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HomeMy WebLinkAbout0268 BUMPS RIVER ROAD - Health 268'BuM, 3, River-Road Osteiville A 120 133 i " I o v a r Commonwealth of Massachusetts ��--/f Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Rd. Property Address Cheri M.Whelan r Owner Owner's Name information is n F required for every Osterville, Ma. 02655 3/31/2015 page. City/Town State Zip Code Date of Inspection' Inspection results must be submitted on this form. Inspection forms may not be altered irtany. way.Please see completeness checklist at the end of the form. Important When A. General Information filling out forms - ✓ �j on the computer, 'I use only the tab 1: Inspector key to move your cursor-do not Raymond Dumas . use the return key. Name of Inspector ' Dumas Landscape Const. " —� Company Name 564 Old Stage Rd. Company Address Centerville_ Ma. 02632 , Cltyfrown State 508-778-0249 S1437 Telephone Number License Number B. Certification A 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. ,, 0 Fails - ❑ Needs Further Evaluation by the Local Approving Authority 3131/2015 Inspecto s Sig tune Date The system inspector shall submit a copy of this inspection eeport 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 des"ribes 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 f ure under the same or different conditions of use. s t5ins•3113 Title 5 Official Inspection Form,Subsurface Sewage Disposal System• age 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 268 Bumps River Rd. Property Address Cheri M. Whelan r Owner Owner's Name _ information is Osterville, Ma. 02655 3/31/2015 required for every ' page- Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B;C,D or EI always complete all of Section D A), System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. ° Comments: B) System Conditionally Passes: ❑ One or more system components,as described in the"Conditional Pass".section need to be replaced or repaired. The system, uponcompletion 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 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ` 268 Bumps River Rd. Property Address Cheri M. Whelan r ; Owner Owner's Name information is required for every Osterville, Ma: 02655 3/31/2015 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.): _ „ r ❑ 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 Q 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 . r. Title 5 Official Inspection Forth: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 268 Bumps River Rd; Property Address Cheri M.Whelan # Owner Owner's Name information is required for every Osterville, Ma. 02655* 3/31/2015 page. Citylrown State Zip Code Date of Inspection , B. Certification (cunt.) 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 aseptic tank and SAS and the SAS is within 50 feet of a private water i 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 waterjsupply 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: f t 1 , 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 1. clogged,SAS or cesspool Discharge or ponding of effluent to the surface of the ground`or surface waters El ® due to an overloaded or clogged SAS or cesspool {. El ® Static liquid level in the distribution box above outlet inverf 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 Y day flow t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Rd. r Property Address Cheri M.Whelan Owner owner's Name information is required for every .Osterville, Ma. 02655 3/31/2015 page. Cityrrown State Zip Code Date of Inspection ` B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)..Number of timespumped:, ❑ ® 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: s ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® - Any port€on 4f 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. ❑ Z 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 tie 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 ❑ O the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 z Commonwealth of Massachusetts Title 5 Official Inspection Form_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h 268 Bumps River Rd. Property Address - Cheri M-Whelan Owner Owner's Name • information is required for every Osterville, Ma.-.- 02655 3/31/2015. page- Citylrown State Zip Code Date of Inspection, V C. Checklist — „ _ Check if the following have been done.F You must indicate"yes"or"no"-as to each of the following Yes No t _ ® _ • ❑ -Pumping information.was provided by the owner, occupant,or Board of-Health m ® ;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? " ®" R 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 rtot ® ❑ available note as N/A-) I ® ❑ Was the facility or dwelling inspected for signs,of sewage back up? 8 , 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 ortees, material of construction;.` dimensions, depth of liquid, depth of sludge and depttf of scum? ® El Was the'facility n owner(arid occupants if different from owner)provided with _ 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: k ' ® , F1Existing information., For example;a plan at the Board of Health- µ '. 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' ,.., t. Residential Flow Conditions. ; r .. Number of bedrooms(design) t3 g Number of bedrooms(actual); 2. DESIGN flow basedoa 310 CMR 15.203{for example:�110 gpd x#of bedrooms): 330 �.. r t5ins 3/13 e Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts t UVI. Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Rd. Property Address Cheri M.Whelan Owner Owner's Name information required for every Osterville, Ma. 02655 3/31/2015 page, City/town State Zip Code 'Date of Inspection D. System Information; ; Description: - 1000 gallon tank, d-box and 16 infilltrators. 0 Number of current residents: Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? El Yes. E No Seasonal use? ! ❑ Yes ®' No t , Water meter readings,.if available.(last 2 years usage(gpd)): Detail: 2014 108000 gallons/2013 32000 gallons ` 9 _ r . Sump pump? ❑ Yes ® No Last date of occupancy: I Date 4 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?. El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 A Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 268 Bumps River Rd. Property Address Cheri M. Whelan Owner Owner's Name information is required for every Osterville Ma. 02655 3/31/2015 page, Cityfrown State Zip Code Date of Inspection D. System Information (cont.) ; Last date of occupancy/use: Date Other(describe below): 1212014 " General Information Pumping Records: Source of information:, ` last pump 12/2008 as per Barnstable treatment plant Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:* . gallons How was quanti ty ty pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool , El *Overflow cesspool ❑ Privy. ❑. -Shared system (yes or no) (if yes, attach previous inspection records, if anyj 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Rd. Property Address Cheri M. Whelan LL , Owner Owner's Name. information is required for every Osteryille, Ma. 02655 3/31/2015 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: Septic tank 1986 D-Box and infilitrators as per plan on record • Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: ° approx.3.5 ft below top of foundation Material of construction: . ❑cast iron 0 40 PVC ❑other,(explain):. Distance from private water supply well or'suction line: "Town water comes in at front of house approx 24 ft from sewer pipe Comments(on condition of joints,venting, evidence of leakage, etc.): all good Septic Tank(locate on site plan): Depth below grade: approx 30 inches feet Material.of construction:= ® concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) It tank is metal, list age:. years 'Is age confirmed.by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑. No Dimensions: 1000 gallon Sludge depth: none t5ins-3113 Title 5 Official Inspection Forgo:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 268 Bumps River Rd. r Property Address ` Cheri M.Whelan Owner Owner's Name information is required for every Osterville, Ma. 02655 3/31/2015 page. Cityfrown ,State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined?. dip stick ruler Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not needed at this time e, Grease Trap(locate on site plan): ' Depth below grade: µ.feet Material of construction: ❑ concrete ❑metal , ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions:. Scum thickness f 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 268 Bumps River Rd. Property Address Cheri M. Whelan Owner Owner's Name information is required for every Osterville, Ma. 02655 3/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations,,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Inlet and outlet tees good no evidence of leakage .. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal El fiberglass 0 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.): r u Attach copy of current pumping contract(required). Is copy attached, ❑ Yes ❑ No 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 li Commonwealth of Massachusetts Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Rd. Property Address Cheri M.Whelan Owner Owner's Name , information is Ma. 02655 3/31/2015 required for every Osterville, page. Citylrown State Zip Code Date of Inspedion D. System Information (cont.) Distribution Box(if present must be•opened)(locate on site plan): Depth of liquid level above outlet invert 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-Box Level, no carryover or evidence of leakage r , r Pump Chamber(locate on site plan): Pumps in working order: ❑'Yes 0 No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition"of pumps and appurtenances, etc.): *If pumps oraiarms are'not in working order,system is a conditional pass. Soil Absorption Syst®m (SAS)(locate on site plan,excavation not required): If SAS not located,explain why: ` as per plans on record i.Y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 268 Bumps River Rd. Property Address Cheri M. Whelan , Owner Owner's Name information is required for every Osterville, Ma. 02655 3/31/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Type ❑ leaching pits number: ` ® leaching chambers number: 16 ❑ leaching galleries number: ❑ leaching trenches number,-length: , ❑ leaching fields number,dimensions: ❑ overflow cesspool number- ❑ innovative/alternative system Type/name of technology: Infiltrators Comments(note condition of soil, signs of hydraulic failure, level ofponding, damp soil, condition of vegetation,etc.): All good • Cesspools(cesspool must be pumped as part'of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth,of scum layer Dimensions of cesspool Materials of construction Indication,of groundwater inflow' ❑ Yes ❑ No t5ins 3/13 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts. ' ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps RiverRd. ' Property Address ; Chen M. Whelan Owner Owner's Name information eve ryOsterville, Ma. 02655 3/31/2015 C /Town page. � 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.): all good 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.): a t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 e Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 268 Bumps River Rd. -ae , Property Address Cheri M. Whelan Owner Owner's Name information is required for every Osterville, Ma. 02655 3/31/2015 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,.including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet: Locate where public water supply enters the building. Check one of the boxes below: - ❑ hand-sketch in the area below t ® drawing attached separately P4 C t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 268 Bumps River Rd. ' Property Address Cheri M.Whelan k Owner Owner's Name information is required for every Osterville, Ma. 02655 3/31/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells 10+ Estimated depth to high ground water. 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: 12/22/2009 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: water contour map ® Checked with local excavators, installers-(attach documentation) } ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: . No water encountered on perc test for septic design at 138 inches Z n Z. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments y 268 Bumps River Rd. Property Address Cheri M. Whelan Owner Owner's Name information is required for every Osterville, Ma. 02655 3/31/2015 page. Citylrown State '• Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to 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 Y r N t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 17 of 17 1/ TOWN OF BARNSTABLE LOCATION E0 Ps SEWAGE# VILLAGE ___,7 ,1J !,&. ASSESSOR'S MAP&PARCEL �020— INSTALLER'S NAME&PRONE NO. SEPTIC TANK CAPACITY t LEACHING FACILITY:(type),4�_1111,l,6 -T02 S (tee) -- NO.OFBEDROOMS .5 (2-eXi49� 345;1n, OWNER Q ra ven (�(AA PERMIT DATE%, i Z2& COMPLIANCE DATE:6 O d Separation Distance Between e: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 3W feet of leaching facility) i^- Feet FURNISHED BY ' , ?� _Sig " . � k e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is Osterville, Ma. 02655 10/25/2012 required for 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. 1 Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Raymond Dumas use the return Name of Inspector key. Dumas Landscape Const. �y Company Name 564 Old Stage Rd Company Address • Centerville Ma. 02632 City/Town State Zip Code 508-778-0249 S1437 Telephone Number License Number 6. 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.inspechon was performed based on my training and experience in the proper function and main enancepfon si e sewage disposal systems. I am a DEP approved system inspector pursuant WSection 15440 of,--,.! Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails- Needs Further Evaluation by the Local Approving Authority tom " :-n r-r>` 10/25/2012 Inspector's Si nature 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-09108 Title 5 Offidal Ins n mr Subsurface Sewage Disposal System-Page 1 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road i Property Address Kimberly A. Delprete Owner Owner's Name information is Ma. 02655 10/25/2012 required for every Osterville, page. City/Town State Zip Code Date of Inspection , B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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 15.3.04 exist.Any failure criteria not evaluated are indicated below. Comments: _ B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section,need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by, the Board of Health, will pass: Check the box for"yes", "no or"not determined" (Y, N, Np)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. u *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): Wins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 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 pipes)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•09108 Title 5 Official Inspection Forth: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 y 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning_ in a manner that protects the public,health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El 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: f D) System Failure Criteria Applicable to All Systems: You must indicate`-`Yes" or"No"to each of the following for all inspections: r 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-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville Ma. 02655 10/25/2012 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. ❑ 0 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. 1 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y` 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected-for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design). 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 tsins-09108 Title 5 Official Inspection Form:Subsurfaos Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 gallon tank, d-box and 16 infilltrators Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] 0 Yes 0 No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: as per COMM 2011 128,000/2010 39,000 Sump pump? ❑ Yes ® No Last date of occupancy: 6/2012 p �' Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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 Forth:Subsurface Sewage Disposal System•Page 7 of V Commonwealth of Massachusetts,{ Title 5 official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road r Property Address r Kimberly A. Delprete Owner Owner's Name information is required for every Osteryille, Ma. 02655 10/25/2012 page. Cityrrovm State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: r , Date g Other(describe below): General Information Pumping Records: Source of information: last pump prior to upgrade Dec. 2008 ° Was system pumped as part of the inspection? ❑'-Yes ® No If yes, volume pumped: a • gallons ' How was quantity pumped determined? Reason for pumping: Type of System: F ® 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) 8 ❑ 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•09108 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 g, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 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: Septic tank 1986 D-Box and infilltrators.2009 as per plan on record with Town of Barnstable Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: approx 3.5 ft below top of foundation feet Material of construction: ❑cast iron 40 PVC ❑other(explain)- Distance from private water supply well or suction line: Town water comes in at front of house approx 24 ft from sewer pipe Comments(on condition of joints, venting, evidence of leakage, etc.):. all good Septic Tank(locate on site plan): y Depth below grade: approx. 30 inches 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: 1000 gallon Sludge depth: none t5ins•0901; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is OSteNllle, Ma. 02655 10/25/2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle . none Scum thickness 2" Distance from top of scum to top of outlet tee or baffle ' 8" 11. Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? stick and measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): should pump every 2-3 yrs 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 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 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 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.): all good and at level Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal I . ❑fiberglass ❑ polyethylene [I other(explain): Dimensions: Capacity: gallons Design Flow: galons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. 0 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 t5vu•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 268 Bumps River Road erty Prop Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 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 at level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): box level no carryover no evidence of leakage 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: As per engineered plans on record t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 Mee Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: 16 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system T e , e of technology: Infiltrators yp_/nam Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): all good cesspool$(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration S E 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•09108 Me 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 `< 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 page. Cityfrown 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): k Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 1 1 t G t5ins-09108 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 <'y< 268 Bumps River Road + Property Address Kimberly A. Delprete Owner owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is Ma. 02655 10/25/2012 required for every Osterville, 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: 10+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12-22-09 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: Water contour map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation:. No water encountered on perc test for septic design at 138 inches 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 268 Bumps River Road Property Address Kimberly A. Delprete Owner Owner's Name information is required for every Osterville, Ma. 02655 10/25/2012 page. Cityfrown 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 t t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � 4 TOWN OF BARNSTABLE LOCATION o� U 9pS IQ 1VF_JZ SEWAGE# VILLAGE CnT�.,-y Av, ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY /2s LEACHING FACILITY:(type),/,& f1L'i°%L�i-74� 5 (size) NO.OF BEDROOMS . 7 22rCi q� 3c�es,'n, OWNER (� raviv\�, un PERMIT DATE/ o� � _ COMPLIANCE DATE: - Separation Distance Between e: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le Feet 4 i FURNISHED BY � ` TOWN OF BARNSTABLIE LOCATION RM Ps iyalZ USEWAGE# �?00E—Y/ VILLAGE ���l�/'%J��ry, ASSESSOR'S MAP&PARCEL 19D— INSTALLER'S NAME&PHONE NO. l�/I/1(Jl�iyj yrjly� j -r(y�Ir�/ SEPTIC TANK CAPACITY 7/®Vev LEACHING FACILITY.(type)����/f/ fj/,�-77j/Z y (size) Ga n/� NO.OF BEDROOMS 22IGN7hq� 3c�¢Si'n, PerM �" 982- 90 r 3.6dit, ) OWNER QI'JvvV\ cAAK J v� PERMIT DATE/�, ®Z 3 COMPLIANCE DATE: Separation Distance Between e: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of.leaching facility) Feet FURNISHED BY �� P7 -A 66 TO ,.... TOWN OF BARNSTABLE LOCATION : ,,- G�'� &mam SEWAGE # VILLAGE7'e'('� , e ASSESSOR'S MAP dt LOT.. . INSTALLER'S,NAME&PHONE NO. SEPTIC TANK:.CAPACITY LEACMG-FACI1=:.(type) • ��� .(size) NO.OF BEDROOMS BUILDER OR-OWNER. PERMITDATE: COMPLIANCE DATE Separation Distance Between the: Maximum Adjuster.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or-within-200 feet of leaching facility) fit_ Edge of Wetland and Leaching Facility(If any w tlands exist within 300 feet.gf leaching.facility) Feet Furnished by U � L�JD ` �-L- a3' r A -0-A a-12-a6' �F No. 0 0 Fee /10 C� ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSYABLE, MASSACHUSETTS Yes ftphLatlon for NopoSar 6pstrm ConstCUition 3permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No ��j��7 S ���'� wner's Name,Address,and Tel.Nod// Assessor's Map/Parcel Installer's Name,Address,and Tel.No.�fj//f !Vw Designer's Name Address and Tel.-No,�. i-IV/W TS'P . � , ��� � e of Building: Dwelling No.of Bedrooms - —� `1�''0` ! Lot Size q.ft. Garbage Grinder( ) Other Type of Building �Z42� � No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) © gpd Design flow provided _ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /�UU Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date Application Approved by Date d Application Disapproved by Date for the following reasons Permit No. ` y 06) Y j g Date Issued 2 23 o -i ---------- ---„�.. ���.-.+��,:,..;.���.+-�..a--sty'^—+�"„^.^w+=...r.».:;:.M+":,�3t•..xr:.+s.a,�.Fv.m.Bycxrs...w�+.-.:..^*rs++..r..R-�-.�+--..+».....,.,..>.-.--..,.-..w--•---........ .�.�.-,..- � ....�.,>.. ..,...-....,Y. " M1 t 'No. I GI— 1 # Fee Q U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARUS'TABLE, MASSACHUSETTS Yes ftpYication;for Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System Xindividual Components Location Address or Lot No/ ''Pj C//.�J/''S ICIIPe/ Owner's Name,Address,and Tel.No.e �'I/,r�- Assessor's Map/Parcel Installer's Name,Address,and Tel. P/XrjDesigner's Name,Address,and Tel.No. M01 IV IW /57 Type of Building: 39Jdw, YTD��J �f Dwelling No.of Bedrooms L•k Xl 1 f f°' _Lot Size I /'�FUG U( sq.ft. Garbage Grinder( ) Other Type of Building � S No.of Persons Showers( ) Cafeteria( Other Fixtures , Design Flow(min.required) Z,_o -4, _gpd! Design flow provided,,. gpd Plan Date Number of sheets. Revision Date Title fi i E Size of Septic Tank �dUU 1. Type of S.A.S. f Description of Soil 1 I Nature of Repairs or Alterations(Answer when applicable) 9 Date last inspected: Agreement: I ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of " . Compliance has been issued by this Board of Health. SigLmd Date _ Application Approved by Date f Application Disapproved by Date - for the following reasons Permit No.—q o C) / Date Issued 12123 U -`1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (tertificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by / T2 7, /-,e_/- , at G P Zj been constructed in accordance, . with the provisions of Title 5 and the for Disposal System Construction Permit No. 9—"� dated d- a a 9 Installer Designer #bedrooms Approved design flow and- The issuance of this permit shall not be construed as a guarantee that the system wily function'as designed. Date �(I%1 �1 e1 Inspector ,� r �/� r No, Fee �Ud THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i9ermit Permission is hereby granted to Construct( ) Repair(v)!� Upgrade( ) Abandon( ) System located at 4e,,- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be completed within three years of the date of this permit Date 3 0 Approved byv C�N �I �' wPC�wMvS _ S�Grr> U t1-aU ' if u id�1 Commonwealth of Massachusetts Title 5 Official Inspection Form .- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for Osterville MA 02655 11-21=09 every page. City/Town State Zip Code Date of.lnspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. ` A. General Information 1. Inspector: A , Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number r 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: <s ❑ Passes ❑ Conditionally,Passes. 4. •; ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 14. 11-22-09 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER. 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. Lid i t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewa Disposal Sys Page of 15 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 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 A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or breakout 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 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts _ r, Title 5 Official Inspection Form s o Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments. 1,M 268 Bumps River Rd ti,. s,. -r •, - Property Address Bank Owned,(Contact David Holt @ Today Real Estate 1-800-966-2448) Y Owner Owner's Name " information is required for Osterville MA 02655 11-21-09 rr - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): , , •� c <. ,, Y, ❑ distribution box is leveled or replaced ' ND Explain: ❑ The system required pumping more than 4 times a year due to broken or,obstructed pipe(s). The system will pass inspection if(with approval of the Board,of Health):; ❑ broken pipe(s) are replaced ' ❑ obstruction is removed ND Explain: 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 '2. System will faii'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,se tic tank and soil absorption s stem 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. „a f„❑ ., . The system has a septic tank and SAS and the SAS is within 50-feet of a private water supply well. # r t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of.15 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) " Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ® El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than '/ day flow ❑ - ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water.supply or tributary to a surface water supply. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage.Disposal System Form'-Not for-Voluntary Assessments . } 268 Bumps River Rd Property Address { Bank Owned (Contact David Holt @ Today Real Estate,1-800-966-2448) - - Owner Owner's Name information is OSteNllle required for MA 02655 11-21-09- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ~= t t W _l ❑ ® , Any,portion,of a cesspool or•privy is within a Zone 1 of a public well. ❑, : ®f_, - ,Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy,isless 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 ' •"". ~` •{ • t '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- z 10;000gpd. _ f ® ❑ 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 1 - E `,necessary to correct the failure. E) Large'Systems: To be considered,ar 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 ❑, + , ❑ r the system is,within 400 feet of a,surface drinking water supply �` + ❑ ,. r ❑' _ -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 If 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. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts `p W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v1M 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No r ❑ ®- 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? ❑ N 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 i 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? .0 ❑ 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)] t5insp official document•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 268 Bumps River Rd Property Address _ Bank Owned (Contact David Holt @ Today Real Estate'1-800-966-2448) Owner Owner's-Name information is •required for Osterville r MA 02655 11-21-09 every page. City/Town , state Zip Code Date of.Inspection D. System Information • r Residential Flow Conditions: - Number of bedrooms (design):' 2 Number of bedrooms,(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: i < '0 Does residence have a garbage grinder? d ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? V ❑ Yes ® No Seasonal use?. v . ' ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 8-09 Y D ate Commercial/Industrial Flow Conditions: , Type of Establishment Design flow(based on 310 CMR 15.203): ;canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): f Grease trap presents { X' El, 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: Last date of occupancy/use: Date Other(describe): t5insp official document,031b8 . Title 6 Official Inspection Form,Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts - W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 268 Bumps River Rd M Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-.966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts , Title 5 Official Inspection Form - v4 Subsurface Sewage Disposal System Form,-Not for.,Voluntary,Assessments I 268 Bumps River Rd F Property Address Bank Owned (Contact David,iHolt @ Today Real Estate 1-800-966-2448) Owner Owner's Name r information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan):,f f Depth below grade: f E, ,, - ' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: , feet Comments (on condition.of joints,venting, evidence of leakage,_etc.):,, Good condition. 3 Septic Tank(locate on site plan): Depth below grade: 24 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: 1000gal 12" Sludge depth: 20" Distance,from top ofsludge to.bottom,of outlet tee or baffle .Scum thickness ,0 Distance from,top of scum to top of outlet tee or baffle 67 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � t 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. ` Grease Trap (locate on site plan): Depth below grade: feet Material of construction: :. ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection-Form s r _ a Subsurface Sewage Disposal System Form -Not for Voluntary;Assessments_+ .. , 268 Bumps River Rd Property Address Bank Owned (Contact DavidHolt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r , Tight or Holding Tank(cont.) Dimensions: Capacity: _ gallons , Design Flow: gauons peg day. w Alarm present: ❑ Yes ❑ No ; Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(conditon of alarm.and float switches, etc.): :f *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site,plan): 1 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.): D-box had signs of back-up with stain lines above inlet invert. ' �F •d " kf Pump Chamber(locate on site plan):, Pumps in working order: t, M-E •.❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: . - ® leaching pits number: 1-1000gal ❑ 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.): Leach pit had clear signs of failure with stain lines above inlet invert. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary.Assessments._ t 268 Bumps River Rd , Property Address Bank Owned (Contact David Holt @ Today Real Estate 17800-966-2448) Owner Owner's Name t ... information is required for Osterville MA 02655 11-21-09 - every page. City/Town w,+. ; ,; state Zip Code Date of Inspection D. System Information (cont.) 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 a. 'Materials of construction —Indication of"groundwater inflow ❑ Yes ❑ No t' Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:): 1 0 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.): t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.fi " �Gk ,d D C J: • a� ' A -D-a6' d-�-ad' t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 268 Bumps River Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Osterville MA 02655 11-21-09 every 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: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ 'Obtained from system design plans on record jf checked, date of design plan reviewed: 'Date ® Observed site(abutting property/observation hole within 150 feet of SAS) h . ® Checked with local Board of Health —explain: ® .Checked with local excavators, installers_ (attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at greater than 20'. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 I ' Town of BA i-astable P# Department of Regulatory Services ar��� • ' Public Health Division Date 200 Main Street.Hy#nnis MA 02601' l % 3 . EED rul►� •i. GIB+ i ;Time_LL�a Fee Pd. Date Scheduled i oil Suitability ASSessment'fog- Sew ge 1?ispos l Performed By: Witnessed By: LOCATION & GENERAL INFORMATION Location Address .�S 8 Ut1/t�S � 0, ' Owner's Name L4VJK 4c e 8/0 w 7 '7(e 9 5V 41 ps 1Z�t.�c r � Address as tC';L l/tL �"M"I Assessor's Map/1`14rccl: (ZQ�f 3 3 I Engineer's Name (A-y r{/r\ I- NEW CONS' 111�1`10N REPAIR j Telephone �,r��Q��y / L ��• Surface Stones Land Use =mac_ �r Slopes Distances from: Open Water Body ZJ V ft Passible Wee Area a ft Drinking Water Well I Drainage Way > ft. Property Line 5/d_ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 149.93 ft m ! C01 0IDI < M 20 I1 . 0-0 j j i o-- SERVICE II 0 G X ITl ZITI u: ! 01 C 0 c i, I m ! I CAS SERVICE. I I I I _I._._._._ �.—.J 0 00- I \ n I \ �I 10 i STONE DRIVEWAY\\ 0 \ O i 0� > I _---------\ � \\ J •, N � k .......................J 125.00 rc / NIA Parent material(geglogic) l=aterin �5� Depth to Bedrock v � . I Weeping from Pit Face Depth to Groundwakdr. Standing e: I - - Estimated Seasonal il-ligh Groundwater tj DtTERARNATION FOR SEASO�' AL HIGH.WATER TA ALE Method Used: I in. Depth to sell Intttttes: In. Depth abperved standing in obs.hole: I in. ©roundwhter Adjustment Depth toiweeping from side of obs.hole: , Adj.At IcIr,,,,,, Ads Oroundwater level Index Well# — Reading Date: Index Well level ?- • �,_..... / PERCOLATIO Date Me TEST - i Observation '( I Time at 9" N --- Hole# ' Time at 6" - Depth of Perc �j Time:(9"-6") ----•--.'.- Start Pre-soak Time.@ -- I T End Pre-soak ; Rate MinJlnch Site Suitability Assessment: Site Passed x Site Failed; Additional Testing Needed(YIN)--- — i Original:.Public I,r�lth Division Observation Hole Data To Be Completed on Basic--------- 4 *>k>� a ibn testis to be conducted within 100' of wetland,.-You must first notify the If pereol Barnstable C44servation Division at least one(1)wedk prior to beginning- Barnstable DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenc g'o Gravel 0tl gtl 1Dy N A 8''- l3g'' C Men. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel cl tt L,0jtMq�&JW jD\jgAj1 \//A Cl''_ 3-711 13g4 G Z' DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color $011 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ra I t Flood Insurance Rate May: ,1( Above 500 year flood boundary No— Yes Within 500 year boundary No (` Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the system? area proposed for the soil absorption P P If not,what is the depth of naturally occurring pervious material? Certification I certify that on d (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the require tr ' ing xpertise and experience described in 3.10 CMR 15.017: Signature l Date l �� Q:ISEPTICIPERCFORM.DOC Town of Barnstable "'E' t. Regulatory Services g rY Thomas k Geiler,Director MAW �,� Public Health Division p' 659. Thomas INIcKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer.Certification Form Date: Sewage Permit# CAssessWs Map\Parcel 3� Designer: Gt Yr2✓+ Installer: ! �� Address: Po 3�X q S Address: z-Z z�� On i G)was issued a permit to install a (date) /c/ (installer) septic system at �-bb based on a design drawn by (address) dated j (designer 1 certify that the septic system referenced above was installed_ substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. (Installers Sib ature)" v " t NITAR\p� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARN FABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-26-Odoc COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED C. NOV 0 2004 *. 'IWN'OF BA,RNSTA8LE 'TITLE S HEALTH DEFT, .OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM PART A CERTIFICATION Property Address: < Met Owner's Name: l n._ canc_P Q,anc a r� xC Owner's Address: ),cog Ru p�c, ��teC'U�1iZ� MCA Date of Inspection: 1100 OL4 Name of Inspector: (please print) SV st,c�P sc,A r 6 i w Company Name:_Qg-1_)A _f pjet !lr%Se_c� l l.ti Mailing Address: F;p.t)Ok 74t3 Mo Telephone Number; x�cgX— N SS— ii0�5� ' 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 REP approved system inspector pursuant to Se ction 1$.340 of Title 5(310 CMR 15.000). ,The system:., A_ Passe' e Conditionally Passes Needs Further Evaluation by the Local Approving4Authority' Fails Inspector's Signature: Date: 11 [}.10c.{ 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. w Notes and Comments f ****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 1 Page 2 of 1 1 4 OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION'FORM ''. PART A CERTIFICATION (continued),.,YF c • 1 Y- r Property Address: t�4i N v fill)5 �)1 1%t' d� 7: Owner: L.6j.3 r)r i�Cl Date of Inspection: 1 1 2� ` •' `d' Inspection Summary: Check A,B,C,D or:E/ALWAYS complete all of Section D n 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: e . B. System Conditionally Passes r s 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. �t The septic tank is metal and over20 years•old* or the septic tank(whether metal or not)is structurally,.Y unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the' t existing tank is replaced with a complying septic tank as approvedby the Board of Health.y *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. t a - r ND explain: a: �n Observation of sewage backup or.break out or high statics water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or.uneven distribution box. System will pass-inspection if(with t , approval of Board of Health) as Y broken pipe(s)arereplaced 3 • s - , obstruction its removed •` � `y ' distribution box is leveled or replaced • ` , '^�^ N_D{explain: �n a' The system required p* pmpmg more thari,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 P i e(s)are re laced ti ' t' ' P P. w . obstruction is removed ' ND:explain:' { Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY'ASSESSMENTS �( SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9,&g J fn rit-e c o Ile-, _tomes— Owner: Date of Inspection: 1) 1 �, LnLA ` 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 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 **Thin system'passes if the well water analysis;performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: ' r Page 4 of 11 OFFICIAL INSPECTION FORM--NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) i Property Address: Owner: ' 1G Date of Inspection: 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 orcesspool i Discharge or ponding of effluent to the.surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or . cesspool ,. Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow 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. 7( Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ A Any portion of a cesspool or.'privy is within a Zone I of a,public well. Any-portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.jThis 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 Sppm,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. f , You must indicate either`yes"or"no"to each'ofthe following: (The following criteria apply to large systems in.addition.to the criteria above) , yes no the system is within 400 feet of a surface drinking water supply a 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. Page 5 of 1 l OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST n + e Property Address: Owner: Date of Inspection: 11 j,-x 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? 1 _ Was the site inspected for signs of break out 7 Were all system components,excluding the SAS, located on site? _ Were the septic tank manholes uncovered, opened,and the interior of the'tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and.occupants if different from owner)provided with information on the proper, maintenance of subsurface sewage disposal'systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. i Determined in the field(if any eof the'failure criteria related to Part C is at issue approximation of distance ` is unacceptable) (310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY A ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:1&6 N ff+l p-MRi0 FIB "+ Owner: LCA ,ci-i o.• v. C�ov n Date of Inspection: j o u FLOW CONDhTIONS RESIDENTIAL - Number of bedrooms(design): 'Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: ! Does residence have a garbage grinder(yes or no):IK Is laundry on a separate sewage system(yes or no):j2 {if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Q y Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy: w COMMERCLUJINDUSTRIAL r Type of establishment: . �} Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: . OTHER(describe): r GENERAL INFORMATION Pumping Records Source of information: 4,t)m Was system pumped as part of the inspection(yes or no): i 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 obtaired from system owner)' Tight.tank' Attach a copy of the DEP approval ' Other(describe): -fa n Approximate age of all components,date installed(if known)and source of information: P I KO'S i. Were sewage odors`detected when arriving at the site(yes or no):_ Page 7 of 1 1 p OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ PART C SYSTEM INFORMATION(continued) Property Address: Owner: i.c �;��.n (�-x.n 3T: Date of Inspection: j 1 c ;4 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _�,_40 PVC other(explain).- Distance from private water supply well or suction line: Comments (on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: (locate on site plan)_ p Depth below grader Material of construction:. . concrete_metal 'fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):=(attach a copy of certificate) Dimensions: Sludge depth: u{\V g t Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: N Distance from bottom of scum to bottom of outlet tee or baffle:lQ� r How were dimensions determined: M `U c%"oC4 P-� Comments(on pumping recommendations, inlet and ou et tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.); GREASE TRAP:X-06cate on site plan) ' Depth below grade: Material of construction:_concrete metal 'fiberglass___polyethylene._other (explain): r Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ; -Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: ' Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): r Page 8 of I I ' OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: (,Q j)c p 6�tatl Date of Inspection: TIGHT or HOLDING TANK: n Ff(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene otlier(explain): ' Dimensions: ; Capacity: gallons.- Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: s , Comments(condition of alarm and float switches, etc.): - DISTRIBUTION BOX:DA(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: 4 (locate on site plan) f 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.): ' Page 9 of 1 I ; ' a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: (,,ys i mf)s i�,oo_1 �ie -.s� it MCA -Owner:LtL,30Cjcy_r Date of Inspection:1 r}, SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS.not located explain why.- Type - leaching pits,number: 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 or no): 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 poriding, condition of vegetation;etc.): I i Page 10 of 11 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . ,SYSTEM INFORMATION(continued)', Property Address: (� ,� [� R e , o;II� Owner: 1ruv, wR a _ Date of Inspection: 1 l SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two per manerit reference landmarks-or,,,- benchmarks. Locate all wells within 100 feet. Locate where public water supply ehters the buildih • 4 1 i Page 11 of 11 OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ^r L<{ (�:�mks p, or, e e, f(tra Owner: t_c,_)r�C. � n a Date of Inspection: g, SITE EXAM Slope Surface water = Check cellar Shallow wells Estimated depth to ground water 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 elevation: , L)-C, m a hot`rS n 1 APPLICANT: f O-AgeIU 4�C fZ , ADDRESS: �(o9 Sum Os DESIGN FLOW: gPd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted [310 CMR 15.220(4) a Street, Lot, tax parcel number and lot number noted on plan'[3.10 CMR 15.220(4)(u)] X Locus Provided 310 CMR 15.2204(t)] ` Plan proper scale?(1"=40'for plot plans, 1"=20'or fewer.for ,components) 310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a)for upgrades]- i not, a variance.is required 310 CMR_15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) 310 CMR 15.220(4)(d)] x Location all buildings existing and proposed-310 CMR 15.220(4)(c)] i Location and dimensions of system components and reserve areas [310 CMR 15.220(4)(e)) System Calculations [310 CMR 15.220(4)(f)j w daily flow septic tank capacity (required and rovided) soil abso p tion system (re uired andprovided)' " whether system designed for garbage grinder North arrow [310 CMR 15.220(4)( )] Existing and ro osed contours [310 CMR 15.220(4)( )] Location and.log of deep observation holes(existing grade el. on each test) 310 CMR 15.220(4)(h)] X Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] �( Location and date of percolation tests (performed at proper elevation?) 310 CMR 15.220(4)(i)] �( Percolation test results match loading rate?`[310 CMR 15.242] Certification statement by Soil Evaluator 310 CMR 15.220(4) ')] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15:103(3) and 310 CMR x 15.220(4)(n)) Location of every water supply,public and private, [310 CMR 15.220(4)(k)) ,Y . Address' � �jy(✓l P� �l�l,/ �af V l�� Sheet 1 of 7 within 400 feet of the proposed system location in the case of surface water supplies and griyel packed public water supply X within 250 feet of the p4ioposed system location in the case JC within 150 feet of the proposed system location in the case . X of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins X located within 50 ft. 310 CMR 15.220(4)(1)] Water lines-i6d dthdf siibsu face utilities located [310 CMR 15.220 4 m) if water line cross see 310 CMR 15.211(1)[1 .) X Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR15.220(4)(6)] X Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] . Test Holes adequate(two in each of the primary and reserve unless trenches as permitted'in 310 CMR 15.102(2)or as .approved for an upgrade under LUA at 310 CMR 15.405(1)(k ] X Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103(4)) X Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] X Benchmark within 50-75'of system [310 CMR 15.220(4)( )] Materials specifications noted? [various sections of.310 CMR 15.000] X System components not>36" deep(unless Local Upgrade Approval or LUA requested)f310 CMR 15.405(l(b)] J( Address 26g 'f umPS W�O, IP- OSkr✓,'I e Sheet 2 of 7 Size OK? '[310 CMR 15.223(1)] x Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14"+5"per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or-approved filter[310 CMR 15.227(4)] Note regarding.installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid de th)' 310_CMR 15.227(2)) - x Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA 310 CMR 15.405(1)(k)] x Minimum cover 9" (Tanks buried more than 9" must have risers ' on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f).) Three access covers (inlet and outlet must be 20"or.greater)- middle access at least 8 (b 7/07) [310 CMR 15.228(2)] �( Access to within 6 "of grade -one port for systemM 000gpd, two fors stems>1000 gpd 310 CMRJ5.228(2)j All at-grade covers secured to unauthorized access? [310.CMR 15.228(2)] X > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done 310 CMR 15.221(8)1 )( H-20 Where appropriatO 310 CMR 15.226(3)J Setbacks from resources 310 CMR 15.211 f Required when other than single-family dwelling or flow>1000 ; d [310 CMR 15.223(1)(b)] . First compartment 200%daily flow; Second compartment 100% daily flow 310 CMR 15.224(2) and'(3)] `.' "U"pipe through or over baffle, outlet of each compartment with. p as baffle or approved filter 3`10 CMR`15 224(4) s e TI Address 2 gUNLP--S e✓ Z R17 Sheet 3 of 7 Located at least ten feet from any water line? [310 CMR 15.222(2 }( Disposal piping at least 18"below water line (when water and sewer cross, see 310 CMR 15.211 1) 1]) Cleanouts required/provided ? 310 CMR 15.222(8)] X Thrust blocks specified in force mains?310 CMR 15.221(6)(c)] X Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] X Proper pitch on all runs?(.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphonproblem/ leachfield below pump chamber) Endca s or.vent manifolds ecified? Size and orientation of discharge holes specified?(not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] x Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) 9 Stable compacted base [310 CMR 15,22](2)and 310 CMR 15.232(2)(a)] k Splash.plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer)[310 CMR 15.323 3)(a)] Riser if deeper than 9 [310 CMR 15.232(3)(f)] Inside minimum dimension 12" 310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] X Capacity(emergency.storage above working=design flow)? [310 CMR 231(2 ] X Proper setbacks [310 CMR 15.211 (same as se tic tanks)] Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep,with piping, disconnects accessible) Alarm floats -alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310,.CMR 15.231(6)and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations y y o s needed ?Provided? [3]0 CMR 15.221(8)] Address 20 13D S r::{- Y�T� Yv�''(- � Sheet 4 of 7 y Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] x Required se, aration-to ouodwater? 310 CMR_15.212)], Aggregate specified,as double washed 310 CMR 15.247(2)] System Venting required/provided? (system under driveway or , >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310'CMR 15.240(13)] , , . Breakout requirements met?(No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and k Guidance Document] Elm Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must k be tograde) 310 CMR 15.253(2)] Aggregate I'minimum-4'maximum. 310 CMR 1,5.253(1)(b)], 2'sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 s ft. [310 CMR 15.253(6)] „ Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet=maximum length 310 CMR 15.251 1) a Minimum separation 2x effective depth or width whichever eater(3x if reserve between trenches) [310 CMR 251 1)(d)] Situated along contours [310'CMR 15.251(2)] Breakout OK7[310 CMR 15.211(1)[4].and Guidance Document] minimum 2 distribution lines 310 CMR 15.252(2)(a)] Maximum separation between lines 6' 310 CM R15.252(2)(d)) Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6"minimum, 12" .x maximum. [310 CMR 15.252(2)(g)] Separation between-beds 10'.minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only 310 CMR 15.252(2)(iA n ��S' �� / Address Z60 �y��f fl V�D` �`'� Sheet 5 of 7 Pressure Dosed System ? Provided pump and piping calculations as re uired 310 CMR 15:220 4 r)] k Pressure dosing required on all systems>2000gpd or alternative systems undW*t4nedial approval [310 CMR 15.254(2) and I%A Remedial Use Approvals] If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd)or quarterly (>2000 ' dgood to note on plan 310 CMR 15.254(2) d ]. Construction in fill -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? x Impervious.barrier and/or retaining wall ? Guidance Document] Impervious Varier installation must be supervised by designer[310 CMR 15.255(2)(b)] �( Retaining wall must be designed by Registered Professional. Engineer [310 CMR 15.255(2)(a)] X Side slope not exceed 3:1 ? 310 CMR 15.255(2)] )< Breakout requirements met? [310 CMR 15.252(2)and Guidance Document] >( At least 5 ft.from impervious barrier to edge of SAS (10 . recommended) [31O C ft MR 15.255�(2)(e)] �C Check DEP Approval letters for credits and design conditions X If used with pressure dosing do not allow pressure discharge x - to scour soil interface Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly"applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has a2plicant submitted a co y of a maintenance Are the variances listed on the plan ? [310 CMR 15.220 (`1)(.) RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.414] Address 2-G2 'Gum PS 1P'wr4—t Sheet 6 of 7 L1) Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR-15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] X Are the nitrogen loads proposed in compliance? [310 CMR y 15.216(1)] P umping septic tank? 310 CMR 15.229 m 310 CMR 15.290 t , Address Z(--" y✓� 1/t�t°/` OL �. Sheet 7 of 7 AsBuilt Page 1 of 1 nTOWN OF BARNSTABL/E LOCATION Xi/��i? -KO-5 Rfye o ld SEWAGE# VILLAGE DS,�ry L l ASSESSOR'S MAP do LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrN LEACb!I NG FACILITY:(type) 7' 7t— (size) �y 9 NO.OFBEDROOMS BUILDER OR OWNER PERMITDATE: • COMPLIANCE DATE- Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility 'Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any w tlands exist within 300 feet9f leaching fAacility) Feet Furnished bys��4W''I e4 Y 4f 4LA o � L/'-a3' A -0-26 ' a-P-Z' �F ��E��{a� R E qd6" http://issgl2/intranet/propdata/prebuilt.aspx?mappar=120133&seq=2 12/15/2014 TOWN OF BARNSTABLE o �r LOt ATION� � '� � Vf-K RW SEWAGE #Y-6 -/o 9eg VILLAGE l (,�t'�` ASSESSOR'S MAP 6z LOT 12-0 3-7 INSTALLER'S NAME 6z PHONE NO. 2,, f-SEPTIC TANK CAPACITY r LEACHING FACILITY:(type) ram. (size)�'a 3.firtC- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER fl. BUILDER OR OWNER DATE PERMIT ISSUED: t' l DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No "•ti 1 �c,K y if 36 1 9 sl Sr � ;�'lJ�*a� pip IOCAT106� �`-"'�v SEWAGE PEttG71T q0. VILLAGE 193STA LLER'S NAME b ADDRESS GUILDER OR OVU ER f DATE PERMIT ISSUED 5-�� DATE C 0 M P L I A N C E ISSUED -Te 7 _J i t I � a- z THE V0MM0WW.EAL.TH OF MASSACHUSETTS _ BOAR® OF HEALTH ...�..17.. _►�.................O F......., .f'.f\. .G�S .1 '.-_-----•---•---.........._.. ApplirFatinn for Uh4poii a1 Morkg Towitrnrtion Vamit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at:--1- ..1�H...... vM��•s..(z�s _'.... s ............ . 4 .�� ............0.8.5....-----------•---•--..........------• Loc tbn A dress or Lot No. .Res.•fit - -P_. '- .................................... -- s?s -lr ,_1.---_....Q.... saw.. _khL C'.........----•-- Owner Address a ...l l_.i.........._1�Lc. s.. .. ......................................... ........................•--...-••-....-- ---........._...........---•-----------.... filler Address Type of Building Size Lot_JE.Q-0.0.....Sq. feet U Dwelling—No. of Bedrooms.....Z................. .Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building t A r ___.... No. of persons .................. Showers X.) — Cafeteria G-i YP g - -------- P ( ( ) Q' Other fixtures ------•--------•---------------- . W Design Flow.....330.............................gallons per person per day. Total daily flow.......... ......................gallons. WSeptic Tank—Liquid'capacityA.0.0gallons Length___e.Q.'._.... Width... ®'..... Diameter_.._. Depth... xDisposal Trench—No. .................... Width.................... Total Length........................Total leaching area....................sq. ft. Seepage Pit No........I------------ Diameter......1.0"....... Depth below inlet.......'_....... Total leaching area..ZA.16....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,aa Test Pit No. 1.2,_G-____-minutes per inch Depth of Test Pit....A.3.......... Depth to ground water.._ ........ f=, Test Pit No. 2._..Zi_P_...minutes per inch Depth of Test Pit-------4`........ Depth to ground water-__ . . ..... --••-------------------------------•------------------------------. ................_...........---....................................................... O Description of Soil-----�r�= -P---._.1R : 5" 5` 's Z `Z� 1° yPA rk V ------------------•--•-----------------------------------------•...................-----••---•----------....------------.....------....--------.--------•------•-•..................................... W -••-----•--------•----------•--•---••••--•-----••-•-•-•-----------------•---------------••-•--•---•---...-•----•-•---------••-•------•------------------•---•---•------•--••--------••-•-•-•-•......... VNature 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 iITL E 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe !�---- ... ' L��' fi Z 11/ D Application Approved BY----------- - --- --=-.�'.•---� ------•-•-•--•-- -•----------�'�-�V. -------- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•----------------------..._------ -----------------------•------------.........._.....-•--•••-•---------------------•....-----••-----------'---•-•-----.....•--•------•---•------------•-------------•-------...---..__ •-----------. Date PermitNo................................................:........ Issued....................................................... Date No... ?.? .`...�... r F>ms....'3. ,C...f .��. THE lOMMONWEAL,TH OF MASSACHUSETTS _ BOARD OF HEALTH ...............OF......... � I. - . . Appliratinn for Disposal Works Tons rnrtinn Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: . 'Locatidn A ress or t No. ...................... _.....................co_`-•-� ---. ....-•---•--...--•-•----•----••-•-• -• ---- $r.._..._. s � t .._._...... Owner Address W . ..'. ...!........ ...-... ......................................... .................................................................................................. er Address UType of Building Size Lot---I...�Q .......Sq. feet Dwelling—No. of Bedrooms.._..2....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............. No. of persons........._................. Showers (X4 — Cafeteria ( ) Other fixtures ................................................. -------------------------------------- -----------------•--------------.....--------..... ------ W Design Flow....._�a_.30.............................gallons per person per day. Total daily flow.._.......43 . .._gallo ns. WSeptic Tank—Liquid capacity.114.QCagallons Length...AP........ Width....AP Diameter__.__: Depth....6.0..... x Disposal Trench—No..................... Width.................... Total Length.__................. Total leaching area___..................sq. ft. Seepage Pit No---------1----------- Diameter......40�...... Depth below inlet....... ....... Total leaching area...Z A.Aa.:.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1...2.tP-----minutes per inch Depth of Test Pit.....0. ....... Depth to ground water....ri _`_ ....... fT4 Test Pit No. 2....Z.-!4_..minutes per inch Depth of Test Pit.__....4l....... Depth to ground water.._- '+• •..... 0+ •-••---•-•••-----------•----•-------••------•---t................. ...............................-•..•-------------- -------------•-•--------------- O Description of Soil------.���-----.=ate.V..\ �` .S.s t ....................... ....t � C. + .s_.v....... c� W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------•---------------•--------------------•-------••................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—'The undersigned further agrees not to place the system in operation until. a Certificate of Compliance has been issued by the board of health. Signed_ ... 1 Application Approved By------------------- ,•, ,..__.„ �� / 3' ' --------- Application Disapproved for the following reasons:---------•-•. •---------•......................••-------....__....---------.....---•----•-----••------........--------•-•••-•-----•---•---•••---•-------------.....-•----------------••----••--•------•-•-•------•---- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH ...............OF........ e h .. ` .. .................... ............................... C9rdifiratr of Toutplianre THIS••IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) y.... A �-i ' ..�Q.A .......................................................... L� I staller at. --cl ........... .-A..... n w•t f 5.....�L.aa��t, -�"� •------�P-�C`--------��� ------_�!AI&S at. been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code. as described in the application for Disposal Works Construction Permit No._0..2 Rt;/J.46............... dated___.._..._._._______.______......_..._...__..... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................... s :.... Inspector-•-•---G--...,�—' -.••`•: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................OF..........� � h� A L .. , :....................: ....................... ... FEE .............. Disposal Work onstrndion Virrmit Permission as hereby granted...... ---- -----•-•-----•----............. --------------------------------------------------•---.._.._...---•--• . to Construe ('� or Repair ) an Individual Sewage�osal System . , or Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... e f V0alth -------------------------------------- DATE.............. ------------•---- ld= ......-•------•---.. .. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 6 s hoOF -r .7A o i Q�area�o� 15 ,; o F co 5 R N� SUR`��'� 4r4' 6 x �d hi 3� 4 ON sPT C qp Lj OL aAC �j TA-N4�- -19+ a �C �. FOVNGi4T10' 1�R /a3 ,b o0,.7 G U All 611" 3 �I �99 9 s�w �►t -� o0 1. -190 e (aq.� W/[)E — PC)8 L I c- LEGEND .. EXISTING SPOT ELEVATION Ox0 ``P�(NOFA44 CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 �--- �' L.0T 7 I v �',� ' FINISHED SPOT ELEVATION FINISHED CONTOUR 0 ---- - Noo10951 ,4 ti IN APPROVED BOARD , OF HEALTH �°9p G15 SAA��,S J° ,�31.A .�� Sa S/ONALE 4 DATE AGENT SCALE, 11/=3 v ' DATE= /Z 71e2 LDREDGE ENGINEERING CQ IN cA`PE Cy n/M,P�, CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REii19Tl�R.ED JOB.. N0,.8 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS. TO THE ZONING LAWS ENGINEER R GR•�Y OF BARNSTA LE, ASS. 712 MAIN STREET,-,_ CH. SYs HYANN I Ss:-MASS., SHEET., e�., ' DATE G. LAND SURVEYOR /VOTE /F E/TNE4 TNESEPTJC TANS OR %-`ACA411V0 QJT ARE :MORAF 77HA,4/ /2"SE40II/ /D. FT MJN. , - :J�'AOE� A 24 'D/AMJET,ER CONCR6T� COtiER SHALL BF BROUGHT TOG ALE t+,v GGNCRCTE / 4'PVC P/PE R EXTRA GG� `0Z• -5 M/N. P/TCN /-Y,5,4Vy CAST /RO/Y Co{iER S/1,4LL C3E USES �•. COVERS �B,AFR,-r. I F/.,V DORI VAF—WA Y �= 2 '1. MiN. CO/VCR�"TE IA . o- G .DOE COVER CLEAN SANG 4"CAST-D - 2 LAYER /RON0/PE l9rJO - - qe / o v o. P OF 8 �B GAL. • • • • • o I: (.. SEPT/C TANK vJST, Av"Rem rrT o , • • . . e • Q° WA 5HEO s7r/NE as BOX , � • � $ • • • ► • � ' .•• •� , s • e • •EFFECT/.VE • • •` 3 4" �2 ° • • • pEPTH • • ' o WASNED STaNE v i � � •.. • • • • • • • ie i a. • • di • • • • p v�D PRECAST SEEPAGE !N{Yi�i�T.EL EY.47"/DNS. • P® • e • • • • r• • e o P/T OR EQL//V. s Cl q2.3 /N'YERT AT QU/LD/NG /NG`ET SEPTIC TANK 9 9..1 FT, �� FT O/A1�'1. C(SFE TABUL.4T)ON� :`..OUTLET SEPT/C_TANK' 2A 9 FT.. /JVLET DISTR/8!/TJON BOX 918 ,7 . FT. GROUND WfaTf�C TAdGE OUTLETD/STR/BfIT/ON BOX 9 8.Y FT SECT/O/V OF' .SELVAGE OISJflOSA t SYSTEM //v[E� cEAcJ,tJwG .o�r 9 S.3 Fr TABULATION_ L NG p/T E.4CN SCALE DJME/V.S/0/V A DESIG/Y CR/TEA 1A k NUMBER OP BEDROOMS 3 D/MENS/ON C FT M rn/ , E GARdAGEO/SP05.4LUNIT A'ORJE 50/L. LOG TOT.►ZL EST/MAT'EG FLGH/ 3 3 O GAL./DA-e SOJL TEST A/ SO/L 7FS7-*2 SO/L TEST NUMBER OF L,-ACAJIVG P/TS / �^E[�K rU' D �J �`-ELFY. �G n,O. ,DATE OF SO/L TEST S/d 'LEACH/NG PER P/T SQ PT. RESULTS N//TNESSED 8Y BOTTOM LE�ICN/NG PER P/T a Z U J .. 7�SQ.. FT. . „� L�at•-M � PtRCOLATJOJv MATE#/ sS MJ NeIINCK � TOrAL LEACH//VG AREA SQ, FT. S (w3 g L SU-/3 S v i L FEhCOLAT/ON RATE 1�2 77t M/N. /NCH RESERVEGEACNI.MS ARZA SQ. FT / Z t�OF OF � /�.L�v/ v� Miss DJ u LOT 7�1 i3UM s' 7zJVC--A Tzh, ry► �0 � Sao N D Sa3-YY.O P �, 02 L T . O�S'T Tz y r y o MO SE . 29874 No.10951 O .. _ �� ELOREDGE`ENGINEERING CO,INC. !�> Q/8T£� OQ` 90 Gr57E �' z•L, 819-;3 �FL, 7/2 MAJN ST. ,'HY,9N.viS, M,gsS, 4N� SURr �FSSi0NAk- ND GR011NL7 yYi4TER ENCOC/NTER��� CL/ENT: jyy1CPL DRTE 4 Z �97 z. GRO UND LvA TE.? AT EGE1/' Q JOB No: 2-OS3 stiEEr?of 2 39j/-__-- � , . LEGEND PROPOSED ,CONTOUR $ y j �..\-39 ® PROPOSED SPOT GRADE• BENCH MARK %' —— 98 —- EXISTING CONTOUR �6°� PAINT SPOT ON + 96.52 EXISTING SPOT GRADE % �.,;�R BULKHEAD CORNER jE j! �,\ff W— EXISTING WATER SERVICE c ao�s ELEVATION = 39. 67 TEST PIT o9 BARNSTABLE CIS DATUM SITE i• auk, RpfR i q a 1\ ROgO \ �_ 39 i TH-1 �°9 ,2 {` \N LOCUS MAP N.T.S. \�:� \ GENERAL NOTES: Existing Leoch its ' \'\ 1- ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL j BOARD OF HEALTH AND THE DESIGN ENGINEER. �A)i (Note 10)l \ 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:. I / Exis tin g 1,000g \ - 310 CMR 15.405 (1) (8): / \ 1) A 0.31 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING TO BE a j / Septic Tank ) 3.31 FT BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. i �j !% _ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF i THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF �j�� I i j HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. L OT 7 A i i 7• WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. - j" G . 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED ��:/ AREA = 15000 s f + i/ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. -9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. o 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION V WATER \��\ / /i \�� j��`l� 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY GATE ii �� j' § AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY p 7° _ j j' 13. NO PRIVATE WELLS WITHIN 100 Fr. OF PROPOSED LEACHING �� i>_ % 14. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) 9 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW ( / 0 Sj 03 �,\ / ji �P / 3 C . FOR THE USE OF A GARBAGE GRINDER \�� // 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING L���<��\ �./ ji O� �/ i j . OF 17. PROPERTY IS IN ZONE II OR NITROGEN SENSITIVE AREA. S � �+ss 17. INSTALLER TO FIELD VERIFY H2O CERTIFICATION PRIOR TO INSTALLATION. o ­ . No. 1140 PROPOSED SEPTIC SYSTEM UPGRADE PLAN �iNlraaOa�' 268 BUMPS RIVER ROAD, OSTERVILLE, MA. MAP.120 Prepared for: Mike Dedecko �I SURVEY REFERENCE: O i LOT. 133 Engineering by: Surveying by: SCALE DRAWN PLAN OF LAND BY BARTER & NYE, INC. DEED BOOK:6372 DARRENM.MEYER,R.S. Zoo-Teoh 8bvimAmente! 1"=20' DMM t DEED PAGE: 277 Po BOX 981 DATED: AUGUST 1, 1978 O EAST SANDIMCH,MA02537 (508) 364-0894 DATE: CHECKED _ SHEET NO. SO8-382-2922 12/22/09 DMM 1 of 2 J NOTE: TO PREVENT BREAKOUT, THE PROPOSED •� NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH. GRADE SHALL NOT. BE < EL'35.69 FOR A DISTANCE OF 15' 'AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.y �� QF M4,(r, T.O.F. EL=40.31 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER OUTLET AND SET TO 6' OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (RIN.) AND SET TO 3 OF F.G. i AR M. y ' i��-- F.G. EL.=39.75t F.G. EL.=39.5f F.G. EL 39.Ot I F.G. EL: 39.0(MAX.) VENT �I YER - I f No 1140 "' 9" MIN COVER/ �/STEM L 12't L = 50' L m 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) 0 S=1% (MIN.) 36" MAX COVER 0 S=1% (MIN.) 0 S=1% (MIN.) S4NITAR�P� 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC t 1o' e' 11.3" TO . ta" \INY.= 36.43 48"LIQUIDINVERT kNV.=36.18 , w LEVEL } PROPOSED INV.=35.48 GAS BAFFLE) D-BOX 3 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE 32.0'/ROW - - -D8 3(H-10) INV. 35.30 INV.=35.68 SOIL ABSORPTION SYSTEM -(PROFILE) EXISTING 1,000 GALLON SEPTIC TANK RESTORE VEGETATIVE COVER ' EXISTING SEWER OUTLET BACKFILL WITH CLEAN PERC SAND TO TOP OF CHAMBERS 75" -� NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ' '•"'`. ' ' PIPE INVERTS PRIOR TO,CONSTRUCTION BREAKOUT=TOP ELEV.=35.69 2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 35.30 y� GRADE ON A MECHANICALL COMPACTED SIX BOTTOM ELEV.= 34.36 INCH CRUSHED STONE BASE, AS SPECIFIED IN 2 83' EXISTING SUITABLE JN L 310 CMR 15.221(2) MATERIAL 5' MIN. ABOVE BOTTOM OF � - .3) INSTALL INLET & OUTLET TEES AS REQUIRED -T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH 3 x 2.83' = 8.49 76" CAPACITY 4) REPLACE EXISTING 1,000 GALLON, SEPTIC BOTTOM OF (6.41 TESTHOLRE EDED27 95-=- ADS BIODIUSE 3O FWS U ER UNTIS-NOSTONE PROFILE TANK WITH 1500 GALLON SEPTIC TANK _ W/ CONTOURED WEDGE IF FAILED, DAMAGED, OR UNDERSIZED. I SEPTIC SYSTEM PROFILE TYPICAL. SECTION 1s" N.T.S. s.rs 1 1.2" DESIGN CRITERIA 'SOIL LOG P#: 12803 NUMBER OF BEDROOMS: 2 BR EXISTING/3 BR DESIGN (PROP. IS. IN ZONE_II) DATE: DECEMBER 22, 2009 f� 34" SOIL EVALUATOR: . DARREN M. MEYER, R.S:, CSE. #1614' SECTION . END CAP CLASS I _ SOIL TEXTURAL CLASS: , WITNESS: •i DAVE STANTON, BARNS B.O.H. DESIGN PERCOLATION RATE: <2 MIN/IN ' . ' 16""+ HIGH CAPACITY (H-20) BIODIFFUSER UNIT DAILY FLOW: 1 10 G.P.D/BR. Elev. TP- Depth Elev. TP-2 Depth , DESIGN FLOW: 330 G.P.D. `39.50 A LOAMY SAND "O" 39.45 A LOAMY SAND 0„GARBAGE GRINDER: NO NOT DESIGNED FOR GARBAGE GRINDER 33:83 B 10YR 4 1 g" 10YR 4 1 MODEL 16" HICA' ( ) LOAMY SAND 38 70 B LOAMY SAND 9„ LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT PROPOSED SEPTIC TANK:. USE EXISTING 1,000 GALLON, CAPACITY 10YR 5/8 10YR 5/8 EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY LEACHING AREA REQUIRED: (330) = 445.94 S.F. 36.34 C1 38" 36.37 C1 37" SIDE WALL HEIGHT 11.2" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. .74 OVERALL HEIGHT 16" DISTRIBUTION BOX: 3 OUTLETS (MINIMUM) OVERALL WIDTH 34" 4640 TRUEMAN BLED PERC 0 34.83 � HILLIARD, OH/0 43026 PRIMARY S.A.S. MEDIUM SAN MEDIUM SAND 13.6 CIF 9ffAw 2.5Y 6/4 2.5Y 6/4 CAPACITY 101.7 GAL ADVANCED DRAINAGE SYSTEMS, INC. USE 3 ROWS OF 5 - 16" ADS 1600 BD BIODIFFUSER H-20 UNITS-NO STONE � ( ) AND EXTENDED 0.75' W/ CONTOURED WEDGES PROPOSED SEPTIC SYSTEM SITE PLAN BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) ► (BIODIFFUSERS) 15 UNITS x 6,25 LF x 4.70 SF/LF = 440.63 SF 28.0 138" 27.95 138" 268 BUMPS - RIVER ROAD OSTERVILLE MA (CONTOURED WEDGE) 3 ROWS x 0.75' x 4.70 SF/LF = 10.58 SF PERC RATE t<2 MIN/IN. ( C, HORIZON) _ TOTAL AREA = 451.21 SF Prepared for: Mike Dedecko DESIGN FLOW PROVIDED: 0.74GPD/SF(451.21 SF) = 333.89 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: ' Surveying by: SCALE DRAWN I � DARRENM.MEYER,R.S. Boo-Tech Bnvironmente! NTS D.M.M. • I, Darren M. Meyer, R.S., CSE, hereby..certify that 1 am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX 981 508 364-0894 ( ) DATE: CHECKED SHEET NO. to conduct soil evaluations and that the above analysis has been performed by me consistent with the EgST SANDW/CH,MA 02537 requirements of 310 CMR 15.017. 1 further certify that 1 have passed the Soil Evol. Exam In October, 1999. 2209 508-362-2922 12/ / D.M M 2 of 2