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Home My WebLink About0521 BUMPS RIVER ROAD - Health 521 Bumps River Road Osterville , A = 143 "039 a TOWN OF BARNSTABLE c Wa-t< LOCATION 5�.( b2L ue� f SEWAGE R Nwjt VILLAGE 0,3—i Nl(C_k ASSESSOR'S MAP&PARCEL 4 INSTALLER'S NAME.&PHONE NO SEPTIC TANK CAPACITY. LEACHING FACILITY;(fie) (size)NO.OF BEDROOMS OWNER LA LUA , . PERMIT DATE; COMPLIANCE,.DATE: , Separation Distance Between the: Maximum Adjusted Groundwater Table to the.BottgTn_-of Leaching Facility Feet: Private Water Supply We11 and Leaching Facility(If:any wells exist on site or within 200 feet of leaching facility) Feet'. Edge of Wetland and Leaching Facili_.ty(If any wetlands exist within 300'feet of;leaching facility) Feet, FUR1�iISHED BY . o e W s A f `dEAT g� 3 a. L0= y L T _ i Town of Barnstable IRECEIPT MAS&BAMSTABL& 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-17-990 Date Recieved: 4/10/2017 Job Location: 521 BUMPS RIVER ROAD,OSTERVILLE Permit For: Building-Alteration INTERIOR Work Only-Residential Contractor's Name: GCI BUILDERS INC State Lic. No: 152253 Address: PO BOX 509, MARSTONS MILLS, MA Applicant Phone: ' 02648 (Home)Owner's.Name: GORE,LAWRENCE S&LEP_LEY, Phone: ELIZABETH JO (Home)Owner's Address: I PO BOX 30582, SANTA BARBARA,CA 93130 , Work Description: Pull Permit fora Bedroom over existing garage. project was completed without a permit.Need to make it legal through the building department Total Value Of Work To Be Performed:, ' $0.00 _ _.. l Structure Size: 0.00 0.00 0.00 , Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded"from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I'understand that when a permit is issued, it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24. hours in advance.. Signed: GCI BUILDERS INC 4/10/2017 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost: $0.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee; $85.00 - Total Permit Fee Paid: $0.00 THIS IS NOT A PERMIT^ T — r Commonwealth of Massachusetts Title 5. Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 521 Bumps River Rd Property Address Lepley Owner Owner's Name -41 information is .1 required for Osterville MA 3-1-17 every page. Cityrrown State Zip Code Date of Inspection as CA Inspection results must be submitted on this form. Inspection-forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out SAW forms on the vv computer,use 1: Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145- Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes . ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority F 3-1-17 gFector6A ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing.this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner, and copies sent to.the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection system met all minimum passing requirements. This report does not predict the future performance under the same or increased used. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):. C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every 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. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysiis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1-of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility'with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat ; or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system_ owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. CityrFown. 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. ElDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 per plan Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. CityTrown State Zip Code Date of Inspection D. System Information Description: According to design plan found at the Board of health the system consists of a 1500 gallon h-20 septic tank h-20 d-box and a 12x40xlft field. plan by Baxter and Nye dated 3-22-95. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: water usage was not available at time that I did the report. Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons w How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and ,maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 according to septic permit#95-582 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 7ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: could not determine due to depth t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 1' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 Bumps River Rd Property Address Lepley Owner Owners Name information is required for Osterville MA 3-1-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness could not determine Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom.of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1 recommend pumping at time of transfer and at least every 2-3 yrs there after for maintenance. r Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Cityfrown 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.): it Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain); Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 521 Bumps River Rd M Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was not opened because there were no swing ties on as-built card and we were unable to locate by probing most likely due to depth Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: s.a.s was viewed through vent pipe by camera_because there were no observation ports located or shown on as-built. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 1' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: - 12x40x1ft ❑ 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.): There were no clear signs of failure in s.a.s when it was viewed through the vent pipe. There were however no actual observation ports available and no swing ties to the s.a.s. 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 I , Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is Osterville MA 3-1-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 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 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every 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 ® drawing attached separately 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 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every page. Citylrown 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: 14feet 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: 3-6-17 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: design plan by Baxter and Nye inc dated 3-22-95 #95044 Before filing this Inspection Report, please see Report Completeness Checklist on next page t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Bumps River Rd Property Address Lepley Owner Owner's Name information is required for Osterville MA 3-1-17 every 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 SEWAGE INSPECTIONS LOCATION_521 dumps River' Road DATE 5/6/03 VULLAGEOsterville,Mass. ASSESSOR'S MAP&LOT!43-039 •INSPECTOR Joseph P.Macomher Jr. SEPTIC TANK CAPACITY 1500 gallons 1-ROX ' LEACHING FACIL TY:(type) Leach trench (size) 1 2'X40'Xl 4" NO.OF BEDROOMS 5 BUILDER OR OWNER Stewart Glasser OWNER MAILING ADDRESS J<< og ps /-iyti /[aWa , vsservjjr, h \� p �,b . Go�zy.e � gpotaw,a.,f' http://www.townofbamstable.us/AssessingiHMdisplay.asp?mappar=143039&seq=1 3/6/2017 No... 5 5-�a � e � F�$:..Obc)•tco •l• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Aji# irtttillu for Dtrppag tl Works Toustrurtion ramit Application is hereby made for a Permit to Construct ( JC) or Repair ( ) an Individual Sewage Disposal System at- S 1 uw1P5 �. Location Address or Lot No. L c� t L p Ie 52► c�c)t�tPs c rZ le o ---•-----------------------..__._.......__.._......._... -- �• OwnerMZZ P. / � a .. _ -.... I.a....4.r___!_ 1_�T1`� l��l�'. 5 GcJ._ r�Ji�lLss.. .. ------------- Itrstaller Ad ress S Type of Building /' Size Lot....A.iQj______________Sq.-feel #V U Dwelling—No. of Bedrooms--------`�l____________________------_----Expansion Attic (qo Garbage Grinder (90) Other—Type of Building _______________ No. of persons............................ Showers a YP g ------------- -------P--- ( ) — Cafeteria ( ) dOther fixtures -----------------------_ -----•---•--... -•••----•----•-•--•------------- --...--•-•-......----•• AG W Design Flow.............5.!5.....................gallons per person per day. Total daily flow_____________:4____________._______.___..gallons. WSeptic Tank—Liquid capacity_99 0__galIons LengthlCO"'�?___ Width-5-:_6__- Diameter__-.—_-__-__ Depth__.__:'8.. x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter_._---__-___---_____ Depth below inlet.............:...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing k ( ) / `"' Percolation Test Results Performed b _ _ 3 j�1.95 a Y•------ --�X ..� �C---•-�!�.lC.----- Date.---- - ------•- •--- --•-•------ � Test Pit No. I.,_�.Z_._._minutes per inch Depth of Test Pit-_V_4.R......... Depth to ground water_.'�Q_�_ �Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil Q '•( t �'c� _ ...`a._.... J— = 'Q- -ME7D A x U ---------•-----••--•----------------------•-------••--•-------•-------•-••-•---•--------._._...--------•--------------------------------------•--••-------------_.............•-•-•.....__...•---•-... W UNature of Repairs or Alterations—Answer when applicable...............................................................:............................... ..._.__.....••------•------••••-----••••••••----•---•-••-----•-•-----•--•••••••••--••-------•--•••••----••-•------------•-------••------•-=•-••••---•---•-•-•--••••-•-••---•-••••-•--•.............••-•- Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp ce s n issuedby the board of health. f Signed ... ' . -- -- - -- .......... :-........ ----. ------ -- .............................. Date Application Approved By .................. --------.................................................... / : ��P- Date Application Disapproved for the following reasons: ...................................................----------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------=-----------------.............. Dare Permit No. .......r. �� .: Issued ...... �I Dace _ __...e_'---- --- ------ ----- - — ——— —`._--' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ge>r#ifirate of Complianre THIS IS TO CERTIFY, That the Individual Sewage-Disposal System constructed ( X, or Repaired ( ) by............................................................... ........:................_.------....--....................................................., --....................................------...........---...........-------- - �- - � InxuJler .. -'2. tJI�.I.n.�.. . ...... .. '.......... : \.. - > has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the'application for Disposal Works Construction Permit No. ��.'� - ,,�- dated �'.-- �.--.5 ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A-GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �� f DATE'"." .... Inspect,L r_......`.. ,=---- -- ........................... • f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE - Disposal Works Tomitrurtion "an it Permissionis hereby granted............................................................................................................................................... to Construcct�( K)_.�r Repair( :), an Individual,-Sewage Disposal System atNo..... -j ._ _L-.-.................................. Street , as shown on the application for Disposal Works Construction Per No.................. Dated....... • r / .-.v- -. -: Board ah DATE..............................................�i______________•-•------------ FORM `"`•^' ` 38908 HOBBS 6 WARREN.INC..PUBLISHERS I Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 BUMPS RIVER RD Property Address GORE/LEPLEY Owner Owner's Name information is required for OSTERVILLE MA 7-21-14 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. wn n filling out A. General Information forms on the I"I1F computer,use 1. Inspector. only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return t key. DOUGLAS A BROWN INC. Company Name P.O. BOX 145 Company Address CENTERVILLE MA .„ 02632 p marten wn State Zi Ci /To p Code 508-420-4534 •• ::; S14297 Telephone Number _ License Number B. Certification , 1 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: ®i Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority 7/21/14 Inspecto s Signature Date ° The,system inspector shall'submit a copy of this inspection report to the-Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a-design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. _ ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection'does not address'how the system will perform in the future under.'. the same or diffeaent conditions of use. t5ins•3/13 Title 5 Official Ins io F rm:Subsurface Sewage Disposal System°Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' �M 521 BUMPS RIVER RD Property Address GORE/LEPLEY Owner Owner's Name information is required for OSTERVILLE MA 7-21-14 every page. Cityrrown 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:. SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION B) System Conditionally Passes: r more stem components as described in:the"Conditional Pass" section need to be - ❑ One o y p _ replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not t. 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,pnot leaking and if a Certificate of Compliance indicating that-the tank is less than 20 years old is available; ❑ Y E N - ❑ ND(Explain below): . t5ins•3/13 _ Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 17 . ,�\ t Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r M 521 BUMPS RIVER RD Property Address , GORE/LEPLEY Owner Owners Name - information is required for OSTERVILLE •MA 7-21-14 _ - every 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.):.y ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System,will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ 'Y ❑ N ❑ ND (Explain below): ❑ :obstruction is removed , = ❑ Y ❑ .N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The• system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below), ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ~ C) .Further Evaluation is Required by the Board of Health; ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR ' a 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: `❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection 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',i wM 521 BUMPS RIVER RD "y Property Address GORE/LEPLEY r Owner Owner's Name information is OSTERVILLE MA 7-21-14 required for every page. Cityrrown State Zip Code Date of Inspection i 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: R. ❑ 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. r- ❑ 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**. 4 ' «t . ` Method used to determine distance: #' **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen,is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria.Applicable to All Systems: f=, 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' .♦❑ ®f .i 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 ' 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 ❑'Y ® than '/2 day flow t5ins•3113 M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r k • . Commonwealth of Massachusetts s Title 5 official Inspection'_ Form { Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 BUMPS RIVER RD Property Address GORE/LEPLEY ' Owner Owner's Name information is required for OSTERVILLE.' MA 7-21-14 every page. City/Town State , Zip Code Date of Inspection = B. Certification (cont.) ; Yes No ❑ ® Required pumping more than 4 times in the last year NOT.due to clogged or.'.. obstructed pipe(s). Number of times pumped: ❑ .`'' ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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. .' ❑ 1Z Any portion of'a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private.water supply well with no acceptable water quality analysis. [This' system,passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm; provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- El 10,000gpd. ❑ ® ' The system fails. I have determined that one or more of the`above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will lie r necessary to correct the failure. E). Large Systems: To be considered a large system the system must serve a facility with a M 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 1 ❑ ❑ 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 El ❑' Area IWPA)or a mapped Zone II of a public water supply well- If you have answered"yes'`to any question in SectioniE 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection• Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " M 521 BUMPS RIVER RD Property Address GORE/LEPLEY r Owner Owner's Name information is required for OSTERVILLE 4 ' MA 7-21-14 t '- - '' - • . 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., a : Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health . ® Were any of the system components,pumped out in the'previou`s°two weeks?" Z ❑ 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: i r ® ❑ ' 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: 5 AS Number of bedrooms(design): Number of bedrooms(actual): BUILT DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3113 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form z _ a Subsurface Sewage Disposal System Form-Not•forVoluntary Assessments 521 BUMPS RIVER RD Property Address GORE/LEPLEY Owner Owner's Name information is OSTERVILLE MA 7-21-14 " required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS_ OF A 1500 GALLON TANK D-BOX AND A - 12FTX40FTX141NCH S.A.S ` Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes, ❑ No Is laundry on a separate sewage system? (Include laundry system inspection+ Yes ❑- No information in this report.) - Laundry system inspected? ❑ Yes ❑ No Seasonal use? - ❑ Yes ❑ No . Water meter readings, if available(last 2 years usage'(gpd)): . ' Detail: 2012------------289 2013=------- ----303GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: ' r 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.): K? Grease trap present? ° r ❑, Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑,-No t Non-sanitary waste discharged to the Title 5 system? ❑' Yes ❑ No ' Water-meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M s 521 BUMPS RIVER RD } Property Address GORE/LEPLEY .Owner Owner's Name information is required for OSTERVILLE MA 7-21-14 . every page. City/Town State Zip Code ' Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date E Other(describe below): General Information.` Pumping Records: Source of information: + Was system pumped as part of the inspection? ❑ Yes '® No If yes, volume pumped: ' gallons How was quantity pumped determined? Reason for pumping: { Type of System: ® Septic tank distribution box soil absorption s stem p P Y _ ❑ Single cesspool, ❑ Overflow cesspool 0 ;Privy w .❑. Shared system(yes or.no) (if yes, attach previous inspection records, if any) , y. ❑ 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: 4. Other(describe): t5ins"3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM 521 BUMPS RIVER RD Property Address ` GORE/LEPLEY Owner Owner's Name information is required for OSTERVILLE MA 7-21-14 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed'(if known) and source of information: 2003 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No... Building Sewer(locate on site,plan): _ Depth below grade: feet - Material of construction: ❑ cast iron ❑40 PVC - ❑ other(explain): Distance from private water supply well or suction line; feet Comments(on condition of,joints,.,venting, evidence of leakage, etc.): - Septic Tank(locate on site plan): s Depth below grade: w feet ; ' Material of construction: concrete ❑ metal, '- ❑ fiberglass ❑ polyethylene •❑ other(explain) - If tank is metal, list age:' years , Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: MODERATE TO HEAVY - t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 BUMPS RIVER RD , ,: Property Address GORE/LEPLEY Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) ; Distance from top of sludge to bottom of outlet tee or baffle t , Scum thickness MODERATE Distance from top of scum to top of outlet tee or baffle : Distance from bottom of scum to bottom of.outlet tee or baffle r How were dimensions determined? 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 COULD USE PUMPING J. Grease Trap(locate on site plan): t ' Depth below grade: feet Material of construction: ❑ concrete ❑ metal ` El fiber ❑ polyethylene El other(explain): Dimensions:'` Scum thickness , Distance from top of scum to top of.outlet tee or baffle, . Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 cf 17 4 Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 521 BUMPS RIVER RD,• - • . ' Property Address GORE/LEPLEY _ Owner Owner's Name information is required for OSTERVILLE MA 7-21-14 � 9 - every page. CitylTown 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.): w Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):' Depth below rade: Material of construction: r • ❑ concrete .' Y.❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): .Dimensions: e •;� •• - • ' , .. r ,,. • � . Capacity: � •� •:." _ R • -` gallons Design.Flow:. gallons per day Alarm present: ❑ Yes ❑ No. t _ Alarm level Alarm in working order: El Yes ❑,No Date of last pumping: X . f _ Date Comments(condition of alarm and float switches, etc.): tr *.Attach'copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 f Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 'Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM s a`'y 521 BUMPS RIVER RD Property Address GORE/LEPLEY _ Owner Owners Name information is required for OSTERVILLE MA . - 7-21-14 every page. CitylTown 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE OR SIGNS OF SOLID CARRY OVER Pump Chamber(locate on site plan); Pumps in working order: ❑ Yes ❑, No*. Alarms in working order: T ❑ Yes ` ❑ No* - Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.) .If pumpsor alarms are not'in working order, system Is a conditional pass.- • � ,, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS-not located; explain why: J. s r. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 _ • - - - I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 521 BUMPS RIVER RD Property Address GORE/LEPLEY I Owner Owners Name information is OSTERVILLE MA 7-21'A4 required for every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) - + Type: ❑ leaching pits number: } ❑ leaching chambers number: ❑ leaching galleries. number: ❑ leaching trenches •. number, length: 12FTX40FTX141 ® leaching fields number, dimensions: NCHES ❑ overflow cesspool number: ❑ innovative/alternative.system Type/name of technology: p. Comments(note condition of soil;signs:of hydraulic failure, Ievel`of~ponding;damp soil, condition of vegetation, etc.):- A CAMERA WAS SENT INTO THE VENT PIPE AND NO SIGNS OF FAILURE WERE OBSERVED AT TIME OF INSPECTION. ' Cesspools (cesspool must be pumped,as part of.inspect ion) (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 ❑ Nox t5ins•X13 Title 5 Official Inspection Porte:Subsurface Sewage Disposal System.-Page 13 of 17 r - Commonwealth of Massachusetts Title 5 Official Inspection.' Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 521 BUMPS RIVER RD Property Address GORE/LEPLEY Owner Owner's Name , information is required for OSTERVILLE MA 7-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.): . Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): r A. Privy(locate on site plan): Materials'of construction: t Dimensions - Depth of solids Comments (note condition'of soil,.signs'of hydraulic failure,-level of ponding, condition of vegetation,• etc.): f . 1 d t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 c'f 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments : wM '� 521 BUMPS RIVER RD Property Address GORE/LEPLEY Owner Owner's Name information is OSTERVILLE MA 7-21-14 required for ,. ' every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System`. Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check,one of the boxes below: 0 hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts= Title 5 Official Inspectin `Form Subsurface Sewage Disposal System Form -Not:.for Voluntary Assessments 521 BUMPS RIVER RD ' Property Address GORE/LEPLEY Owner Owner's Name r. information is required for OSTERVILLE MA 7-21-14 _ every page. City/Town State Zip Code Date of Inspedion'Y D. System Information (cont.) Site Exam: ` ® Check Slope ® ,Surface water ' :®.Check cellar . * ® Shallow wells f Estimated depth to high ground water: ` AT:LEAST,5 p f ' feet , a Please indicate all methods'used to determine the high groundwater elevation: '. ❑ Obtained from system design plans on record' If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150.feet of SAS) ❑ 'Checked with local Board of Health explain: ❑P Checked with local-excavators,`installers (attach documentation) ' ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 2003 CODE t 1 _ Y Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts' ; Title 5 Official Inspection form _ t' Subsurface Sewage Disposal System Form Not for Voluntary Assessments,` M „> � 521 BUMPS RIVER RD . Property Address GORE/LEPLEY Owner Owner's Name information is LLE MA- 7-21-14 required for OSTERVI , every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist . 0 Inspection Summary:A, B, C,'D,or E checked .0 Inspection Summary D (System Failure Criteria Applicable to All Systems-).completed s . ® System Information—Estimated depth to' high groundwater ` ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file s t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Y Assessing As-Built Cards ep Page 1 of 2 SEWAGE'INSPECTIONS', LOCATION 521 Bumps River' Road �� DATE• 5/6/03 VILLAGE Ostervil�le,Mass.• ASSESSOR'S MAY&LOT143-039 •INSPECTOR Joseph P.Macomber 'Jr. . SEPTIC TANK CAPACITY 1500 gallons 1-11ox LEACHING FACILrm(type) Leach trench (size) 1 2'X40'X14" , NO.OF BEDROOMS 5 , w BUILDER OR OWNER Stewart Glasser ti F R OWNER MAILINGS ADDRESS 'Same *. n ------------------------- P ..f, . ,7i.� (h,.Mps .I�wtr �tava .r vsrerv.re• � - �. , r i a , Garz'e y4 r http,://www.towno'fbams-table.us/AsseSsiiig'/HMdisplay.asp?mappar=143039&seq=1 °- 7/ 1/2014 U-�� :�1h �v i �-- 1 r A-b-,Ajer �,� cic � c [RECEIVED DATE:5/6/ Y; 2 8 2003 OF BARNSTABLE PROPERTY ADDRESS: 521 bumps River Road ALTHDEPT. Ostervl�'ille,Mass-=- MAC ------- ------- ----=- l '`-� '� PARCEL , O 02655 LOT ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the -following: 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3. 1 -Leaching trench. ( 40 ' X12 'X14" ) Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code) 5. The septic system is in proper working order at the present time. 6. Ran snake through the vent and through the leaching trench. ( 8 ' below grade) Trench is presently dry and shows no signs of solids carry over. SIGNATURE: Name:-J.P. Macomber Jr_______ f Company: Josei)h_P. Macomber_& Son , Inc . Address: Box 66 Centerville , Ma_-02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE;A GUARANTY OR WARRANTY Mom JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775.6412 i ,per \ COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 521 Bumps River Road Ostervil e,.Mass. Owner's Name:Stewart Glasser Owner's Address: 17 Woodland Drive Rands Point New York 11050 Date of Inspection:spection: 5/6/0 3 Name of Inspector: (please print) Joseph P. Macomber Jr. Company Name: Joseph P. Macomber & Son Inc Mailing Address: _Box 66 CPntPrvj11P Ma 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT ' I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: j /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: "d The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments r"""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. Tithe 5 Inspection Form 6/15/2000 page 1 j w Page 2 of 11 OFFICIAL INSPECTION FORM;NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 521 Bumps River Road Osterville,Mass.. Owner: Stewart Glasser Date of Inspection: S l F j n-j Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S em Passes __C b I have not found any information which indicates that any of the failure criteria deschbed in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure crjteria not evaluated are indicated below. j Comments: The-_septic system is in proper working order at the present time B. System Conditionally Passes: loll 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. A The septic tank is metal and over 20.years old* or the septic tank(whether metal or not) is structurally' unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pwnping 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: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 521 Bumps River Road Cl�i-Prvi 11PyMacs , ,; ' Owner: Stewart Glasser Date of Inspection: 5 6 0 3 C. Further Evaluation is Required by the Board of Health: AA0 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 su.-face 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. 4-0 The system has a septic tank and SAS and the SAS is within a Zone l of a public water supply, ko The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t+ 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 f,Ija&ez "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well istree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT_S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 521 Bumps River Road " Osterville,Mass. Owner: stPwart Glasser 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 or cesspool Discharge or or cesspool g of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool d—J r'L Static liquid level in the distribution box above outlet invert due to an overloaded or clogged S cesspoolOrJC/��/�i'�9(,�i+�� l/ gg AS or Liquid depth in eeaspobl is less than 6" below invert or available volume is less than ' Required pumping more than 4 times in the last year NOT due to clo ed or obstruc i da now /°f times pumped O . p pe(s). Number -- 1L i�nY Portion of the SAS, cesspool or privy is below hig h gh 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. 11Anv 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. (Tbis system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist a described in 310 CMR 15.303. therefore the system s y m fails. The sy stem owner should Health to determine whatould contact the Board of will be necessary to correct the failure. . E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) • yes no the system is within 400 feet of a surface drinking water supply -- — g I Pp Y . the system is within 200 feet of a tributary to a surface drinking water supply i� the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area Zone 11 of a public water supply well ea— IWPA)or a mapped I you have answered "yes"to any question in Section E the system is considered a significant threat, or answered J "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 521 Bumps River Road" Osterville,Mass. Owner: Stewart Glasser Date of Inspection: _5/6/0 3 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No/ Y Pumping information was provided by the owner, occupant, or Board of Health J- 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? Y/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 eluding 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 y Existing information.For example,a plan at the Board of Health. v _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR I5.302(3)(b)) 5 Page 6ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:521 Bumps River Road Osterville Mass. Owner: Stewart Glasser Date of Inspection: 5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): So' Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ��u ,�� f' rd W 4 Number of current residents: Does residence have a garbage grinder(yes or no): Na Is laundry on a separate sewage system(yes or no): V0 [if yes separate inspection required] Laundry system inspected(yes or no): YP,6 Seasonal use: (yes or no): Al D Water meter readings, if available(last 2 years usage(gpd)): 2 0 01 =4 5 4, 0 0 0=1 2 4 3. 8 4 GP D Sump pump(yes or no): IQ 2002=522, 000 gallons =1430 GPD Last date of occupancy:� Sprinkler System is 'present COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): AM gpd Basis of design flow(seats/persons/sgft,etc.): 0 Grease trap present(yes or no):_A),9 Industrial waste holding tank present(yes or no):LII� Non-sanitary waste discharged to the Title 5 s stem(yes or no): ill/ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): , GENERAL INFORMATION Pumping Records Source of information:Tanks pumped 3/2 9/0 2 ° Was system pumped as part of the inspection(yes or no): Al If yes, volume pumped: 0 gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM V Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool ,V(,* Privy Aw Shared system(yes or no)(if yes,attach previous inspection records, if any) Zl Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) !O Tight tank VA Attach a copy of the DEP approval Other(describe): Approximate age of all com orients, to installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 521 Rumps River Road Osterville,Mass. Owner: Stewart Glasser Date of Inspection: 5/6/0 3 BUILDING SEWER(locate on site plan) k Depth below grade: Materials of construction: Alaast iron /40 PVC&2other(explain): 164 Distance from private water supply well or suction line: 4`r Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight No evidence of leakage SEPTIC TANK: P (locate on site plan) /6W 374)A�-� Depth below grade: 17 / Material of construction: concrete 6 meta Wd fiberglasVD polyethylene Al�ther(explain) 41 If tank is metal list age: b is age confirmed by a Certificate of Compliance (yes or no);"Ue(attach a copy of certificate) ensions: l0� �W WW Dim ,0 Sludge depth: .AA� Distance from top of Judge to bottom of outlet tee or baffle:/ e'J Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: t9?R. yn� et Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump optic tank every 2-3 years Inlet & outlet tees are in plare-The tank ; s structurally sound and shows no evidence of leakage.The liquid level at the outlet invert is 51 " GREASE TRAP1,3/1klocate on site plan) Depth below grade: Material of constructions Mconcrete.�,4metaW4 fiberglass✓t/,4 olyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sc,u�,�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.): Grease trap is not Present 7 Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _521 Rumps River Road Qs_terville,Mass. Owner.Stewart Glasser Date of Inspection: 5 6 03 TIGHT or HOLDING TANKVoeftank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal 0,4 fibergl ass i, 1 Aolyethylene4�4_other(explain): AM Dimensions: Alh Capacity: allons Design Flow: gallons/day Alarm present(yes or no): AJA Alarm level: 40 Alarm in working order(yes or no): 14),4 Date of last pumping: V, Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not resent. DISTRIBUTION BOX: /(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: AJi) e."4A, 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.): Distriba ion box has one lateral Did not dig up box Box is 71F11 helow grade. PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no): � Alarms in working order(yes or no): ,4 Comments(note condition of pump chamber,condition of pumps and appurtenances, etc): Pump ehamhpr is n0 Present 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 521 Bumps River Road t7sterville_Mass, Owner: Stewart Glasser Date of Inspection: 5 6 03 a SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 40 ' X12 ' X14" Leaching trench, If SAS not located explain why: Located• See Page 10 Type /)Q leaching pits, number: O leaching chambers, number:_0 W/ leaching galleries,number:0 H _&5Aeaching trenches,number, length: Nd leaching fields,number,dimensions: �lJ$ 9P overflow cesspool, number: innovative/alternative system Type/name of technology:)/2'1p, Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to sandy loam to medium fine sand No signs of hydra111 i t fa i 1 iirn or prindjnrr So 1 c are dry VagPt=atj nn i .) is normal.Leaching trench appears dry, 8 ' below grade ran snake ), into fie hrough vent pipe. Trench is presently dry. CESSPOOLS .y cesspoo must be pumped as part of inspect ion)(locate on site plan) Number and configuration: (� _ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: /Q Dimensions of cesspool: Materials of construction: /R Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are not present PRIVIlk locate on site plan) Materials of construction: Dimensions: / 14 Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Pr-i;z y is not pria-ri ant.. 9 Page 10 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 521 Bumps River Road s ervi a Mass. Owner:Stewart Glasser Date of Iaspectioo: 5 6 03 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. ol 521 8un,ps �ivc� ZoW OSlerv,/le Ira M - a O Gar�9e=1 gpeA,--,, 10 • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property AddressStewart Glasser 521 Rumps River Road Owner: Osterville,Mass. Date of Inspection: 5/6/0 3 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: NO Obtained from system design plans on record-If checked,date of design plan reviewed: NA YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: NA YES Checked with local excavators, installers-(attach documentation) yE,q_Accessed USGSdatabase-explain:http- /./tawn harnstable.ma'.us. You must describe how you established the high ground water elevation: Jsed: Gahretz X Mil 1 er Mr,rlpl 1 9/1 6 /gA rrr„tnrl �,IatPr a}aove—sea 10vel. Jsed: USGS, so uati on w I 1 daia .Tnno 1 QQa Jsed: USGS• Top of n 0 1 Leaching trench 40 'X1 2'X1 4" ;eet Groundwater f�Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is _45-A feet. . . 11 ` '.nr•.—nlT,r>—.rr�t+nrmr•ntenrrnrt re'rrsrrl:�r+:tsett�'n tfs'q-al 1�s•�Ipll Ostervil�e,Mass. 'I'UKN OF WARD OF HEALTH, 1 .•'•T!1�T•'."t1—T.IIE�:81111SURFACR 'SNAGF 1)I fUSAL SYYSTF,M IN�91"ECTION FORM -p.PART D •= .C IrRTIFICAT,ION n JtH1.111iI1'RRT�'1TT'TIT�.•.�I.1"'1• 'r..•. —. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED 4 STREET ADDRESS521 Bumps River Raod . Osterville,Mass. ASSESSORS MAP, BLOCK AND PARCEL # 143-039 OWNER' S NAME Stewart Glasser PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P. Macomber Jr., COMPANY NAME Joseph P. Macomber :.& StYfi 'Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 stray[ Town or C1ty COMPANY TELEPHONE (508 ) 775 - '3338 s[ata tlp !f FAX { 508 ) 790 :. 1.578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage di'sposa7 system "nt this address and that the information reported is true , accurate , and omplete as of the time of .inspection , The inspection was performed and, any Crecommendations regardirrg . upgrade , . maintenance , and repair are consistent with my training and experience in" the proper function And maintenance of on- site sewage disposal systems , Check one . System PASSED The inspection which I have conducted ha's not found any information which indicates that the system fails to adequately protect public ' healLh or the environment as defined in 310 CMR 1513031 Any .failure criteria not evaluated are as stated in -the FAILURE CRITERIA secticr this form , v l of System FAILED# \ The inspection which I •have con cted has (found that the, system fails' to Protect the public : liealth and ttie environment in accordance 'with Title 5., 310 CMR, 151303, and as spec-ifically noted on, PART ,C FAILURE CRITERIA of - this inspection, form . Ins c w ,,. •� • pector Signature r / Date= : G d� ne coDy of this c rt.ification must be provided to the OWNER, ( uhez a appl icable ) and the BOARD OF HZALTII. the BUYER *.'IE the .inspection FAILED, the owner or'1"opez'ator shall u ~ within one year -of the date of the inspection, unless allowed d or t requireem otherwise. as provided in 3.10 c�IR 16 , 3061 partd£ doc AsBuilt Page 1 of 1 SEWAGE INSPECTIONS LOCATION-_521 TWmps RiverRoad -DATE 5/6/03 VU-LAGEOsterville,Mass. ASSESSOR'S MAP&LOT143-039 •INSPECTOR Jose h P.Macomber Jr. SEPTIC TANK CAPACITY 1 500 gallons 1-Ro.x = ' LEACHING FACILITY: (type) Leach trench (size) 1 2'X40'X1 4" NO.OF BEDROOMS 5 BUILDER OR OWNER Stewart Glasser OWNER MAILING ADDRESS. •Same a1 1' Go�zye � Rpcf�wamf' http://issgl2/infranet/propdata/prebuilt.aspx?mappar=143039&seq=1 4/10/2017 ! COT-,..`v1ONWEAL,TH OF MASSAC:HUSETTS 1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v r DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE 11 INTER STREET. BOSTON. MA 02108 617-292-500 WILLIANI F.WELD TRUDY CO1iE Governor Secretan I ARGEO PAUL CELLUCCI G` ;i� �1 B.STRUHS j Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM iI JSPECTION FORM � @ _pC issioneT PART A Ly s `x�,, ._.r a � (� Q CERTIFICATIONS _ 4 Property Address: �� aUtf1 S. t�l ►W� ©s ��I��e Ad'd es� of Owner: _ REr`� Date of Inspection: 'Tar',-�jjgW (If different) �Ir JA N 9 C!09 Name of Inspector: I�� n� . 1�tty��' I am a DEP approved sy m inspecl.0 purs ant to .�ection 15.340 of Title 5 (310 CMR 15.00 ��,: 10'i��C:3p�•iE Company Name: 161gH0�[ Mailing.Address: 6SGJ Telephone Number: 508 — �t bi CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew a disposal systems. The system: L Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: `�j Date: The System Inspector shall submit a copy of this inspection report to the Approvi/Auth y within thirty (30) days of completing this inspection. If the system is a shared system or il;° a design fL:,w of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of tn^ Department of Environmental Protection. The original should be sent to the system owner I and copies sent to the buyer, if applicable, ant.' .,te approving;:uthority. I I INSPECTION SUMMARY: Check A, B, or D: A] S STEM P SES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. i Any failure criteria t aced are indicate belovi i COMMENTS: _ - B] SYSTEM CONDITIONALLY PASSES: ji One or more system components a descri d in t onditional Pass" sEt_tion need to be replaced or repaired. The system, upon completion of the replacemen or1epa r, s appr. a !, :;ie Board of Ht?zltn, will pass. es, no, or notdetermined (Y N, or N ). Des t mination ;n all instances. if"not determined", explain why not. The se i eta u ', ss the er perator has provided the system inspector with a copy of a Certificate of Compliant Me �g-t (20) years prior to the date of the inspection; or the septic tank,. het er f r ,.:c m 1, is cr :ked, structurally unsound, shows substantial infiltration or exfiltiration, or tank failure is immi ent. sy�.•In ill pass i ,pection if the existing septic tank is replaced with a conforming septic tank as approved b the rd ct iE th.0 !25/97) Page 1 of 10 UDEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep ej Printed on Recycled Paper In SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r {�CERTIFICATION (continued) Property Address: Owner: �eo i l Aack Date of Inspection: jggq �ar�a B] SYSTEM CONDITIONALLY PASSES (continued) 1 Sewage backi ip or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or clud to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hea th). Describe observations: broken pipe(s) are replaced obstruction is removed l distribution box is levelled or replaced The system r quired pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if with approval of the Board of Health): j broken pipe(s) are replaced r obstruction is removed i C] URTHER EVALUATION I REQUIRED BY THE OA D OF HEALTH: Con&tions exist which require furt er`evalua 'on the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the envir nment_ 1) S STEM WILL PASS UNLESS BO RD OF HE TH ERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE P BLIC HEALT AND AFETY AND THE ENVIRONMENT: Cesspool or privy is wi hin 50 feet of a surface water Cesspool or privy is wi hin 50 feet of a ordering vegetated wetland or a salt marsh. 2) S TEM WILL FAIL UNLE S H BOARD OF AND ,-H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T E SYSTEM IS FUNCTIO G IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE E IRONMENT: i The system has a se c a k and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface at supply. The system has a sep ' to and soil absorption. system and the SAS is within a Zone I of a public water supply well. The system has a septi tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) O HER (revised 04/25/97) Page 2 of 10 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: J � Ou M Ps I:tu4-r '"^' 0$fe((�(� o NJ Owner: �t 1 d�q Date of Inspection•r-�-� U0.V1, "1 DJ SYSTEM FAILS: You must indicate ei;!,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct he failure. Ys o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more th n 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pu e Any portion of the S it Abs rpti System, cesspool or privy is below the high groundwater elevation. Any portion of a ce spool o, iv is within 100 feet of a surface water supply or tributary to a surface water supply.. Any portion of a c spool or ivy is within a Zone I of a public well. Any portion of a spool or pri i within 50 feet of a private water supply well. Any portion of pool or priv `is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable wat r u ity analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteri , o ile organic compounds, ammonia nitrogen and nitrate nitrogen. E LARGE SYSTEM FAILS: Y u must indicate either "Yes" or "N ' as t each of the following: he following criteria apply to larg systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: I i j Y's 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) T e owner or perator of any such system shall bring the system and facility into full compliance with the groundwater treatment program re uirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 1 I (revised 04/25/97) Page 3 of 10 i w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �a`1 4Vn"..Ps ki V@C R'N& ®s c(tui lle mc4 , Owner: �_eo ldeq Date of Inspection: arA Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this.inspection. As built plans have been obtained and examined. Note if they are not available with N/A. T facility or dwelling was inspected for signs of sewage back-up. Th ystem does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were.uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. i _ Existing information. Ex. Plan at B.O.H. I _ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) i i I (revised 04/25/97) Page 4 of 10 j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION Property,Address:^— Sal �UrAM Rlve� Os er�ill� �1a. Owner: k-,eo G r t ao'y Date of InspectiarV, -I1ogg, J CL , l FLOW CONDITIONS RESIDENTIAL: /J Design flow: ' e edro m for S.A.S. I Number of bedroom � Number of current resid nts: Garbage grinder(yes or no): Q Laundry connected to syst��mj (yes or no):� 0 Seasonal use (yes or no): ND / 0 Water meter readings, if avai b e (last two (2) year usage (gpd): Sump Pump (yes or no): i Last date of occupancy: �i COMMERCIAUIN USTRIAL: Type of establishme c I Design flow: aT Grease trap presen (y Industrial Waste H Idint: (yes or ro)Non-sanitary wast dise Title 5 system: (yes or no)_ I Water meter readi gs, if available: Last date of occu an P cy: i OTHER: (Descri.be) Last date of occupancy: j GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: . gallons 777 �Reasonmping: TYP 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) I/A Technology etc. Copy of up to date contract? j Other APPROXIMATE AGE of all components, date installed (if known) and sour a of information: 1 Sewage odors detected when arriving at the site: (yes or no) i (revised 04125/97) Page 5 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address- //� `� Bump t VAC ' I��VI (C'I fI t�' Owner: �e® GAAeek Date of Inspection O BUILDING SEWER: (Locate on site plan) j Depth below grade: Material of construction: cast iron 40 PVC other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,.etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of ludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of i I t an outlet tees or ball s, depth of liqui I el in relation to outlet invert, t r integrity, evidence of leakage, etc.) Xf�� ° 6 �'C � '; �c�� GREASE T P: (locate on si a plan) Depth belo grade: Material of onstruction: _concrete _metal Fiberglass _Polyethylene _other(explain) Dimension: Scum thickness: Distance from top of scum to top of outlet tee o baffle: Distance from bottom of scum to bottom of out et tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 ,n s 'i . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (;SYSTEM INFORMATION Property Address: "V m PS yet P�(Jt Ntex V, Vl , Kck' Owner: -Q Date of Inspection; l c Jan, TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) ` Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Ye'; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm a d float swit hes, c.) it DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet inv rt: i Comments: (note if level and distribution is equal, gvidence of solids carryover, evidence of leakage into or out of box, etc.) I I I I PUMP CHAMBER:_ (locate on site plan) i 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.) I i 'I 'II ' (revised 04/25/97) Page 7 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION yy(continued) Property Address: o� Bu r(t pS R t VC( �• OsfeC v I lie I f►bQ, Owner: keo GIOeq II Date of Inspection' SOIL ABSORPTION SYSTEM iSAS):_ (locate on site plan, if possible; excavation not required, but may be approximate by -intrusive meth s) If not determined to be present, explain: i Type: leaching pits, number: leaching chambers, nuj r._ leaching galleries, num leaching trenches, nulength: leaching fields, number, imensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hyc raulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site ,plan) i 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 (cesspool must be umped as part of inspection) i i Comments: (note condition of soil, signs of hyd aulic failure, level of ponding, condition of vegetation, etc.) I i ` PRIVY:_ (locate on site plan) Materials of construction: _ Dimensions: Depth of solids: Comments: 'I (note condition of soil, signs of hydr ulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property ddress:r �U a, (DdeCv i l le, J r ct, Owner: n V o i Iaev- Date of Inspection: ' 'gcid Jan. ' 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: / include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) f� ce 45 i I- 0 { i (revised 04/25/97) P 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN(FOOR}MATION (continued) Property Address: 5y ou 1Y Rlue( � v'��V it 1' Owner: �Q© l71 1C'Q Date of Inspection Depth to Grou dwater �qeet Please in 'cafe all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions j Check with local Board of health i Check FEMA Maps i I Check pumping records i Check local excavators, installers I Use USGS Data I Describe in your own words how you established the High Groundwater Elevation. (Must be completed) //,17 i i I Page 10 of 10 (revieed.09/25/97) ' .� Town of BarnstableglIlgIl g BARN�� Post This Card!So Thaf t-is VisiblesFrom the Street Approved-Plaris Must,be,Retained on Job.andAhis Card Must be"Kept P,osted".Until<Final:Inspection Has Been Made ° Where a,Certificate of OccupancyJs,Required,such Building,shall Not be Occupied until„a Final Inspection has,been made. Permit Permit NO. B-852 Applicant Name: E J JAXTIMER, BUILDER, INC. Approvals Date Issued: 05/16/1995 Current Use: 1090 Structure Permit Type: Addition/Alteration -Residential Expiration Date: Foundation: Location: 521 BUMPS RIVER ROAD,OSTERVILLE Map/Lot: 143-039 �--^�� Zoning District: RC Sheathing: Owner on Record: GORE, LAWRENCE S& Contractor N e: E.J.JAXTIMER, BUILDER,.INC. Framing: 1 Address: PO BOX 325 Contractor License:\003251 2 COTU IT , MA 02635 } - ---,, - Est. Project Cost: $ 0.00 Chimney: Description: 37765 24 X 28 2 CAR GARAGE NO INLAW APT ) Permit Fee: $ 0.00 Insulation: " - ` Fee Paid $ 0.00 Project Review Req: 37765 24 X 28 2 CAR GARAGE NO INLAW APT. Date ` 5/16/1995 Final: Plumbing/Gas Building Official Rough Plumbing: k This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Final Plumbing`. f All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes`. Rough Gas: ) This permit shall he displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ( / i Final Gas: r The Certificate of Occupancy will not be issued until all applicable signtures by the Building and-Fire-Officials are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work:I 1.Foundation or Footing Service: 2.Sheathing Inspection I Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed,---,.-- ,_ �-- 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in M G L c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT- ISSUED RECIPIENTi Final: , No....`.........---...... Fz�s ..�� . ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di_v-,.Vo.!3ttl Workri Touotrurtiou'prrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at S? 1 Zomes Q1Ui5P_ Qc>pcp �.t=tit ��ttrk—CE ------------------------------------------------------------------------------------------•------ --•--------------------------•-----------•-----------------...-•-------------------------------•-- Location-Address or Lot No. Leo_C��c.c sic �'� r�tc �V ►2 ►2© t ----- ...... W -. 1 .�- �...... gi p .................. � Q s Installer Address Ac-ee 5 dType of Building Size Lot--.-A.&�A..............Sq.-,f� Dwell Grinder p., Othering a Type of Bildi� ms g -------.�............ No. of personsnsion Attic (qo hoovers (Oa e Cafeteria (�� Q' Other fixtures ------------------------------- - - - --------- W Design Flow.............? gallons per person per day. Total daily flow-----------..'��._..._...._...........gallons. WSeptic Tank—Liquid capacity.lS-W. ..gallons Lengthl0"4;�... Width-57=.6... Diameter---.--------- Depth_57:._ -- x Disposal Trench—No. .................... Width.................... Total Length..................-. Total leaching area....................sq. ft. 3 Seepage Pit No------------_------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing k ( ) tt`-' Percolation Test Results Performed by------- X ,. �G L.....!.! ..--- Date . ......... Test Pit No. I...4Z....minutes per inch Depth of Test Pit--- JC ......... Depth to ground f14 Test Pit No. 2................minutes per inch Depth of Test Pit..---............... Depth to ground water........................ P4 ------------ ---- -- ------------- --- ...................................._.......... --- O Description of Soil Q. ©` �� La . .v.�_�.�1.�--... _`?... ....ME ..................... A - -- x x ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable...__........................................................................................... --------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli -ice Ims bwn issued,,by the board of health. Signed ... . .... .. ...... ............. -------------....-...----------------- . Trace --------------- A Application Approved B ----------------------------------- PP PP y . ................ . -- ... -------------- � ------------------------ �a�5 Date Application Disapproved for the following reasons- --------------- ---------------------------------------------------------------------------------------------------------------- ......... ................................................ ................. ... ... ... . Q Date Permit No. 9.r- Issued .............. '..�'�.....57-57................. ------------------- Dace No................-....... -- FEs.... 0 a.,c ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuu fur Di-riputittl Worlai Towi#rur#lurt lirruti# Application is hereby made for a Permit to Construct ( K) or Repair ( ) an Individual Sewage Disposal --�... System2 k Su Ym ' •------------------------------------------------------------------•-•••••--•••••••--••---.._..... .....••••••-•--•--•----••-•••••••••-•-----••••-•-••••-------••-•--•---••-----•--•--------------••- L _ Location-Address' _ Lot (_U i -O L f-� 521�5 1`e 1 v c 1 Z a ,or No. ...................... 1J - ! Owner F"j- c r = dss -C................................ ,_: /C 1 L Installer Address �Ac_ke . -S Type of Building Size Lot.... :vA..............Sq.'feet Dwelling— No. of Bedrooms._-__-_-� --------------------------------Expansion Attic (K�0_) Garbage Grinder (A o) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- -------------------------- w Design Flow.............55 .....................gallons per person per day. Total daily flow...._.__.___-a'�-----•-----__-__-__---gallons. W Septic Tank—Liquid capacity SUS-gallons LengthlC�_`�2... Width__.`.'."_�__. Diameter.-."_.___--_ Depth.`>_�8.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) �+ '-' Percolation Test Results Performed by....... XT 4�:.41Nt `(-c___..l.iU...... Date....3 z(U/9`57 Test Pit No. L.2_.7_--_--minutes per inch Depth of Test Pit_A_!:______---- Depth to ground water.:.f_v�; GZ. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ..................-.......................................................................................................................................... 0 Description of Soil.... TLc> Am u UM I-• --- 5 !... 1 x w U Nature of Repairs or Alterations—Answer when applicable.------......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance /has been issued by the board of health. Signed l_ .1...r[X. Z1/ ------ ---------------- r De[e Application Approved By ................ - �1� h .�...:�,�3--�� - .......--'------------------------f-.......----'-------'------ Dace Application Disapproved for the following reasons: . .... -- . . . ....................................................... .. ........... . ......... . ........................................ ......................... . ... ....... . . . . ........................................... ........................................ Da[e Permit No. ------- r.-..5..�n ---------------------------- Issued ................ ..............- Daze - ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertif ra e of C11ompltana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X� ) or Repaired ( ) by ----------------------------------------------------------------------------------------------------_-------------------------------- --------.--------------------------------------------------------------------------------------- Ins,auc[ )....- �.. � 0 \ t - v -_= � 4a - --- ..... - . - i .. . - . ......... --------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ��. �_ ------- ------------ dated 3 ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ATE--------.+� '... ..7..' - Inspect :.------ ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... .ram'r._. '� FEE...... �tu�ruu�tl ur�u �u�t�#r�r#iun �rrmi# Permissionis hereby granted-------------------------------------------------------------.-.-----------------------------------------•-----------------••---•------•----- to Construct ( K),^or Repair ( ) an Individual-Sewage Disposal System at No.... �_ 4 c r ;JS �� -I fp 1 �' � rr r1 . Z ..l -�/ 1. ...G.---------------------•--........... Street qq as shown on the application for Disposal Works Construction Permit-N,o./_5---��'-- Dated-------�3.7:7; --�=_ . 571. Board o H alth DATE ... ... .. ....•-- .�? ...... FORM 36508 HOBBS IN WARREN.INC..PUBLISHERS f ' THE COMMONWEALTH OF MASSACH.USETTS -,' BOAR® OF HEALTH ................................I..........O F.......................................................................................... Applira Lion for Uhipoti al Works Tomitrurtion Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .........••.......j-•--... a:4:-!L!.re�:..l.'-rc-...... �?q. ..................... •------------------•..--•.........------. •- Location-Address J �oLot No. 1` U .....C.(.r.Y........ .... ...... ....... ................•--•-•-•--•-•-------•----._..._ .�d?..._Y4C. --•=......-•--•• Owner Address a ........... ....................................... l ..;4-#-- ............ .... ------------ Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................. .Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Buildingf rNo. of persons..kn..................... Showers z. — Cafeteria 114� Other fixtures ------------------------------------------------------------------------•----•------•-- --•--•----.........-•------------------------•--------...--•• W Design Flow............. ....................gallons per person per day. Total daily flow..............................................gallons. WSeptic Tank—Liquid capacity.!tV.'O.gallons Length................ Width_............. Diameter---------------- Depth................ xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area.........._.........sq. ft. Seepage Pit No..GKV1-------- Diameter.....V ............ Depth below inlet................ Total leaching area.XYK)c®sq. ft. Z Other Distribution box (&,�' Dosing tank Percolation Test Results Performed b ..... ............ ........ . r __ ...._.._..._....._.... Date. ___ ��/' 3 .. y Test Pit No. 1. '.y__minutes per inch Depth of Test Pit...... ........ Depth to ground water.____.! fi Test Pit No. 2__ y_.minutes per inch Depth of Test Pit_1-�9. ...._._.. Depth to ground wate...._.l.`�.... �+ ------------------- --••--••--•••-•---------•-•------••-----•-------------......--......--•--••---.........................................................- - p �„ ------------------r `�.� ��. �./�. Description of Soil.. .._30. � U1 ru -- --• - - - ------------- ----------------------------------------•--••-------••-••-•---••-•--•------- -----------------•----------------------------------------------------------------- --...------------------------------------------------------------------......-----------------------•--••--••----... UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------•-----------------------------------------•-------------•----------------------...........-•-•------•------•-•--•••-••----------••-•------------•••---••-•--••--••--------•---••------........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.; 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. Sid-----------•-------•--•-•--•••---•------------------------------•--•---•......-•--- e ApplicationApproved B . --•-•-•-------------------------------••-••-••----------..........._....... �a:......._.. Date Application Disappr or he following reasons:-•-------•-•--•••••-•-------------------••--••••-----•-•--•----•--------•-----•-•••---•--------------......-•--• ............................................•-•-•-••-•••--..._.....•---••---•---------•------•---•..._....---------•---•--••----•••-•-••..............................---...----... ......_....... Date PermitNo......................................................... Issued....................................................... Date 'Vo-----------r.�:...... FEx.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OFi HEALTH ...........................................OF ........... ......................................................................... Appliration for Uhipatial Works Tonstrurtion ramit Application is hereby made for a Permit to Construct or. Repair an Individual Sewage Disposal System at: 744L 40T ..................... -- ------ ...................................................... ................................................................................................. 5jwt No. ............................. .................................... I'm.............................. 9. ddre • I -. . . Address ---------------- . --7 . . Installer ............................................ U Type of Building Size Lot............................Sq. feet Dwelling—No., of Bedrooms.,:. ..........Expansion Attic Garbage Grinder ... (I---------------- _ - Other—Type of Building ............ ..�..*"4No. of persons—._`....................... Showers Cafeteria Otherfi ....................................... ,Itures ........................................... ............................................ W Design Flow........................................:..gallons per person per day. Total daily flow........................I....................gallons. WSeptic Tank—Liquid capacity...a?�' �allon's Length................ Width............... Diameter__........__.... Depth....._.......... Disposal Trench—No..................... Width.................... Total Length._......,........... Total leaching area....... sq. ft area.......:._____ - 4,7 F4, - Seepage*Pit No.._A'6�K....... Diameter.......f........... Depth below inlet........ ......... Total leaching area..................Sq. f t. Z Other Distribution box ( '4< Dosing rnk .......... Percolation Test Resulls Performed by...... ------I........ Date- O&I....../..I-., Test Pit No. I minutes per inch Depth of Test Pit--- f...... Depth to ground water........7....... Test Pi ................minutes per in it t N ---------- o 2....,. _4' inch Depth of Test P .................... Depth to ground water........................ .................. ..... ......... . .......... .. ....... ........ ............. 0 Descriptign of Soil------..... ......y----_----------------zior.................................................. ......................................... ......................................................................................................................................................................................................... .......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the afore.described Individual Sewage Disposal System in accordance with the provisibns of'11 Ty"7 5 of the State Sabitary 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. S'. ed,............................... .................................................. .......... Application Approved ............................................................. --------- . ....... _.V............................ Date Application Disapp o for thi�following reaso'ns:.................................................................................................................. ........................................ .........................................................................7.......r............................................................................. Date Permit No......................................................... Issued_.:,.:....--------.. ssued_.__.:................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................*................................................. Intifiratr of Tautpliaurr T,H, IS TO X LIAXThat the Individual Sews DispFsall S-/j-stem constructed or Repaired by.............. .......... ................................n------- /. .... . ....... ........................................................................ Installer' 4�6 al ...................... I ............, ............................................................................................................. ......................... has been installed in accorda'n"'ce with the provisions of W'A2La JqfThe State Sanitar scribed in the y�/6�/e Now—.)... ............. application for Disposal Works Construction Permit dated-- ---- ---------------- ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A'60ARANTEE THAT THE SYSTEM FUNCTION SATISFACTORY. DATE.-.. -------------------------------------------------- Inspector... ...... ...................................................................... 0 THE COMMONWEALTFi"OF MASSACHUSETTS BOARD OF /�IEALTH 02... .................J_r'�......0 F.............. No .................... ................................................................... ..................... FEE......................... Disposal lVorkv onstrudian "prrmt Permission is hereby granted.... . . ..... ----- .......................................... ---------------------------*------ ;.......... to Construct nor Repair an Individual Sewage Disposal System at No. --------------------------- .......I... ... ............ .. ... ..1..................... Street as shown on the application for Disposal Works Construction Permit No....... a ............ .�1;01........................ ............................... tr3i------ ............ Board f Health DATE...........e./......f ..................................... FORM 1255 HOBBS & WARREN. 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