The URL can be used to link to this page

Home My WebLink About0031 BUMPS RIVER ROAD - Health 31 Bumps Rivc,r Road Osterville A; 120 001 006 4 i Ikl l a s e- ' � - - T-0" 12'-829/32" 15'-0" 9'-0" g'_6" lo'If All Al t' 0 W ATE fL {1 7c—�, cTUCA I I{j._- Cl�tt1J(1Co0r-- I w I i IfP'-- III I I CroITN cic�,rr� cloxT v, _ a T-0" 14'-0" 11'-0" ` ficopSE () 'ut)6e J,-,e _.= SA06C Pv\A�n 3a►w� �o HIM tr _ m_-_ r 0 00(L "t71 eo�l III jll _ Iff'®�911 I�oe�l - III III 71 k�®�-411 I1L __W 1co IL oe./ B 9: . 1 • , . . . `off � 69 o PXHARD SDU� I' COVI`ITY g WER ta'� t._ Iia.8i0�3 `.► M14P 1'GL �m cE,e�-i�iEo o�T �aC,47-/0/(/ 0'57-Ex/rLLE 4T T,�� O/-14Al /2EI�c E/2Ellt/C`ld.- W17-X1/1 TyE F,GoaDPG4/.�! L CC 766 UA TE- 4-7' ,BA XT,E.2E Tf//S �,UN/S �t/vT BQSEO GN A,,V _AEG/STE�EI� L�Q.��O SU.2Y6ya� OFFSETS Sh�a�//V S/�oUL� iVO7- Z7,c-- I USED .T� OET��/�E .�-!>T�./N�.S. APi�.L./C.�/✓T ,(�i4 yS/IJE ,8v/�/�/G o. AC 3 Commonwealth of Massachusetts jo20—001 bO� . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is t servill Ma 8/15/18e I required for every O �� 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:When filling out forms A. General Information j on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return key. Name of Inspector VQ H.P.S. �y Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/15/18 In or's Sign'5 a Date The system, inspector shall sub It a copy this inspection report to the Approving Authority(Board of Health or DEP)within 30 d s of pleting 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Citylrown 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 is working as designed. No failure criteria was encountered during the inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of. Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a-Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. CityrFown State Zip Code Date of Inspection- B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health-determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 31 Bumps River Rd M Property Address Feuer Owner Owners Name information is required for every Osterville Ma 8/15/18 page. Cityrrown 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 i supply well. El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: - ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Bumps River Rd Property Address Feuer Owner Owners Name information is required for every Osterville Ma 8/15/18 page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous-two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface-sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , y 31 Bumps River Rd i Property Address t Feuer f Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No •Last date of occupancy: current Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gauons 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 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 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes [D No Building Sewer(locate on site plan): Depth below grade: 21 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line 20+: feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed b a Certificate of Compliance? attach a co of certificate ❑ Yes ❑ No 9 Y P ( PY ) Dimensions: 1000 gal H10 311 ; Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments M , 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is Osterville Ma 8/15/18 required for 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 31 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee orbaffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural.integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2 years under normal usage as maint. to protect leaching.tees in place no visable cracks or leaks. tank was at normal working level Grease Trap(locate on site plan): i Depth below grade: feet Material of construction: ❑ concrete ❑ metal E fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Citylrown 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 ❑imetal ❑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•3/13 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 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. City(rown 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.): no carry over present. no major cracks or decay visable. Camera inspected. 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•W13 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 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.). Type: ® leaching pits number: 1 6'x6'with 2'of stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit was opened during inspection and was dry staining 3'10" below invert pipe. clean concrete above that level 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•''r 31 Bumps River Rd Property Address Feuer Owner Owners Name information is Osterville Ma 8/15/18 .required for 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.): 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.): I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � g Desk r c� a a 3 - cam 3a y _ 39 /9 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 31 Bumps River Rd Property Address Feuer Owner Owner's Name information is required for every Osterville Ma 8/15/18 page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) . Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells . Estimated depth to high ground water: 26'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: septic location at town GIS level of el.36' You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Bumps River Rd Property Address Feuer Owner Owners Name information is required for every Osterville Ma 8/15/18 page. Citylrown 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 Al 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 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 r" COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 31 Bumps River Road i O _pd/ ,0 Q 4 Osterville, MA 02655 , Owner's Name: Tom&Mary Olsen Owner's.Address:. `J Date of Inspection: July 3.1, 2006 Name of Inspector: (Please Print)"James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. Ikam a DEg approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:t ✓ Passes Conditionally Passes . �. N eds Further Evaluatiomby the Local"Approving Authority F i s '.% Inspector's Signature: Date: August 2. 20061 r t� The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or r" DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1-0,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving. authority. -Notes and Comments 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. Title 5 Inspection Form 6/15/2000 r page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 Bumps River Road Osterville. MA Owner: Tom&Mary Olsen Date of Inspection: July 31, 2006 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: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: tr • 2 Page 3 of 11 t I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 Bumps River Road Osterville. MA Owner: Tom&Mary Olsen Date of Inspection: July 31. 2006 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: Cesspool or privy is within 50 feet of a.surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has,a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other• 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - ' CERTIFICATION (continued) Property Address: 31 Bumns River Road Osterville, MA Owner: Tom.&Mary Olsen Date of Inspection: July 31, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply.to large systems in addition to the criteria above) Yes -No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well P PP Y 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. 4 t i Page 5 of 11 OFFICIAL INSPECTION FORM-INOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 31 Bunins River Road Osterville. MA Owner: Toni&Mary Olsen Date of Inspection: July 31, 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: 1. 4 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 ? l ✓ — 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: Yes No ✓ _ 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(3)(b)]. � r 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 Bumps River Road Osterville, MA Owner: Torn&:Mary Olsen Date of Inspection: Julv 31, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)) Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALIINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE' OF SYSTEM ✓ 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed on 5122195-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Bumps River Road Osterville, M,4 „ Owner: Tom&Mary Olsen Date of Inspection: July 31, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 awl— Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage The tank was pumped after the inspection for maintenance GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 ' Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Bumps River Road Osterville. MA Owner: Tom&Mary Olsen Date of Inspection: Julv 31, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no), Alarm level: . Alarm in working order(yes or no): Date of last pumping: , Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): r ~ 8 a Page 9 of 11 OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Bumps River Road Osterville. MA Owner: Tom&Mary Olsen Date of Inspection: July 31, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gat)-per as built card leaching chambers,number: leaching galleries,number: leaching trenches,number.,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of sofa,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): A video camera was used for the inspection. There did not appear to be anv signs of failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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): 9 I " Page 10 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Bumns River Road Osterville, MA Owner: Tom&Mary Olsen Date of Inspection: July 31.2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 8ALk Q� i Q �y yy 3 � s3 sy 10 Page 11 of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 Bumps River Road Osterville, MA Owner: Tom&Mary Olsen Date of Inspection: July 3.1, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to,determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) , ✓ Checked with local Board of Health-explain: Topographic and water contours tnap Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+/ to-around water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 It1L FAMILY 3 $Eti'ec�M� Sf E �T' dj- 2 ;.: D 6AZF3AI;E G�ZIIlp)E-z DA fP� . :s��rl c -rA tJ� =��o X I� y=ds1�G-P� • Us G FOOD G A.c._._ -per PIT i- ►000. GAe. 2`,rokw Sltz� RA44 oN BA 51'DEw4LL Ap;-A- (w5r tar � • O�v1 - '1 g sF To/wps Vamc fib. So. covotx VCp, 6fV, 0,5(2y.-�2 vI `rOrAL IDAILy rLoYJ = S3v a- o = 04--. 7=-2G 0 C'A`M oN OATS 0)W 2ir,I W 44 C95$ OF < `� Yn PETER c� EWERM , SULLIVAN M0. 29733 soya t�G` I7:�oSc.. -`o/iq 1q:3 . F(o=40 = 3 TF=44 RV.c. lov �� is , �� g �� ,G� S�rlc ' ,g 37,0 SAtJ� TANV. t T.. WMPs;, co, MOW TgAq q! •per 14ALL BE. �A-Zo j _"DNEI.a�� ►�. C�'I•FI� P� Pad N Ll✓ - La �TIoN o S�-�'Zv�c. L -._�, - � SFIow N N�ztaN co,��pc.y 5 4vl�µ T�1� 51'p��1E �- A�tD I�; IJrr-L-a�dTE'� wt !�I u � map�'TA�I� -7667 �t5 t�L�'J: IS t�cr rjA�� o�.! AN l�l� vti4E�1T p�`flo�J4�_�dui Suev�/ru, L)SCI� 5TezviLus MA,4 . ��S Ij7Gs Q3V I u�t uC„ (,o. IIJG N r o Dw a\LIw6TAjl � 4 \ 1 o . \; PETER SULLIVAN iMm 'P --------- ASSESSORS MAP NO: No.. .- PARCEL NO- DO GFizz ......./ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Bi-tipooal Vorlai Tonotrnr#inn Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at ... ' .� .1...................... = . oe , ddre s or Lot No. W er Address a Installer Address UType of Building Size Lot_..r°_ ...................Sq. feet Dwelling— No. of Bedrooms -___-_-----------------------------_-Expansion Attic (f/a Garbage Grinder ( ) a Other—Type of Building `f" �.. No. of persons---------------------------- Showers Other fixtures - ( ) — Cafeteria ( ) W Design Flow................1/0--------------------gallons per ` n per day. Total daily flow.......... _______---_--___-----__gallons. W Septic Tank—Liquid capacity__.�Jgallons Length................ Width.______.-_.---- Diameter._.__._..__..._ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_-___-_.-----_.-----sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing n '—' Percolation Test Results Performed by.... :... . .............y_.__... . ��/f ` a ----- Date ---------------- Test Pit No. 1---,Z�-----minutes per inch Depth of Test PIt--.__l _.______ Depth to ground water..yd .___ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 1:4 - - ------ ---- _ Descriptionof Soil------- - ----- 't -------------•--------•----•--•-------------------------------•------•-•.------••----•-•---•-----------------.....---- V ....-----•-------------•-•------•---------•-----•---•--•-•-----•. W U Nature of Repairs or Alterations=Answer when applicable----------------------------__--.-.._-__.-.------_-_-.._-__--_-_----------•_--_----•----..---__. ..------•--------------•-------------•••---------•--•-----•--•-•--------•-------•--••_...---------••---------•-------------------------•------••-----------------------••--•-••-•-------.---••---------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issu d by the board of health. Signed --------- _-... :.. -----------=------ Application Approved BY - - .. �.�.. . j e ...... Application Disapproved for the following reafonr: ----------------.._----------------------------------------------...-------------------------------------- :---------------- --------------- ---------------- Dace Permit No. ---�, ' -.�... ----------------------- Issued ............. .:^..� ace --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF�HEALTH' TOWN OF BARNSTABLE , Ap Airatiun for Big uuai Works Tunutrurtiun rrrm t Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at ---... .- . -• •-• --- r-L7oca4`�oi -Addre s or Lot No. / ,/ - -gyp .. !nd' ...............�.._._... ....__... -••--•--• •---•••./r?.C......--•--... r ........................................................ �� 9r � � O}ner .. n ✓)/1/� Address W �� ✓ Installer Address PQ r Type of Building Size Lot......_7.to��.......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Vd) Garbage Grinder (Al)) aOther—Type of Building ?Fv! __ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures .................. -------------------------------------------- ----------------------------------------•-------------------- W Design Flow................/&....................gallons per p on per day. Total daily flow-._.-.----.3��-----------------------gallons. W Septic Tank—Liquid capacity_,�! JgalIons Length---------------- Width________________ Diameter-._...-.--___.__ Depth................ x Disposal Trench—N v__,� Width.................... Total Length.................... Total leaching area..........._........sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z -Other Distribution box ( ) Dosing tank Percolation Testt Results Performed by----� .... /��--•--•---•••......--•-••--••.. Date--- �� 1 �l3 as Test Pit No. I---Z. ......minutes per inch Depth of Test Pit__._!-?.._._.... Depth to ground water..�Q��...... G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ xDescription of Soil....... U •--•--•--------------------•------------------------•--•---------------------------------...--------------------------------------------••-•........... W -----------------------................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 1ce.... �,.._:-- ' - .,—- ................. !✓ _ Dace......._.._.... Application Approved By ..... ` v � -._c Dale Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------- --- ------ - ----------------- Dare Permit No. __. ...-._---------------- Issued ...................... -:' �.`%................ r � Dare --------------------- ---------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Ertifirate of Compliance T S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V ) or Repaired ( ) by .. --1- - 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. .......�� .__----pL6._-2 .,_ dated ----------_.._---------------- " THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ '........ - ........., ._---------- Inspector 4--------------------------------- ----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q TOWN OF BARNSTABLE I No....!,�� '..��✓ FEE.An:............ Diupuual Works Tunotr tiu G --- � . �, , - - _ Permission is hereby granted-- - _. ..- ---------------------•-•---•--•--- to Construct ( 1/� or Repair ( ) an Individual Sewage Disposal System at No. t_l1T �� r �/ /Z � .:. �:Tx �2✓11=L" -------------------------------------••-.......... Street PPP as shown on the application for Disposal Works Construction Permit No. ,_: __ Dated-------- .. ---- ......... - Board of Health DATE........................ - 6-=----•-- FORM 38908 HOBBS 6 WARREN.INC..PUBLISHERS r TOWN OF BARNSTABLE LO' ATION �(J ,j l G/ U SEWAGE# VILLAGE OSTeN��4" ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.- SEPTIC TANK CAPACITY C!(11) LEACHING FACILITY:(type) por 6X�o� (size) (� NO.OF BEDROOMS 3 OWNER TQ/►i PERMIT DATE: COMPLIANCE DATE: Separation on Distance Bet ween the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200..feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fact ty) Feet FURNISHED BY :Z / -- _ _ �. �� , � �� Q � �y yy` 3 � � S3 �y � y� �� Meg E AYI TABLE LOCATION L� "� - �.` � ^�� SEWAGE # ` 2-6- VILLAGE. `ram°r%r;1�� ASSESSOR'S MAP & LOTZg INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /�5 0 6 LEACHING FACILITY:(type) /00'0 size) /,00-0 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER !'� %�•<v/,�� , DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No c� � 3 dC � pir A g6