A �t-.- ._..7 . 1.._._I�!Ar..N....... _�d1•:��t
r �_______Z ��r`` v. - Ytl._.yr✓ ..�I
W ••-•____________________-------------------_____-___-._----- _______-___-_----------•-----___--_--____-•-__-_.________-_--.---_--_-__-____-•-•----•••--__-----___--__--_--....................
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 Compliance has been issued by the board of health.
Signed ------------------------------------------------- ------ ----------------------------------------- ..............................--------
Date
ApplicationApproved By .................................................................................................. .. ........................................... ........................................
Date
Application Disapproved for the following reasons- ------------------------------------- -- -- --- --------------------------------- ---------------------------------- -
------------------- -------------------------------------------------------- -- -------------------------------------------------------------- ................................................. --- -- ---------------------------
Date
PermitNo. .................................................................... Issued ---- ------ -- ----......................------....--------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
T. BOARD�OF HEALTH
OF /......-_----------�.:...' ........................................
0-lertifi a e of C�ontylinure j
Individual Sewage Disposal System constructed or Re aired
THIS VSO C�,'RTIFY, That the In Se g p y ( p by------------------- �. ----------------------------------- ------
---------------------------------------------------........................................................
Install, - r.
+� o ... .:r ... -....-..
at .........:4?---0...�7....., ................. .... : .....: .. .. ------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental C de as described in _
the application for Disposal Works Construction Permit No. 57 -../1 0. l'f.-.. dated . _°',/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�� ......---. .......................... Inspector
DATE.......... ......... - ---- --� ..
THE COMMONWEALTH OF MASSACHUSETTS G/
BOARD OF HEALTH
................... .....:�e..........OF.................. 11�..J.'....:...t...`........_.........................
No......................... FEE........................
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Permissionis ereby granted............:..............•-•---...........--.•-•••-•----•--•••••••••.........-•••--•-••••-•-•-•••-•-•-•-....................................-
to Construct ( or pat ) an Individualw8M&a Di posal Sy
at No. t ' -. ....«. r ' "L --�--'-�- ----
6 �
D Street G
as shown on the application for Disp sal Works Construction Permit No..................... Dated..........................................
1 .......................................... .........................................:..................«
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LOCATION 005 SEWAGE#
Va:LAGE ��1�UB�, � ASSESSOR'S MAP&LOT
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type).45 ax (size)14'Aw ffr6
NO.OF BEDROOMS —:�p //�/�
BUILDER OR OWNER �12 'V 4w'r'1y—
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 fe o ea g faci ' ) Feet
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.� TOWN OF BARNSTABLE
LOCATION 7-F R r b b-6- ! T— SEWAGE
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INSTALLER'S NAME&`PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)f X{�®
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: ee'�J, 20 60MPLIAO�CE DATE: 17�-"1�
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
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