HomeMy WebLinkAbout0045 BUMPS RIVER ROAD - Health 45 BUMPS RIVER; oiq OSTERVIE-L—Ef—
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UPC 12134 � •
.2.1534-ON a
Comii onwe. 6th of Massachusetts
Tifle
r- Subs prface Serfage Disposal Systei�i Form - Not for Voluntary Assessments
.45 Bumps River Rd
Property Address
Mbtther =Lewicki
Owner- .. .: - _._..._.
Owner s Name
'information eon is Osterville Ma 02..............
.._ ....
page•, Cityrrown: state Ztp Code Date of Inspection
Inspection results retest be:stabmitted can this form. Inspection forms may:not be altered in any
viiay. Please see.co pleteness checklist at the end of the form.
important:When. Ae Ge eral .infor atfot1
filling out.fotms _
orrthe computer,
use only the.tab Inspector'
key;to move your
cursor-do not I
Sean f I Jones 1 � ......... ....._...... _...__..._
useahereturn — -------- - - - --.._.---________.._. __.._,.,_.,_
key: Name of Inspector
C.apeWidee Enterprises._ _.._
rob Company Name
153 Commercial St.
Masiipee Ma 02649
........
Cet /Town Zip
y. State Zi -Code
p
508-477-8877 . Sl 4522
Telephone klumber License Number
C rfifi afior
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 inspectior.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 D P ap roved.system inspector pIprsuant to Section 'l&Ud'df
Title 5(390 CMR 15.000i:The system:
Passes ❑ -Conditionaiiy Passes ❑ Fails:
❑ Needs Further Evaluation by the Local Approving Authority.
... .. . ..._.._._ _ _.
8/23/2013
: Inspectors 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 systen 'or
has a design flow of 10,000 gpd or greater, the inspector and the system owner>shall submit tine
report to the appropriate regional offace-ofEIEP: The original should be sent to the system owner
arcs _
and copies sent to the b e tLappiicable affthe approving authority.
****This report,only describes conditions at the time of inspection,and rai der the c®ndii ions.of use
at that time.This inspection does nbt addreiss hovu.the�systern ill pe or the f taare�ra er
the same or different qon. isti s of vs*.` "''`
wo IOU
0
Ole-
15ins•3113 Title S,Ofrclal'InspectionTo,m: s' ce Sewage f3isposotsystem.Pale 1 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Bumps River Rd
n,
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
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:
The dwelling located at 45 Bumps River Rd Osterville is served by a Title V septic system consisting
of a 1500 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The system was
found to be in proper working condition at the time of 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. Cityrrown 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
I�
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. Citylrown 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. i
❑ 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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is.required for every Osteryille Ma 02655 8/23/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or y
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
❑ ❑ 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 45 Bumps River Rd
M
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Bumps River Rd
M Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) El Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
1/2 2013—40,000G, 2012— 114,000G, 2011 —94,000G
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Cisterville Ma 02655 8/23/2013
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:
9/19/1994 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El polyethylene El other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallons
Sludge depth:
6"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
Seey`e
45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
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 311
W
Scum thickness
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? opened covers, took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
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-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
,M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day,
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Cisterville Ma 02655 8/23/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
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•3/13 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
c�M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2x1000 gallons
❑ 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.):
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
15ins•3111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
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.):
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
ton F
_ Subsurface Sewage Disposal System Form -got far Voluntary Assessments
°' 45 Bumps River Rd
Property:Address
Matthew Lewieki
Owner
Owner's;tVarne _
informationAs. Osterviile Ma- 02655 8J2312013
required for;every - _—. __. _
pag's: G3tylTowr7 State Zip Gode Date of lnspeation
System Information (cone.)
Sketch Of Sewage Disposal System: Provide a view of the`sewage;dispc sal system., including ties to
at least two permanent reference landmarks or benchmarks: Locate all wells within 106 feet. Locate
where public water supply enters the building_Check one of the boxes below:
hand-sketch in the area celov
Ej bra ino attached separately
giyee. 144
..
t5ms tt3 ,3s -c . unurfa....Sawa"ge _. s} �r-'Page15of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
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: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
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
45 Bumps River Rd
M
Property Address
Matthew Lewicki
Owner Owner's Name
information is required for every Osterville Ma 02655 8/23/2013
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
Commonwealth of Massachusetts
'u Title 5 Official Inspection Form
4. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the S s,4
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
t� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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
5/14/2009
Insp or's ignature 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. /
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every 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
I
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:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M- 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will I
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. CityTTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 1/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/14/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Bumps River Rd.
M.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every 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): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•09/08 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner
Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon septic tank, distribution box and two leaching pits
I
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2007:172,000
g ( y g (gP )) 2008:101,000
Detail:
2007:471 gpd 2008:277gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/14/2009
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p om �
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
f` Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every 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:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 19„feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 104
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500
Sludge depth: 211
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
4' Title 5 Official Inspection Form
a' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. Cityfrown 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
30"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 711
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Measured
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 septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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•09/08 Title 5.0fficial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Officinal Inspection Form
;. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 45 Bumps River Rd.
':... Property Address
Matt Lewicki
Owner Owners Name
information is required for Osterville Ma. 02655 5/14/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is I!evel and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No
evidence of leakage into or out of box.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Pits were dry at time of inspection.Stain lines were 54"
and 48" below inverts.
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-09/08 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 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
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.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is
required for Osterville Ma. 02655 5/14/2009
every page. Citylrown 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
Svx� S �IYG✓ Vol
.
A6
o;
terA.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. Cityrrown 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: 35'
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:
As-Built Card
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Bumps River Rd.
Property Address
Matt Lewicki
Owner Owner's Name
information is required for Osterville Ma. 02655 5/14/2009
every page. Cityrrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
DATE :_ 9_/12/01
PROPERTY AOORESS: kl Bilm_nnc_ Riuer,. _
----Ostervlllp---- ------- 1�/tl 60F
Mass 02655-_--- ---
On Iho above data, I Inipootod the ooptlo oylte'M at the aboY0 addro55
This iyslom conalals of the lollowing,
1 . 1 -1 500 gallon septic tank: RECEIVED
2. 2-1000 gallon. precast leaching pits.
OCT 0 9 2001
aeied on my Inipec:lon, I oerilfy the following oondltlona;
3. This is a Title Five septic system ( 78c dm)VNQ'F8ARNSTABLE
4. The septic system is in proper working - dJ
ALTHPT.
rat the present time.
5. There is 12" of waste water in pits.'
$IC1NATuRfflA
Company Joo .p:h P _ N•comb�r—b Son , Inc , '
,
Addre� a :_ Box bb--- ..-----
ConcirYIllsL He , 02V2'006b
Phone : 509- 7) 5- )> >8
TMI$ CCRTIfICATIOH 00CS NOT COHSYIYVTC A OVARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC,
Tinki-0t l Ipool 1-Lv ichllild�
Pvmp�d 4 Initillid
Town 3iwfr COnn1011on1
P,O. 8ox 66 CinlirYllh, MA 026J2-0M
r7s ���a rrs.6� lz .
I \_
COMMONWEALTH OF MASSAC14USETTS
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: 45 Bumps River e Road
0stryi 1 1 e
Owner's Name: — --hn --- i,
Owner's Address3 601 N Ocean Blvd
Gulfstreatn FL 33483 .
Date of Inspection. 9 1 2/01
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & son Inc
Mailing Address: Box 66 Centerville
Telephone Number: 508-775-3338
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. I am a DEP
approved system inspector pursuant too ction 15.340 of Title 5(310 CMR 15.000). The system:
��v Passes ,
Condiiiorially Passes
_ Needs Further Evaluation by the Local Approving Authority
_ Fail
Inspector's Signature Date:
The system inspector shal mit 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.
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 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:45 Bumps River Road
Osterville
Owner: John McGg4W
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S stem Passes:
I have not found an information hich indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: - -The septic system is in proper working order
at the present time.
L _
B_ /System Conditionally Passes:
AJ6+ 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:
X-d 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_ 4
pass inspection"if(with approval of the Board of Health):
Y,
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
f
Page 3 of 1 1 ,
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Bumps River Road
Osterville
Owner:John McGraw
Date of Inspection: 9/12/01
C. Further Evaluation is Required by the Board'of Health:
Wd 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:
Ab 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 Publle Water Supplier,
( pp r, 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
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.
t The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/6 The system has a septic tank and SAS and the SAS is less than 10 feet b4,50 feet or more from a
private water supply.well". Method used to determine distance 9 I
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compot nds 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
i
} Page 4 of 11
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Bumps River Road
Osterville
Owner: John McGraw
Date of Inspection: 9 12 01
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes ;��DMis
of sewage into facility or system component due to overloaded or clogged SAS or cesspool
charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
ogged SAS or cesspool
tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
tg�
cesspool �� ',�
iquid depth'in oe Apoel 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
f times pumped .
y 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.
�y portion of a cesspool or privy is within a Zone 1 of a public well.
y 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.]
(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 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
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/ ,
i� the system is within 400 feet of a surface drinking water supply'
e system is within 200 feet of a tributary to a surface drinking water supply
_ he system is located in a nitrogen sensitive area(Lnterim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well " e
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
!y� Page 5 of 11
„
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:45 Bumps River- Road '
Osterville
Owner: Tc)hn MrC;raw
Date of Inspection: 9/12/01
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
er-. any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
1 Have large volumes of water been introduced to the system recently or as part of this ins ection ?
P
v Were as built plans of the system obtained and examined?(If they were not available note as N/A)
117 Was the facility or dwelling inspected for signs of sewage back up?
1�
Was the site inspected for signs of break out ?
Were all system component re�reluding the SASjlocated on site
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected foe 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� g informati n.istin y _
!/ Ex o 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))
5
f Page 6 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:45 Bumps River Road
Osterville ,
Owner: John McGraw
Date of Inspection: 9/12/01
FLOW CONDITIONS;.
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):0-?(/lOrr y �
Number of current residents: 2
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no):.h� [if yes separate inspection required]
Laundry system inspected(yes or no): S
Seasonal use: (yes or no):_ap
Water meter readings, if available(last 2 years usage(gpd)): 19 9 9—2 7 2, 0 0 0 ga 1 l ons G.P.D.=7�,�s. 21
Sump pump(yes or no): 4_01 , gallons -G.P.D.=589. 05
Last date of occupancy: present
COMMERCIAL(INDUSTRIAL w
Type of establishment: .�
Design flow(based on 310 CMR 15.203): AW 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: ' r
Last date of occupancy/use: ,U
OTHER(describe): /}
•
GENERAL INFORMATION
Pumping Records
Sourceofinformation: 6/1 /99 pumped septic tank b J.P. Macomber ,
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped:_.0--ga(Ions-- How was quantity pumped determined? �
Reason for pumping:
TY OF SYSTEM p
Septic tank,distribution box,soil absorption system
,�1Single cesspool
Overflow cesspool
Pri ry
C 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)
Ae_ ' fight tank �) Attach a copy of the DEP approval
!! )Other(describe):
Ap
proximate
ximate
o ,.
ae p = of all o onents,date installed (tf,known)and source of iriformation.
7ur'A" ��
Were sewage odors detected when arriving at the site(yes or no):
6
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Page 7 of 1 I i.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 45 Bumps River Road
Osterville
OwnerxJohn McGraw
Date of Inspection: 9/1 2/01
BUILDING SEWER(locate on site'plan) ,
Depth below grade: 19
Materials of construction:,01cast iron x 40 PVC/y other(explain):
Distance from private water supply well or suction line: ,e'%-
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appear tight. No evidence of leakage: System."is vented
through house vent.
SEPTIC TANK:_(locate on site plan)
Depth below grade: 12
Material of construction: x concrete -VPmetal A/lfiberglass.r/L►polyethylene
wother(explain) AO
-
If tank is metal list age: ' Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1 0 ' 611x5 ' 81'
Sludge depth_ f. t_'e
Distance from top of slime to bottom of outlet tee or baffle:
Scum thickness: 0 /,44.""L
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bottom of outlet tee or baffle: 0L• Cv
How were dimensions determined: Pumped in 99
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 septic tank every 2to 3 years• Inlet, & outlet tees
are in place Tank is structurally sound" No signs of leakage
GREASE TRAP:10KI&ate on site plan)
Depth'below grade: na
Material of construction: naconcrete nametalna fiberglass na polyethylene 40 other
(explain): na
Dimensions: na
Scum thickness: na
Distance from top of scum to top of outlet tee or baffle: <na
Distance from bottom of scum to.bottom of outlet tee or baffle: na
Date of last pumping: na
Y
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present.
7
I
Page 8 of 1 I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,`}
SYSTEM INFORMATION(continued)
Property Address45 Bumps River Road
O-;terviIle -
Owneraohn McCraw
Date of Inspection: 9/12/01
TIGHT or HOLDING TANKFtone(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: NA
Material of constructionNA concrete NA metal Nlfiberglass NA aolyethylene, NA other(explain):
i
Dimensions: NA
Capacity: NA gallons
Design Flow: _NA gallons/day
Alarm present(yes or no):NA
Alarm level: NA— Alarm in working order(yes or no):_NA_
Date of last pumping: —
Comments (condition of alarm and float switches, etc.):
Fight or heldina tank not prPsent
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) °
Depth of liquid level above outlet invert:No_ i
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.):
-D.istr_ib>>t;nn hnsr has 4-Tan l atnral c Did not dig up box Shrub
over box.
PUMP CHAMBERNone(locate on site plan)
Pumps in working order(yes or no): NA
Alarms in working order(yes or no):NA N
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:45 Bumps River Road
Osterville
Owner: John McGraw -'
Date of Inspection: 9 12 01 `
100 al� l n �leach pits
SOIL ABSORPTION SYSTEM (SAS): 2 (loca?e site plan, excavation not required')
If SAS not located explain why:
Type t
___X_ leaching pits, number: 2
_Xa leaching chambers, number: 9 ,
leaching galleries,number:
,67 leaching trenches,number, length:(l ,
leaching fields, number, dimensions:' 0
overflow cesspool, number
innovative/alternative system Type/name of technology: . NA Title 5 78 Code
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to course sand.No signs of hydraulic failure or ponding.
Roils are dry. Vegetation is normal
CESSPOOLS:nonocesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: 0
Depth—top of liquid to inlet invert: NA
Depth of solids layer: NA
Depth of scum laver: NA
Dimensions of cesspool: NA
Materials of construction: NA
Indication of groundwater inflow(yes or no):
NA
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present
PRIVY:non locate on site plan)
Materials of construction: NA
Dimensions: NA
Depth of solids: NA
q,
Comments (note condition of soil, signs of hydraulic failure, Level of ponding, condition of vegetation, etc.):
Privy is not present
I -
9
f -
.v Page 10 of 1 I 2, .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress:45 Bumps River Road r
Osterville
Owner:John McGraw
Date of Inspection: 9/1 2/01
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.
�s Fv,u S 7 mow,•
I
10
r
« Page l l of 1]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Bumps River Road
Osterville
Owner: John McGraw
Date of Inspection: 9/12 L01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_2-2
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:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevaiion;
Used Gahrety & Miller Model Groundwater elevation %above sea level
IGPCI; J.gGS Wa Pr Iry y 92-0001 l a # 2
aged; USGS Observation well data For June 1992
Top of Ground
r
Leaching r
Pit Qif-eet
Groundwater: Feet Below Bottom of Pit
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is �
feet.
° 11
I
I, rrnre.-rtrrsr-.-rrrn-mr•nmrr-mrrrrrrm:-n+-r-ranr•nr*s.•mn m-r+t-aa r.a•�rrre - •�,
1 TOWN OF BARNSTABLE BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D CERTIFICATION
•'•T"t�T••.-'.:t—T.itf.-.ITT 7S r.n-rr.•/Ti rrtre•SsearRe*•T.T—'.r'1mrY s.nla/—'�1Rl�etr1011OrlRf7RT �sn.►. :.-nrrr•R-1. .�..�
-TYPO OR PRINT CI.EARW'-
PROPERTY INSPECTED
STREET ADDRESS 45 Bunps River Road Osterville Mass
ASSESSORS MAP, BLOCK AND PARCEL # Map 120Parce1001 /008prce1 extension
OWNER' s NAME John McGraw
PAP7' D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.. p
COMPANY NAME Joseph P. Macomber•`& `'St ' Inc
COMPANY ADDRESS Box 66 Centerville"I46ss 0.2632
Street Town, or City State LIP
COMPANY TELEP14ONE ( 508 ) 775 • - 3338 FAX ( 790 ") 1 578= 508
CERTIFICATION STATEMENT
I certifythat
I have personally' inspected the sewage disposal system at
this address and that the information reported is true ,- accurate, and
omplete 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 .
Che7 one : ,l ;,i�• ,
,P Systeui PASSED
The inspection which I have conducted has, not found any information
which indicates that ''the ' system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in- the FAILURE CRITERIA section of
this form.
System ,FAILED
The inspection which I have con toted has found that the- system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as: specifically noted .on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
ecopy of this c ification must be provid d to the OWNER, the BUYER
On
where applicable ) and the I30ARD OF HEAL1'1(.
* If the inspection FAILED, the owner or"•operator shall u
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 16 , 305 ,
partd .doc
TOWN O BARNSTABLE
LOCATION a SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Z
LEACHING FACILITY: (type) `��� i� (size)
NO. OF BEDROOMS
BUILDER OR OWNER�T,b�l1
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 Leac 'ng Facility (If any wetlands exist
within 300 fe7etf leg f ility) Feet
Furnished by c
. . �
;�, y ,
� � �� �'
� , � � ,
� ' `` � �
y� -� �
/ fx�'� �
�,�3�'
4�..
y� S��s Ri�veis- �d � i11;e, � �_�
DATE: 6/3/99
PROPERTY ADDRESS:-----------------------
45 Bumps River Road �..
Osterville, Ma.
--------- .�
JUN 9 1999
On the above date, I Inspected the septic system at the move D�e"°'�s. �
This system consists of the following:
1 . 1 -1500 gallons septic tank
2. 2-1000 gallon precast leaching pits .
Based on my Inspection, I certify the following conditions:
3 . This is a title five septic system. ( 78 Code )
4. The septic system 'is' in proper working order
at the present time. o�, CyOd�Od
5. Pumped septic tank at time of inspection .
6. There is 10" of waste water in pits .
SIGNATURE:1
Name:_,L.,F_ Macomber Jr�_
Company: Jose_2h_P. Macomber_& Son , Inc .
Address: Box 66
--------------------
Centerville , Ma.-02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY COX
Socreta
ARGEO PAUL CELLUCCI DAVTD B. STRUI
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address45 Bumps River Road Name of owns. Janet Barbato
Osterville Address of owns.:
Dsu of 4upocvon:_m / /q
Nae of inspector:tW, Pr& Joseph P. Macomber Jr.
1 am a DEP approved system kupector purwarn to Section 15.340 of T*rde 5 (310 CMR 15.000)
coma nyName: Joseph P. Macomber & Son, Inc.
hlZaV Address: Box 66, Centervi_1 1 P., Ma _ 02632-0066
T e1 eprwne Nun Z":_S 0 8_7 7 5_-4 V A R
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at We address and that the Information reposed below is true, eccurat•
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 Ev luation By the Local Approving Authority
_ Fails
Inspector's Signature: Data: `
r shall
The System Inspect submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days or
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
Mail submit the report to the appropriate regional office of the Department of•Envkonmerual Protection. The original should be sent totrrt
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
I
revised 9/2/98 Plitt 1of11
�, Printed on BscyClsd P,pu
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddre": 45 Bumps River Road, Osterville
Owner Janet Barbato
Date of Inspection: 6/3/9 9
INSPECTION SUMMARY: Check A, B, C, or D:
A. pSYSTEM PASSES:
.I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDMONALLY 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.
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 complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction Is removed
distribution box is levelled or replaced
- The system required pumpirig-Tnors than-fourrtimes a yeardue to broken or obstructed pipe(s). The system will-pess--
inspection If(with approval of the Board of Health): -
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIFICATION (con*x.rod)
PropsrtyAddraas: 45 Bumps River Road, Osterville
D'r'.w-. Janet Barbato
Dat,at Lnsp.cd-u 6/3/9 9
C. FURTHER EVALUATION LS REQUIRED BY THE BOARD OF HEALTH:
Condldons exist which rsquIts further evsJuation by-the Board of Health In order to determine If the system I, failing to protect tfla
public haalth, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE W)T-H 310 CZAR 16.303 (1)(b) THAT THE SYS
LS NOT FUNCTIONWO W A WAKNFR WHLCJ Y4UPAQIECT THE PUBUC EILA- rtiAND SAFM ANO THE ETl�30N1cFxT:
•7-�� Cssspooi or privy Is within 60 feetvf surface water
4Cl/ Cesspool or privy Is within 60 fast of a bordsring vegetated wstland or a salt marsh.
2) SYSTEM WLLL FAIL UNLESS THE BOARD OF HEALTH(AND PUBUC WATER SUPPLIER. IF ANY)DETFRJ LNES THAT THE SYSM
FUNCTIONWO W A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONiAEXT:
The system has a septic tank and soil absorption system(SAS) and the SAS Is wlWn 100 lest of a surlaca water suppy
trlbutary to a sumacs water supply.
The system has a septic tank and aoU absorption system and the SAS Is wlWn a Zone 1 of a.public water supply weu.
The system has a septic tank and eoU absorption system and the SAS Is wlthln 60 feet of a private water supply weu.
The system has a septic tank and soil absorption system and the SAS Is less than 100 fast but 60 last or more from .
private water supply well,urtlsss a waU water analysis for coUform bacterls and volatile organic compounds inGcate, v,,
well Is ties hom pollution from that facility and the presence of'ammonia nitrogen and musts Nvogsn Is eQual to or les,
than 6 ppm. Method used to determine distance l (approxlmadon not valid).•
3) OTHER
444
revised 9/2/98 Page 3of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
pr,P,MAd,dr&,:45 Bumps River Road, osterville
owner: Janet Barbato
Dias of Inspection: 6/3/9 9
D. SYSTEM FAILS:
You rLtust Indicate either 'Yes' or 'No' to each of the following:
I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis tot this
determination Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No /
Backup oFaewage Irttoiac)(it{-or-vYatem component-dueqo an overloaded orcbgged'SAS-or•c ass pool.
Discharge or ponding of eHlusnt to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in a,distrlbyftionbox above outlet Invert due to an overloaded or clogged SAS or cesspool.
e
Liquid depth in oceepeof Is less than 6' below Invert or available volume is lass than 1l2 day flow.
Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe($).
Number of times pumped 1.
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 60 feet of a private water supply well.
_ Y Any portion of a cesspool or privy Is Nss•than 100 feet but greater than 50 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. -
I_ LARGE SYSTEM FAILS:
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:
_L)2) The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and tha 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
IV the ay atom•I&-witWn 200 leetol-s-t«butary-toe out 160" 0"(4-g-w&ter-oupP4y —"
/oo the system is located In a nitropan sensitive area(Interim Wellhead Protection Area -I%VPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further Inforpation.
revised 9/2/98 Peee4orit
I
! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B j
CHECKLIST
Property Address: 45 Bumps River Road, Osterville
Owner: Janet Barbato
Data of Inspection: 6/3/9 9
Check If the following have been done:You must Indicate either"Yes" or "No as to each of the following:
Yes No
_ I�/ Pumping information was provided by the owner, occupant, or Board of Health.
None of the systamconspoasnis.haua:baen pucnpod�korat-Jeast two-Ives."and•the'system hasb"agzocaiQiwg.wsaal Clow
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.
Y The system does not receive non-sanitary or Industrial waste flow.
Y _ The site was Inspected for signs of breakout.
_ All system components, e*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 baffle:
or toes, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
_ Existing Information. For example, 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)
115.302(3)(b))
_ The facility owaw.(and.ocrulpants.If diffaraw irnut_outnerl.warapcnsrided.wiih inlnunatioaDn
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
l
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 45 Bumps River Road, Osterville
Owner: Janet Barbato
Date of kupection: 6/3/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 116 g.p.d./bedro
Number of bedrooms(desig Number of bedrooms(actual):-
Total DESIGN flow
Number of current residents:_
Garbage grinder(yes or no):
Laundry(separate s system) ( e or�:_; If yes,sepawalrupaction.required _
Laundry system inspected or nd)
Seasonal use (yes or no):
Water meter'readings,If av ble(last two year's usage(gpd): !
Sump Pump(yes or no):
Last data of occupancy: s/C �� �re
COMMERCIALANDUSTRIAL: �
Type of establishment:
Design flow: qpd ( Based on 16.203)
Basis of design flow _
Grease trap present: (yes or no) . 'n
Industrial Waste Holding Tank present:(yes or no)4
Non-sanitary waste discharged to the Title 5 sysjafn: (yes or no)
Water meter readings,if evailgble: xi3y
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pi4a�
or no)33
If yes, volume pumps
Reason for pumping: y, ,t ,�k, &
TYPE OF SYSTEM
,�YSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Ah Privy
Shared system(yes or no) (if yes, attach previous inspection records,If any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank ��Copy of DEP Approval
Other aid
APPROXIMATE AGE of all components, date Instali'edV known)•end source,ofwmformation: ••� w
Sewage odors detected whemarriving at the site:(yes or no)1
revised 9/2/98 P2ee6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PTopertyAddraas:45 Bumps River Road, Osterville
Ownw: Janet Barbato
Date of Irupection 6/3/9 9
BUILDING SEWER:
(Locate on zits plan)
Depth below grade:
t/►�1
Material of construction: _cast Iron 40 PVC other(explain)
Distance hom,private water supply well or suction line A'76 _
Diameter q41 _
Comments: (condition of Joints,venting, evidence of leakagti,-etc.)
Joints .
SEPTIC TANK:
(locate on site plan)
,y a
Depth below grade:/.
Matsrlal of construction: concrsto_metal_Fiberglass ,_Polyethylene_other(explaln)
If tank 1s Enstal,list age 1s,aga.confirmad by Certificate of Compliance_[Yes/No)
Dimensions:
Sludge depth:_ —
Distancs from top of sludge to bottom of outlet tea art-&Mo. .
Scum thickness:_
Distance from top of scum to top of outlet tsa or battle:
Distance from bottom of scum to bOtHm of outie tse or baffle:,(Y _
How dimensions were determined:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees of-baffles, depth,.onllqueld level In t idol to outlet 'invert, wucturat;nts9nty
avidencs of leakage, etc.) 1 1 t leg
tees are In n a-rp The truct y nttnri TanL h
no eviden
GREASE TRAP: ei
(locate on site plan)
Depth below grads:
-19
Mats(W of con3uuct)on:(1 concrets4amstal,ldfFiberglass 4/APolyethylena000ther(explain)
Dimensions
Scum thickness:
Distance from top of scum to top of outlet too or baffle:
Distance from bottom of sc m to bottom of outlet tee or baffle Ad
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. structuraJ intsgmi
evidence of leakage,etc.)
Grease tran iq nnt ,
revised 9/2/98 Page 7of11
� I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuad)
PropartyAdd,o": 45 Bumps River Road, Ostervile
Ownw: Janet Barbato
Date of inspection: 6/3/9 9
TIGHT OR HOLDING TANK: "(Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:A
Material of con3truction:44 concreto4Jf metaLt1 Fib erglass4AIPolyethylano&oth aria xplain)
AM
Dimensions: AM
_
Capacity: BB gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In working order:Yes&19 Noll$
Date of previous pumping: Ad
Comments:
(condition of inlet tea, condition of alarm and float switches, etc.)
lightOr hoiding tanks nrp not i regent
DISTRIBUTION BOX:,
(locate on site plan)
Depth of liquid level above outlet Invert: !�
Comments:
(note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — —
Distri hnti on hnx has turn 1 ntprnl g jli r_nDt di uT hriX
Srhrlih palor, tbo LQX •
PUMP CHAMBER:A�(/el-
(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.)
Pump rhsmhPr is not pregeslt
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddreu:. 45 Bumps River Road, Osterville
Owner: Janet Barbato
Data of Inspection: 6/3/9 9
SOIL ABSORPTION SYSTEM (SAS):�''f��l� �! .
(locate on site plan, If possible; excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number..
leaching chambers, number: V
leaching galleries,number:_
leaching trenches,number,length:
leaching fields, number, dimensions.
overflow cesspool,number-
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to coarse sand - NO S; oncof hydsauii6 f;a}lllr.e
nr pn—ni'lins. Soils aFa dry . Veg' s 11vrnra1 .
CESSPOOLS:
(locate on site plan)
Number and configuration: d
Depth-top of liquid to inlet invert: ,AU
Depth of solids lever:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: 014
indication of groundwater:
inflow(cesspool must be pumped as part of Inspection)
r : Cesspools are not nracent
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,condition of•vegetation, etc.)
Cesspools are not present _
PRIVY:1 ,
(locate on site plan)
Materjais Of construct) n: /�� Dimensions: j A'p
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,revel of ponding, condition of vegetation;etc.)
Privy is not present _
revised 9/2/98 Piee9ofII
SUBSURFACE SEWAGE DISPOSAL SYMM WSPECTION FORM
PART C
SYSTEM INFOR-lAT10N (corton.+ad)
NopwiyAddr"4: 45 .Bumps River Road Osterville ,Mass .
owno: Janet Barbato
Dau of f`"°"d°: 6/3/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include Iles to et lent two perm&nent reference landmarks or benchmark&
locate ell wells within 100' (Locate white public water supply comes Into house)
b rd
revised 9/2/98 P&Ye 10ofu
,�,'� l{�� cjk�>✓' -�.r�)W N OF BARNSTABLE
LOCATIONIC4 bC)'^r,e, , ,rt ; �la SEWAGE # ` `I ` .3
VILLAGE v'';rzv;���'.
ASSESSOR'S MAP & LOT/.,�-�
INSTALLER'S NAME & PHONE NO. S 3 D;�Sco1� 771- 10,16
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ��� i �t e) SOO jAi(cmi
NO. OF BEDROOMS * PRIVATE WELL O PUBLIC WAT�F_R .
BUILDER OR OWNER �?-,/f,rl{
DATE PERMIT ISSUED:- -)eQ4. 1991
i
DATE COMPLIANCE ISSUED:
' VARIANCE GRANTED: Yes No
i
it
.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAd&—: 45 Bumps River Road, Osterville
Ownw: Janet Barbato
Date of Inspection: 6/3/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Collar
Shallow wells .
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site(Abutting prope y bservation hole, basemeot sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_P/Checked pumping records
_zchecked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model .
revised 9/2/98 Page 11of11
' e
••n.n�r�n i t+�r- rn`-wn•nm.n.-�.�aee..�...rne.rnn�ere.m1n.nrreti n�r�n+"n .rn-rr�r-.ate.—:.....r..,'
'J'UKN OF _ BAP R WARD OF HEALTH pJ - J
ti_.��_�....;.,_,•„n_*,�„ [tFACF 9F,K�GE I'OSAL SY3TF.M I H9i'� FCTION FORM PART D . CERTIFICATION
SUBSURFACE R 1 _
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 45 Bumps River Road, Osterville '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Janet -Barbato
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber & Son', Inc .
COMPANY ADDRESSBox 66 , Centerville Ma . 02632-0066
Street Town or City State tIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578
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 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 :
Systeci PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately Protect public
health or the environment as defined- in 310 CMR 15 . 303 . Any failire
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The Inspection which I have conQ"Ucted has found that t
he ails
Protect the public health and the environment in accordance swith tem fTitleto
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this Inspection form .
Inspector Signatur Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the I30ARD OV 11BALT7I:
• If the inspection FAILED, th'e owner or"'operator ahall u
Within one year of the date of the inspection, unless alloweddortrequiredm
otherwise as provided in 3.10 CMR 16 . 306 .
partd . doc
ev 4U OF BARNSTABLE
LOCATION L °bc-)ti',,c V SEWAGE ALI` 3-79
VILLAGE �r'z v;��' ASSESSOR°S MAP & LOT 1�0,CO/ e0%
INSTALLER'S NAME Sz PHONE NO. ,3-,3. VOScAl -77 k IOq U
SEPTIC TANK CAPACITY 76 0
LEACHING FACILITY:(type)
t; ye) 000
NO. OF BEDROOMS . WELL O PUBLIC WATER ,
BUILDER OR OWNER f aq 9q
DATE PERMIT ISSUED: 191H
DATE COMPLIANCE ISSUED: —' y
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativii for Diripwial Workii Cnowitrurtion ramit
Application is hereby made for a Permit to Construct (V(or Repair ( ) an Individual Sewage Disposal
Sys at: ( -
�Y `-�� �/ 4014 s
......... ................... - -.----.---- ---- --
ca t t dress Lot No.
....... ....._.. ._ . .__... ............ ............. ..................................................
ne Address
a ...._----- �.......:
-----------•-------------------
� Installer Address ,`
Type of Building t Size Lot........�____ .....Sq. feed
Dwelling—No. of Bedrooms _-_._. _______________________-___Expansion Attic (��) Garbage Grinder (V)
aOther—Type of Buildi>>gG _ _✓�(! No. of persons____________________________ Showers ( ) — Cafeteria ( )
Other fixtures ........................................e_
W Design Flow__________________//l.0----------------gallons per p per day. Total daily flow_---____--._______...._____._..____.._..._gallons.
WSeptic Tank—Liquid capacity..'�Qgallons 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 t k
~' Percolation Test Results Performed
byW --•-
�IA : ..aldI �
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
f? Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
0 Description of Soil........IQ- 0". . a Z'
1 �i_..........
V __........................
•-----------
--------
•••-••-------------------------------------------------------------------------------------------
•-------•--------•---------------
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 Cod —The undersigned furth a rees not to place the
system in operation until a Certificate of Co fiance has ben issued the board o e
Sign8��;
................... ......... DteApplication Approved By .... - .............................................................................. ...... .T.../.1...- .��'!�!.-
Dwe
Application Disapproved for the following reasons: .... .............................. -- .............. ............. ....... .....-...............-..--...-...--......
Pe rm
-------it-----No...
------------------------------------------------- ------------------ :------------
Date
. .... q....! �.. �..-...... .7..% - Issued ........................... ... . ..... . ...... ..
Mm
^� Y
....N-37.7
A — Fine .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
, pphratiuii for Drip* mil Wi urk,5 Tonstrurtiun ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
Ad (4-�
..................... ......Z............................... ........................................................ ...............'//-----------------
Lorit'�i �ddress r Lot No.
AV
j ................... _..............................................
t a �� O}"ncr t /� ��j/Address
M Installer Address C`
S6 "6!1.....S
� Type of Building Size Lot_____...%.__._..___.. q. feet
Dwelling—No. of Bedrooms.________ _____________________________Expansion Attic (f/f}) Garbage Grinder (
Other—T e of Buildin __ ✓�/M .. No. of ersons______________________.._. Showers
—Type - p (-",I Cafeteria ( )
Other fixtures -----------------------------------------ea.;=-•------------------------------------------------------------
='
W Design Flow...................:/�.1.................gallons per persarl�per day. Total daily flow.......... .......................gallons.
1:4 Septic Tank—Liquid capacity S700gallons Length---------------- Width---------------- Diameter................ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( f}:. /
`~ Percolation Test Results Performed by.---- ��},�(�'! - ------------------------ Date..../ 0/ l_�.....-•----.
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1 GZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x Description of Soil_......
fl...711 G?�I. .... ����._......_...
f
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 Cod —The undersigned further agrees not to place the
system in operation until a Certificate of Co Nance has beenn issued b .the board of
Signed � .
Dare
A lication Approved B r
pP PP y ......... - .........- � j.. - .................... . 1.....�.�.gar..
Application Disapproved for the following reasons: ..... ..... ................................... ............................... ..............................
................................................................ .......... .... . . ..... ..................................................... ... .............a..ce...............
D
I' Permit No. AX..-�------371 .. Issued ........................................................ ..........
Dare
I
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
TOWN OF BARNSTABLE
'IT r#tftrate of CTomplia nre
THIS. IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V ) or Repaired( )
- ------------------------------_--------.-----------------------..-----------............----------------------------
v - InsuJic
/! � � l
at ....r�( ........ ......._ .. ....... 4 ....tJ .. - � ........ ... . . ...... C -------
,
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ._ . . . 7 ` dated ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL-FUNCTION SATISFACTORY.
_.............. Ins ec or .. Y - '00�''�-'_FC,.
DATE....... ...- ......- -......................................... P
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No. .. ..- �T/.. FEE.... :%......
Diupuit1 urku Tuntrudiun rrmit
Permission is,hereby granted....._...... L�
to Construct (v) or Repair ( ) an Individual Sewage Disposal System
!. at No.. k -�(�/111-e-�.•-•------ _I t/ l� ----••.I t (�ST :e 1/..
Street e�
as shown on the application for Disposal Works Construction Per ' �oL ;,379._ Dated.. .... ...............................
9 / � ,� /. oard of Health
DATE --✓
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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AsBuilt Page 1 of 1
OF 13ARNSTABLE
LOCATION L c,4 � boi, e &lj SEWAGE #1 379
VILLAGE r � ':v���� ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO. U k5ca1) '771 04 G
EPTIC TANK CAPACITY S 6�} ��, l ,,S
�� �,
LEACHING FACILITY:(type) � � } �iC� lat mi
NO. OF BEDROOMS *.PRIVATE WELL O PUBLIC WATER_ .
BUILDER OR OWNER
DATE PERMIT ISSUED: �� 1`7f 191N
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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NOTES -
ttr7 T i.DATUM IS NAWBB �
Zp 44 2 THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
Up T BE USED FOR LOT LINE STAKING OR ANY OTHER
a1. 1 PURPOSE otjEY
S7374' S� aCONTRACTOR SHALL BE RESPONSIBLE FOR CALLINGaq
' 7J 92 4 f A T Ss DIGSAFE(1-8BB-344-7233)AND VERIFYING THE
`11/ ro
` I LOCATION OF ALL UNDERGROUND B OVERHEAD Ul1UTE5
52 PRIOR TO COMMENCEMENT OF WORK. O
4.EXISTING SEPTC LOCATION PER TIE-CARD ON FILE 4 8
'TH TOWN:
5.POOL 4 SHAM HAVE SELF-CLNG
SELF-LATCHING GATES,SIZE AND MATERIALS TO MEET
LOCAL AND STATE BUILDING CODE,ALL DWELUNG
(I DOORS OPENING TO POOL SHALL BE ALARMED TO
CODE.
4[ LOCUS MAP
y` 2p t SCALE 1"=2000't
R� 4 p
T000.0
0 ASSESSORS MAP 120 PARCEL 1-8
3 52
DRIVE ZONING SUMMARY
m Al o
ZONING DISTRICT: RC DISTRICT
A, MIN.LOT SIZE 87,120 S.F.
a5 I MIN.LOT FRONTAGE 20'
.9 MIN.-LOT WIDTH 100'
° { MIN.FRONT SETBACK 20'
f V - MIN. SIDE SETBACK 10'
MIN.REAR SETBACK 10.
MAX. BUILDING HEIGHT 30'
SITE LOCATED WITHIN THE RESOURCE
PROTECTION OVERLAY DISTRICT
53
f' sv SITE IS LOCATED WITHIN THE WELLHEAD
-. PORCH c5 PROTECTION OVERLAY DISTRICT
Tv/
SITE IS LOCATED WITHIN ESTUARINE
WATERSHEDS FOR POPPONESSET BAY,
,- EXISTING THREE BAYS, RUSHY MARSH, AND
DWELLING - CENTERVILLE RIVER
} / TOF = 58.0
' VED
/ DfCK E ff -
PROPOSED
+ POOL
U
y
U /
PAT/p
+ 55
T \
F j T
/ SITE PLAN
OF
s } I #45 BUMPS RIVER ROAD
i
OSTERVILLE, MA
+ } 11 PREPARED FOR
+ } CLASSIC LANDSCAPING & MASONRY
DATE: SEPTEMBER 19 2019
y
I^S Scale:1"=20'
1 h ] a / 0 10 20 30 40 50 FEET 4
O' 11 s08-3Bz-asal
I JJALA CIVIL 3fi2-98B0 .
S /1 u;,aJ980-, No a6502Q 11
G Y r � n% I downcope.com
down cape eagineefing,Inc.
HY civil engineers
land surveyors
DATE DANIEL A. OJALA, P.E., P.L.S.. V 939 Main Street (Rte 6A)
YARMOUTHPORT MA 02575
DCE #19-300
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