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HomeMy WebLinkAbout0578 BUMPS RIVER ROAD - Health 578 Bumps Diver Road, nsterville A=144 - 027 , a u n 6 a j, n, li + it F e s' � F F i Commonwealth of Massachusetts Title 5 Official Inspection Form COQ Subsurface Sewage Disposal System Form = Not for Voluntary Assessments �� 578 Bumps River Road �M Property Address h.n Leo Desrochers Owner Owner's Name9 information is ,. required for every Osterville MA 02655 September 18, 2;Q17 page. Cityrrown State Zip Code Date of Inspection F Z+ 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. Y Important:When A. General Information �g3 filling-out-forms _.on the computer, useoniythetab- 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key.VV Company Name 4 Glacier Path Company Address East Sandwich MA 02537 Citylrown State Zip Code 508-833-217T S 1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature V 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 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. C V t5ins.doc•rev.6/16 Title 5 Official Inspection Form: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 578 Bumps River Road �M Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18, 2017 required for every P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D 4 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: The observations noted in this report represents the condition of the system only on September 18, 2017 at the time of the inspection and does not represent the operation of the system in the future. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18 2017 page. City/Town 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18, 2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is.within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: DI stem S Failure Criteria Applicable to All S Y pp stems:Y You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 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 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18, 2017 page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18 2017 required for every P page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18, 2017 required for every p page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail: 2016; 53,000 gallons and 2015;128,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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: t5irs.doc•rev.6/16 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 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 7/5/2015 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: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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 typical Sludge depth: 2" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18 2017 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 34" Scum thickness 1" 5"Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. New tank (as of 2015) in good condition. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18, 2017 required for every P � page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is p required for every Osterville MA 02655 September 18 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with 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.): Dbox is 32" below grade and riser is within 13" of grade. No solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18 2017 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers are 43" below grade. Riser is 12" below grade. There is no standing effluent in the chambers. No sign of hydraulic failure. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Road Property Address i Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18, 2017 required for every p page. CityrFown 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.doc•rev.6/16 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 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18, 2017 required for every P 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 j where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I I i i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18 2017 required for every P , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 14+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2015 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Based on previous perc test logs and groundwater contour map I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Road Property Address Leo Desrochers Owner Owner's Name information is Osterville MA 02655 September 18, 2017 required for every P page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION S78 Sie-)V-, II-- SEWAGE# o2Q S-/(; VILLAGE Y (IS SOR'S MAP&PARCEL& 1/4 INSTALLS S NAME&PHONE NO.Z6,�� ��_ SEPTIC TANK CAPACITY I p LEACHING FACILITY:(type)Ltj- (size) �6ee C-3 NO.OF BEDROOMS '3 OWNER 1 PERMIT DATE: — COMPLIANCE DATE: Separation Distance Between the: A'De Cc} t,mt, Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility n( m; Feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 00,1 e, fro�rJ, Ata 37 Ga2n�e cot- I AY I� to io-`Y7 >� 7� QJ"� �'' `3�7 (/ I C S `o i I l z 1 _u7 f I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=144027&seq=2 9/19/2017 i TOWN OF BARNSTABLE (;,LOCATION S 7 �.� II,,,� v SEWAGE# VILLAGE ,.r K t ()6 ESSOR'S MAP&PARCEL/`/'/- . 7 INSTALLS S NAME&PHONE NO.�� SEPTIC TANK CAPACITY I1!j-00 � LEACHING FACILITY: (type) L M (size) 1Fb&e_p\o,3 NO.OF BEDROOMS OWNER PERMIT DATE: s COMPLIANCE DATE: Separation Distance Between the: A)Oa@ C(A Aime Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Ova ^3T i(nA:--Rjk &e Q�Y ( 7 ME ' j s _Y7 2 � C ( r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppIicatiou for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Loc ' Ad s f or Lot No.578 �3,,,,,,P5�� , `Z0 Owner's Name,Address,and Tel.No. C Assess s Map/Parce _ ,2 CV° Insta er's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 3�L0w p-7! _ Iro (,coo,{ 77—5313 Type of Building: Dwelling No.of Bedrooms :3 Lot Size /j�77;?— sq.ft. Garbage Grinder( ) Other Type of Building v p 13-4pa r,�,i No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 [7 gpd Design flow provided 3q6. `7 gpd Plan Date Number of sheets 2 Revision Date Title Size of Septic Tank 1 5-00 Type of S.A.S. c..tl(�n1 C I[y_en�1as Description of Soil Nature of Repairs or Alterations(Answer when applicable) (�►S}C�[ i S-� C,([O„S :kr'A `WY C %3 1. 15-100 r�l (S2nl cyy No s S toaw.i �e n., 1eA.-J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. I / ll Fee THE COMMONWEAL�H.OF MASSACHUSETTS Entered in computer: Yes - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(✓Upgrade( )'.Abandon( ) ❑Complete System ❑Individual Components Loca' ess or Lot No.57 S B omps R �� Owner's Name,Address,and Tel.No. Asess9�Ad Map/Parce _ Z-1 Ct,<I`Q /lit Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �c7��taS A �3to oTac �(Y3^ Od-7/S �r� �•vr iro (.Wok 7- S-3/3 Type of Building: Dwelling No.of Bedrooms )' Lot Size 11�y7 2 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3`3�� gpd Design flow provided ? gpd Plan Date G 12 1 I S- \ Number of sheets IL- Revision Date Title Size of Septic Tank 1'5_00 Type of S.A.S. ;L S C)C> n j)r A C Jnr ,kpQt u�i' Description of Soil J . I Nature of Repairs or Alterations(Answer when applicable) i © An. L/1c.Ae) _ p CAG It fn rJ C`A('�\O 2!5 CGS S \n n, ICA,-J J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health.' 3 Date - c Application Approved by ' Date 552 Application Disapproved by Date for the following reasons Permit No.� ' Date Issued to THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by :1yo A R f ow a I /vc at -5 7 QN4�5 �-y '� 2� �PwJ f P/J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No y D/5_/6 D dated Installer Al C Designer J•F ►NY r'/i.4r I Ile-S #bedrooms Approved design flow gpd The issuance of this�pert$it shall not be construed as a guarantee that the system wil inc' n s design. Date 7 1 ( � Inspector ---------------------------/------------------------------------------------------------------------------------------------ -------------- No. l !O v Fee ✓�1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal &pstem Construction permit Permission is hereby granted to Construct( ) Repair( 1� Upgrade( ) Abandon( ) System located at ,;7 g ` iM!e s _\_2_3 C P and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must pleted within three years of the date of this p rmit. Date /uo0 [�/ Approved by Town of B.arnstable 04 IME T � ' Regulatory Services , of Richard V. Scali, Interim Director` Public Health Division Thomas McKean, Director 200 Fain Street,Hyannis, MA 02601 , Utii e: 508-862-4644 - Fax: 508-790=6304 Installer•& Desi"er Cer-t f cation Fdr'M­:. Da e: -71 � Sewage Perrmit# 20/,5--Z6 Assessor's Map\Parcel 1-1LI ^77 De igner: Kr Installer: JOS - Ad Tess; I w, C,,-o Address: d` (30x ` ,. . • � tall a On G-S/5 (A` 3 rb `� �� was issued a permit to ins (date) (installer) sepy'c system at 57F 1Zom ys 'p-tvR., R �(evit• based on a design drawn by E (address) C"�te `�-M.�.Em gee..�` (+�L dated ,✓ (/l rA-1 ' desi er) A I certify that the septic system,referenced above was installed'substantially according to j the design, which may include.minor approved changes sucht as lateral relocation of the distribution box and/or septic tank: Strip out(if requir6d)'was inspected and the soils' were found satisfactory, , I,certify than the septic system referenced a"oove was i-istallea =with .major changes (i.e, greater than 10' lateral relocation of the SAS vertical relocation-of, oomponeet of the septic system),'but zn accoi dance with State & Local Regulations. Plan a r;vsion or certified as-built by designer to follow,. Strip out(if required)was inspected and the soils were found satisfactory, A t I certify that the system referenced above was,constructed r with the terms of , the 11A approval letters (if applicable) •ti a Yj �Y � � t • .. r 1 �it,r °i t � .. • �`'' C It f i c» �istalles ignature) rl °ti {�?.s' tt µ (Designer's Signature) (E'ffix Designer's Staisip:Here} ; PLEASE RETURN TO BARN STABLE PUBLIC HEALTH DIVISION. CERTIFICATE U1 COMPLIANCE WILL NOT BE ISSUED UNTIL. BOTH THIS FORM !.ND AS B. T CARD ARE IcECEIVED BY'THE BAR1NSTABLE PUBLIC>HEALTH DIVISION T YOU. Q:1 eptic0csigner Certification Form Rev 8-14-13.doc 1 4- Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments ,•''• 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, ' use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the return Name of Inspector key. Robert Paolini Septic Service Company Name 17 Playground Lane Company Address Yarmouthport MA. 02675 City/Town State Zip Code 508 362-3555 S14454 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this addre`ts and that-te 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 maiptenanceMf on sire y...wy � sewage disposal systems. I am a DEP approved system inspector pursuant tq;;§ection 1?,'340 8&Title 5(310 CMR 16.000). The system: = = r ❑x Passes ❑ Conditionally Passes ❑ Fails-1 `• ❑ Needs Further Evaluation by the Local Approving Authority 11/27/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspectioeoce Sewage Disposal System-Page 1 of 17 t ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will 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•11/10 Tide 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 578 Bumps River Rd. Property Address James Daughtwy Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following.for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or-cesspool ❑ 0 Static liquid level in the distribution box'-above outlet invert due to an overloaded or clogged SAS or cesspool- ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x 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. ❑ O Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ED Any portion of a cesspool or privy is within 50 feet.of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- El y 10,000gpd. ❑ N 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 16,000 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•11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑x Were any of the system components pumped out in the previous two weeks? ❑x ❑ Has the system received normal flows in the previous two week period? ❑ ❑x Have large volumes of water been introduced to the system recently or as part of this inspection? n ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑x ❑ Was the facility or dwelling inspected for signs of sewage backup?. ❑x ❑ Was the site inspected for signs of break out? ❑x ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? x❑ ❑ 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: ❑ ❑x Existing information. For example, a plan at the Board of Health. ❑ ❑x Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5in5-11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes X❑ No Laundry system inspected? 0 Yes ❑ No Seasonaluse? ❑ Yes 0 No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail Sump pump? ❑ Yes 0 No Last date of occupancy: 11/27/12Date 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-11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owners Name information is required for every Osterville MA. 02655 11/27/12 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current,operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑x Other(describe): One main cesspool with overflow leaching pit. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑x 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 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: Sludge depth: t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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? 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(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•11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 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 No 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 is level.box has one outlet laterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: , ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Water level was 4' below invert with stain line 3' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 main cesspool with overflow leaching pit. Depth—top of liquid to inlet invert, 1 6" Depth of solids layer - Depth of scum layer 4" Dimensions of cesspool 6'x8' Materials of construction Concrete Block Indication of groundwater inflow ❑ Yes 0 No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): I Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 114 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately t5ins•11/10 Ti le 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 115 of 17 I lap, http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=1440... Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® Zoom Out I j a O U fl o In :fie•"°.'�" NO �Il 5 T 1 l S� t j 1 0 20 F et Set Scale 1" = 20 ' Aerial Photos MAP DISCLAIMER of 11/29/2012 11:07 AM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. City[rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope 0 Surface water 0 Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 8' ti feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) 0 Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater elevations.Gas Augered 5' below Ieaching.No groundwater observed. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 578 Bumps River Rd. Property Address James Daughtery Owner Owner's Name information is required for every Osterville MA. 02655 11/27/12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑x System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•11110 Thle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 T6WN OF BARNSTABLE CF THE OFFICE OF I DAUSTAn i BOARD OF HEALTH NULL �0p 039. `{�' 367 MAIN STREET OMpYp HYANNIS, MASS.02601 October 23, 1997 Craig R. Short, P.E. P. 0. Box 1044 South Dennis, MA 02660 RE: 578 Bumps River Road, Osterville Dear Mr. Short: You are granted conditional variances, on behalf of your client Norma Dougherty, to install a replacement septic system at 578 Bumps River Road, Osterville. The variances granted are as follows: Part VM, Section 10.00: Section.1.13 To install a leaching facility 80 feet away from one wetland and 85 feet from another, in lieu of the required 100 feet separation distance. Part VUL Section 10.00: Section 1.16 To install three pipelines from the distribution box, in lieu of the requirement to connect each leaching unit separately. The variances are granted with the following conditions: (1) No more than four(4)bedrooms are authorized in the dwelling. Dens, study rooms, finished attics, sleeping lofts, and similar-type rooms are considered bedrooms according to MA DER (2) The septic system shall be installed in strict accordance with the submitted plans dated revised September 23, 1997. (3) The designing engineer shall supervise the installation of the septic system and shall certify in writing to the Board that the system was installed in strict accordance with the submitted plans. short '� 11 The variances are granted because the existing cesspools are located closer to the wetlands, and are in all probability, sitting in the groundwater table. Therefore, the use of a new septic system, which meets all of the State Environmental Code, Title V requirements, may alleviate a source of pollution to the wetlands. Sincerely yours, Susan G. ask, R.S. Chairman Board of Health Town of Barnstable SGR/bcs snort CRAIG R. SHORT, P.E. 235 Great Western Road P.O. Box 1044 South Dennis, Massachusetts 02660 PROFESSIONAL CIVIL ENGINEER, SOIL EVALUATOR Telephone (500)398.0311 SEPTIC DESIGNS Fax (508)396-3063 October 03, 1997 CERTIFIED MAIL RETURN RECEIPT REQUESTED !} T Fe W : j0 6 NMFICA ON To ABUrfERS OF: y°jyaoN `�99� Applicant: Mina Vaughan & Norma Daugherty 578 Bumps River Road c� Osterville, MA 02655 g RE: 578 Bumps River Road, Osterville Dear Abutter: As an abutter to the above referenced property, you are hereby notified that a request for variances from the Regulations to the Town of Barnstable Regulations for .Subsurface Disposal of Sewage has been submitted to the Barnstable`�Board of Health to take action as follows: Town of Barnstable Regulation: 1.13 Distance from primary 7 reserve leaching facility (SAS) to watercourse (wetland); a 46' maximum variance required. 1.16 Requires that each leaching unit is connected to the Distribution Box; a variance of 3 pipe lines required. A public hearing has been scheduled with the Barnstable Board of Health. Said hearing will be held in the Hearing Room of the Barnstable Town -Offices, 367 Main Street, Hyannis, MA on October 21, 1997 beginning at 7:00 PM. Sincerely, Craig R. Sh6 t, .P E a< .s * CC: Abutters Barnstable Board of Health " File CRS/cwk ABUTTERS OF MINA VAUGHAN AM 144/27 578 Bumps River Rd Osterville CRS#1-816/RWW#1308 NORMA' DAUGHERTY AEI 144/27 (Subj.ect) 578 Bumps River Rd Osterville., MA 02655 DAVID A LEWIS Am 144/42 541 Bumps River Rd ' Osterville; MA 02655 DAVID. A GUERRA AM 144/26 568 Bumps River Rd Osterville, MA 02655 WILLY TANT Am 144/28 588 Bumps River Rd Osterville, MA 02655 ` DANA M LAPHAM A4 144/6 614 Bumps River Rd Osterville, MA 02655 NO. DATE unrter�®tt FEE �oS F �'� ��`� =� n of Barnstable j'OW REC. BY Board of Health ® S E P 2 5 1997 3.6 Main Street, Hyannis MA 02601 TOWN OF BARNSTABLE Susan 0.Rmk.R.S. HEALTH DEPT Me: 508-79 -P8'2 Brian R.(Itbdy,R.S. FAX: 508.775• Ralph A.Murphy,M.D. VARIANCE HEOUFST FORM All vnrilnce tcqucses mull be submitted.I Icasl rirleen r15)devs ptior to the scheduled hoard or llealth meeting. NAME OF APPLICANT c� � ^ 1 o r TEL.NO. 5;D6 e65 e8-1 k ADDRESS OF APPLICANT NAME OF OWNER-OF PROPERTY SUBDIVISION NAM DATE APPROVED ASSESSOR'S MAP AND PARCEL NUMBER LOCATION OF REQUEST 51-8 SIZE OF LOT l(p 1 )Sl= SQ.FT WETLANDS WITHIN 200 FT.YE x VARIANCE FROM REGULATION(List Regulation) hacc� �cl C O gYa n G G- t ro r"^ r LJL" Gov 'S �rle G�cd REASON FOR VARIANCE (May attach if more space is needed) PLAN - DOUR COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING VARIANCE REQUEST. VARIANCE APPROVED_ Susan G. Rask, R.S.,Chairman NOT APPROVED Brian R. Grady, R.S. REASON FOR DISAPPROVAL Ralph A. Murphy, M.D. CRAIG R. SHORT, P.E. 735 Greal Western Road P,O, Box 1044 South Dennis, Mossochusells 02660 PROFESSIONAL CIVIL ENGINEER, SOIL EVALUATOR Telephone (500)390.0311 SEPTIC DESIGNS Fax (500)390-3003 September 25, 1997 Thomas McKean, Health Director Health Department 367 'Main St. Hyannis, MA 02601 RE: 578 Bumps River Road, Osterville for Mina Vaughn & Nora Dougherty Our File # 1-816 Dear Tom: This is to request approval of the enclosed septic design for the referenced project. This design is to replace the existing cesspools but will require the following variances from the Town BOH regulations: 1) Section 1.13 Distance from Primary & Reserve Leaching Facility SAS to watercourse/wetland, a 461 , 201 , & 15' variance required. 2) Section 1.16 requires that each leaching unit is connected to the Distribution Box, a variance of 3 less pipelines required. Therefore, please schedule us for the next available BOH hearing. If you have any questions or comments on this matter, please contact me at 398- 8311. Very truly yours, Craig ort, P.E. cc: Mina Vaughn & Norma Dougherty @ 578 Bumps River Road Enc. Check for $65.00 4 Copies of site plan TOWN OF BARNSTABLE 1I C LOCATION _5 7� "13 -„ tivr SEWAGE # a� VILLAGE ,QS4- I�c ASSESSOR'S MAP & LOT / V/02 '7 INSTALLER'S NAME 6i PHONE NO. Mo,,�c, -7-S Xlyo SEPTIC TANK CAPACITY ? logo LEACHING FACILITY:(type) �'� (size) yX4 NO. OF BEDROOMS ,3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� „ f a L. `\e No.. ... Fizs. .. ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Biipnsa1 Warkii Tomitriirtivai Permit Application is hereby made for a Permit to Construct ( ) or Repair (//f an Individual Sewage Disposal System at: ' a^ Location Address _ t t No ........ ........ kOwner �.7 �:�5....�'r - 9 Add'dress L ........................................ rY(��n�l 1 Y w �,N\ L.G_.�uV'� �G.n Q 5. .!�.T��/✓�: _.........._......--.-•------ -------------------•------.. •'__._ ....._.. taller Address � Type of Building Size Lot___________________________S q. feet V� Dwelling—No. of Bedrooms............. -----------------------.....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----•-------•-------•-•-----•--••-•---•-----•.....------•----•---•--•---- Date------------------ ... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-----_____-__---_-_-- f4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ P4 --------•-••--••-•--•---•----•-------•--•-------....•-•---••••....---•-•-------------••••-•-----------... ---------- --------- •-------------------------- •'••-- 0 Description of Soil...............................................................................-----------------------------------.................................................... W c.� ------------------------------------------- -------------------------- -------------------- •-----------------------------------------------------------------------------------------------•------------- W ----------••------------•...------•-•---------•-------------------------------------------•-•-•--------•--•-••--- --- -----------••. -------- -------------- V Nature of Repairs or Alterations—Answer when applicable-------.C�.c .c�___--� w...... d-� � _.._._ ----......-•-- ---------------------•------------------------------------------•-------------------•------------....---••------- 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 ha been issued by the oard of health. / Signed ...................... ............................ .......... . .���'-2 Date ApplicationApproved By .. .. . ........... ... ............... ...--............. ..... ...................... .........------.e ......----- --- Application Disapproved for the following reasons- ----- -------------- ------- ------------------------------ -------------------- -- ---------- ------------ - --------- .. .-- 4 Permit No. Q Issued --- 9 .. .. .................. Date ! D� No.. ........ Fss. _ THE COMMONWEALTH OF MASSACHUSETTS t BOAR® OF HEALTH TOWN OF BARNSTABLE 'Appliratiun for Diipuual Work, Tunifrnriiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair (/) an Individual Sewage Disposal System at: .....� �.JGt 7 Location-Address ^� { •- or Lot No. ......................-----....._•-•-....s?.......----- -•................ .............. ..............-------- Owner Address r C_�3 v_S ........................................ 1 G Guy1 1 S�a�.Q .. 1_ Lk . . I�dtaller Address � Type of Building Size Lot...........................S q. feet U Dwelling—No. of Bedrooms.............. ............._._...__..__..Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g -------------------------•-• P ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------------------------------•--•------------•----------•--------....._....••-----------•--•-...._......_... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No...................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..............................-.......... Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth _o ground water----_--____-_-__---__-_. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .------•--•-------------------------------------•------------------------------......------.............................................. 0 Description of Soil...............................................................................------------------------------------............................... W U ........................................-........................................................................................................... --------------------------------------•------.. W ••--------------------------------------------------------------------------------------------------------------------- - U Nature of Repairs or Alterations—Answer when applicable..--_-__-G.S�.S _...__!-_t-.w =__.,-PAS-�^..... 4 i•-•--•----------------- .......................................................................................................................... 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 oard of health. Signed .. r .... �J E S Z, ----�----------------------'-- ---._........� re.........:......., Application Approved BY . .`./v-°..- ,� . _.... // y - ...................... Dace Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------........................ ....................................-------------J--- --- - ---------.......... .. .....: .._............... I �......... Dace ............ Permit No. ... ...� _........ Issued ....._..... .� .. Dace -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cex#tfirate of CITampliance T S T� T F;,A t I "div' Sewage Disposal System constructe3 ( ) or Repaired (X ) 7 by..... -....1 �� q ,f Ins II r osuat ..... -------------------------------------- .... ......... �L' has been installed in accordance with the provisions of TITLEf f he�St onmental Code as described in the application for Disposal Works Construction Permit No. .._...... ...._. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNNCTI�O/N SATISFACTORY. DATE--------------------------------4-.......... ------------------------------------..._..-- Inspector ........--........... .--- ...------... --------------...----------------- THE COMMONWEALTH OF MASSACHUSETTS -� BOARD OF HEALTH TOWN OF BARNSTABLE 20 — No.... (mod ......... FEE........................ I -' r/ Ton i><x�ttrutit Permission is hereb raAel- to ...... .. ... .... ..( .�.. ....._._ _.._��/..v ...._...... , - Y g ------•--•--------•0-•........................ Constr .( or Re i -Indiv•. ra Dis.S o SysY'at No-------------�-�-•--.... t/ It's. ....-- .� � �-- 0 --- . � c+.._.... St as shown on the ap licab on for Disposal Works Construction,reet it No.---- ---- // =Ited!- --------------------Board of H�alth(✓ DATE----------q -- ....................................................... z I FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS ` AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION_+`Z j, `3' , fuv- SEWAGE `'/` . • VILLAGE_0,S`m r%j, Zt ASSESSOR'S MAP Cc LOT / `/Y02 '� INSTALLER'S NAME & PHONE NO. M o c�, 7 a.l uy SEPTIC TANK CAPACITY loc7J $.ass aaei LEACHING FACILITY:(type) ,°}" .(size) �xG NO. OF BEDROOMS ,3 PRIV•—A'-TE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 5 .t DATE COMPLIANCE ISSUED:ram! VARIANCE GRANTED: Yes No_�� jam`/, j http://issgl2/intra-net/propdata/prebuilt.aspx?mappar=144027&seq=1 11/16/2012 / f Town of Barnstable P# Department of Health,Safety,and Environmental Services �Im Public Health Division Date - 7 367 Main Street,Hyannis MA 02601 BARNBPABIE, " .h �{• .'; �:. !' x' -� j t MABB. - �-•,. ,Date Scheduled > 7.' t��1 J Time- ` `` Fee Pd._'l y 4, d.• Soil Suitability Assessment' r Sewage Disposal C r-C4 r R . —5lkz m 0 `t Witnessed By: Performed By: — T LOCATION &:GENERAL;INFORMATION Location Address S 8 h� -�—p Owner's Name Alr n a ; TLoc��✓� Vd 4 ''7 n�1.•s 0&-J7 eat' Address S 7 g .J 3•�0-t �G, 21 Assessor's Map/Parcel:, C_7 2 Engineer's Name . ._ 1-yam_ � �.,_.., .� y , NEW CONSTRUCTION REPAIR X Telephone# .S C3 8, 3 9 8 . 8 a// Land Use Rel'i co(c-rr4 I Slopes(%) / Surface Stones Distances from: Open Water Body 7 5* ft Possible Wet Area Is—ft Drinking Water Well N1k ft Drainage Way /�I.4 ft Property Line I SS r ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 1 - � - � -' l Parent material(geologic) C d 1 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: VIA—Weeping from Pit Face Estimated Seasonal High Groundwater �'��'�4 p �y �) r� LLTU Ylll�tt,'�TIVi'V -FO rr7LA �i,�hY i13to 3a �� AT i'C �i�i Method Used Depth Observed standing in obs.hole: ' in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION;TEST Date J Z7 Time /Z Observation Hole# / Time at 9" / Z: 7:3 0 Depth of Pere !,o a Time at 6" 2 18• Start Pre-soak Time @ /z%!� Z Q 9 0�.i Time(9"-6") End Pre-soak /z : /L •?� Rate Min./inch < -Ile�7 Site Suitability Assessment: Site Passed ✓. Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----) Copy: Applicant `DEEP OBSERVATION HOLE LOG hole# Depth from Soil Horizon Soil Texture Soil Color • Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Gravel) 4-Xt411 A.,^n Zl .� hl 7.rW? 4!18 t/ " � Ir I( If DEEP OBSERVATION HOLE LO;G Hole Depth from I Soil Horizon i Soil Texture Soil Color. Soil Other Surface(in.), (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° ra 1 f DEEP OBSERVATION HOLE LO;G Hole# . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency• °° ravel t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil i Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Gravel) ' t Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No_ Yes Within 100 year flood boundary No_ Yes Depth of Naturally ccurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ye S If not,what is the depth of naturally occurring pervious material? Certification I certify that on Nov 9 4 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature < Date 'Y 27 r> �?r N LOCUS ® x 15.5 - 1159 vio1 Rood __ . E-YI&TING CESSPOOLS Bumps 3 _ -�- TO BE PUMPED, FILLED W1TH ' / \ SAND AND ABANrRONED. 90 \ N 83•26'4 LOCUS MAP �i ' 9" ) " ( (! �m V102 NOT TO SCALE // -- 00• / I I i 13.19 23. I - x 24,80 / I� 25.1) x 23 I / _ / f 22.48 - 2 2 Ol �\ ~ LOT 2f VEGETA 23.4 I MBLU 1414-27 /) j 1 o WETLAND D 1 I 16,772 ISF I I V103 / ( - �22,04 13.2 r 21.55 �.` l , \ x DECK 0 \ \ •� V 10 4 r., \ + 21.4 *18 12,94 22,52 21.08 BH 1 - /REPIPE AND AC 1 % PLUUGG OLD SEWER ®- 23.25 \\ \ 1 I EXISTINGOUTLE/ ^' \ \ I HOUSE(#578) I I GARAGE • T.O.F.=23.66f' to to I I cv NEW SEWER l \ \ 1 1 22.73 SET TO INV.=20.1 E x 24�b& OR HIGHER 23.17/ 23.37_ TBM-1 / 23.31 23.8 / �:94\ ` PROPOSED � • SEPTIC TANK , / :`:`.' `_.:.� '.'':' . ..:.` 4 O O 24.73 23.87. `DR/1/EWAY: '. O 9r v / �.`• I �� x 29 X 27.72 x 18 /.. ;:.. 24.54v'�• .i O. TO (/ �•��. .�• 22.76 L=120.00' ` FR T --- 0 �.� R=443.42.' '�` BRB CURB STOP 24:03 23.93 x 23.30 24.30 ff x 24.54 24.72 24.39 edge of ru 25.00 24,33 Pavement 24.58 o PETER T. G� BUMPS '.RIVER ROAD. M�V,L N p, k No. 35109 �60 FT. WIDE PSIE��° �oF �lptENG 0 OWNER OF RECORD - - MURPHY, RICHARD H JR _ -- 153 HICKORY HILL CIRCLE • _---- 8--------- -- - -f.8- OSTERVILLE, MA 02655 _------------ lfr--' '�v __ LEGEND 24--EXISTING CONTOUR x 26.12 EXISTING SPOT GRADE _ _ -W-- EXISTING WATER SERVICE --_---- ---__-1�- =N PROPOSED WATER SVC. (SLEEVED) ,,��•. EXISTING GAS SERVICE V2095i .� V02 0 10.29 � W 9.21`•�•� OVERHEAD WIRES .� EDGE 9.29 �,`• 08, 0 WETLAND FLAG WETLAND DELINEATION &" VEGETATED VACCARO Environmental Consulting WETLAND Sandwich, MA 02563 V05 WETLAND SYMBOL Box 9 FLOOD DESIGNATION 9.10 TEST PIT San (508) 888-5855 NON-HAZARD-IN AREA OF PROPOSED WORK BENCHMARK Engineering by: SCALE DRAWN JOB. NO. PROPOSED SEPTIC SYSTEM UPGRADE PLAN Engineering Works, Inc. 1"=20' P.T.M. 152-15 - 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET No. 578 BUMPS RIVER ROAD` CENTERVILLE MA (508) 477-5313 6/2/15 P.T.M. 1 of 2 Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 1' NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL•19.75 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX PROVIDE TWO ACCESS MANHOLES TO WITHIN 3"' OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER OF FINISH GRADE FOR INSPECTION PURPOSES T.O.F.=23.66t SET TO 6" OF GRADE F.G. EL.=23.1 t r F.G. EL=23.0t F.G. EL.=23.Ot F.G. E1.=23.Ot /MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L = 33' L = 4' L = 5 ' @ S=1% (MIN.) ® S=1� (MIN.) ® S=1% (MIN-) 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC 6' t0"1 as O as 14" 8 EZSaaBS •" INV.=19.75 48" LIQUIDaaaaaaa LEVELINV.=19.50 INV.=19.46 INV.=19.29 4' 4.8' 4' GAS BAFFLE PROPOSED D-BOX EFFECTIVE WIDTH = 12.8' .. . ... - -Am -dim Awl& mk INV.=19.25 2-500 GALLON LEACHING CHAMBERS PROPOSED SEPTIC TANK SURROUNDED' WITH STONE AS SHOWN PROVIDE NEW SEWER OUTLET FROM AT HOUSE H-10 RATED 3" LAYER of 1/8" To 1/2" WITH OUTLET SET AT, OR ABOVE, INV.=20.16 DOUBLE WASHED STONE (OR APPROVED FILTER FABRIC) TOP CONC. ELEV.=20.0t NOTES: BREAKOUT ELEV.=19.75 fX- 1 CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=19:25 SIZE INVERTS, PRIOR TO INSTALLATION. aaaM EEES0 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL & ° BOTTOM ELEV.=17.25 TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' 8.5' 4' 6" CRUSHED STONE BASE, AS SPECIFIED IN 310 4' OF NATURALLY OCCURRING VARIES-REFER TO SKETCH CMR 15-221(2). PERVIOUS MATERIAL 4' MIN. SEPARATION TO G.W. 3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION 3/4" TO 1-1/2" DOUBLE . NO G.W. EL.=12.0 - 4) CONTRACTOR SHALL INSTALL A GAS BAFFLE ON WASHED STONE THE OUTLET TEE. • , SEPTIC SYSTEM PROFILE GENERAL NOTES: 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND'MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V,_AND ANY APPLICABLE LOCAL RULES AND REGULATIONS_ ` + 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE /EXISTING DESIGN ENGINEER. . 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING. HOUSE(#578) -- FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN GARAGE T 0.F.=23.66f ENGINEER BEFORE CONSTRUCTION CONTINUES. j 5-ALL ELEVATIONS`BASED 'ON`AN-ASSUMED`DATUM (BARNSTABLE G.I.S.t).. o . 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ' 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. THERE ARE NO WELLS WITHIN 150' OF THE. PROPOSED S.A.S., ,L9 N N 9. ALL AREAS. CLEARED FOR CONSTRUCTION SHALL'BE RESTORED AS �� rn NCP AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE a'- DIRECTED BY THE APPROVING AUTHORITIES. 1 Ds . O 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE-LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING ' L CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S.-AND ' REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). ' PROP. 12. AREAS REQUIRING STRIPOUT OF .UNSUITABLE MATERIALS SHALL BE S•A Ss INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. '13.'THIS PLAN IS TO BE. USED FOR SEPTIC SYSTEM PURPOSES :ONLY AND SSA"S. LAYOUT IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. SOIL LOG DESIGN CRITERIA - 8.5'. f--12.8` � DATE: MARCH 27, 1997 (REF P#8911) NUMBER OF BEDROOMS: 3 BEDROOMS r' '1 P3.7' SOIL EVALUATOR: CRAIG SHORT PE, T1 L_ WITNESS: JERRY DUNNING HEALTH AGENT SOIL TEXTURAL CLASS: CLASS I ELEV. TP- � DEPTH ELEv. TP-2 DEPTH DESIGN PERCOLATION RATE: <5 MIN/IN U�, BOTTOM AREA n, ' 1 DAILY FLOW: 330 GPD I O 24.0 A 0 320.0 S.F. 25.3 A 0 1 DESIGN FLOW: 330 GPD 3 L-���-�J1 LOAMY SAND LOAMY SAND GARBAGE GRINDER: NO ~-21'3'- 23.5 B 10YR 4/1 6' 10YR 4/1 24.8 B 6.' PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY PERIMETER=75.6' LOAMY SAND LOAMY SAND SAS DIMENSIONS 10YR 5/8 10YR 5/8 LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 22.2 21" 23.5 - 21" 74 GPD/SF SKETCH - c C w PERC USE 2-500 GALLON LEACHING CHAMBERS 1N SERIES 42"/60" SURROUNDED BY 4' DOUBLE WASHED STONE-ALL SIDES F-M SAND F=M SAND SIDEWALL AREA: 76.4'(PERIMET'ER LENGTH) x~2'(EFF. DEPTH) = 151.2 SF . 2.5Y 6/4 2.5Y 6/4 BOTTOM AREA:................. .. TOTAL AREA:.................................................................................... 471.2 SF 12.0 1 144" 13.3 144" DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) 348.7 GPD NO GROUNDWATER, PERC RATE: <5 MINJIN. Engineering by: 'SCALE DRAWN JOB. N0. ' Engineering Works, Inc. N.T.S. P.T.M. 152-15 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET No. 578 BUMPS RIVER ROAD CENTERVILLE MA (508) 477-5313 6/2/15 P.T.M. 2 of 2 Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 t BENCHMARK � TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR SOIL TEST /oN 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST 3/2 7 7 T ELEV. CLEAN SAND SOIL TEST DONE BY c._ :. f'•g (ASSUMED) CONCRETE WITNESSED BY ;r -D u COVERS 4• SCHEDULE 40 PVC PIPE LOAM AND SEED OBSERVATION HOLE 1 ELEV.- 2`- 2y OBSERVATION HOLE 2 ELEV.- MIN. PITCH 1/8' PER FT. 2' UyER OF PERCOLATION RATE MIN./INCH AT -C:l INCHES PERCOLATION RATE MIN./INCH AT INCHES 1/8' 70 1/2' DEPTH HORIZ I TEXTURE COLOR MOTT. OTHER ! DEPTH ASHE:D STONE HORIZ TEXTURE COLOR MOTT. OTHE 4' CAST IRON PIPE R �• . ,'� -- W VENT cn o,..: i ' a Y.2 ` ` ��'� ! NOT REQUIRED (OR EQUAL MINIMUM 9xs� PITCH 1/4 PER FT. rl! 1 CU. FT. OF a _-. _ , y� - _ -- �, CONCRETE � i L3FLOW UNE ` `; ANCHOR Ar �. EL.EV. _ _ a sz Y I I �• �-=— MIN. -� e e m ELEV. _ ' ,.2"� ., BAFFLE I 'ELEV. - S;"i 6' SUMP �V. Er'_�" " x DISTRIBUTION ELEv. - UIO OUTLET I BOX 9S r` INFILTRATORS WITH STONE IN AN (TO BE PLACED ON FIRM BASE) i z I )4 4 4 14 INCHES TO BE WATER TESTED t 5 19 INCHES i I A-4-6 '�° .".; �t. ?� � FORMATION IF MORE THAN ONE OUTLET 6 ET 24 INCHES 1 1500 GALLON 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) SOIL A B S 0 R P Ti O N � � WELL f V7 WATER ENCOUNTERED AT _ f'4' ELEV. _ 9 7• WATER ENCOUNTERED AT ELEV. - i 8 FEET 34 INCHES SEPTIC TANK ZONE�. L I ( WASHED STONE SYSTEM (SAS) INDEX ADJUST ! r LEA-7END: DESIGN CALCULATIONS SEWAGE DISPOSAL SYSTEM PROFILE BOTTOM OF TEST HOLE ' ELEV. - _� EXISTING SPOT ELEVATION 00,,0 NUMBER OF BEDROOMS 4 ` NOT TO SCALE OBSERVED TABLE / / �V• �� • EXISTING CONTOUR ----00---- GARBAGE DISPOSAL UNIT N� F1NA'._ SPOT ELEVATION TOTAL ESTIMATED FLOW FiNA> CONTOUR (JGAL/BR./DAY X �' BR.) '`� GAL/DAY ` _ r SOIL ?EST LOCATION REQUIRED SEPTIC TANK CAPACITY GAL ! JTIL'TY POLE -.0- ACTUAL SIZE OF SEPTIC TANK 00 GAL TOW 4 WATER —W'��1N�- SOIL CLASSIFICATION CATCH BASIN \NJ DESIGN PERCOLATION RATE S� MIN./IN. i �/ EFFLUENT LOADING RATE © 7 ./ f �.. N '/ ` i GAS UNE G ' , . "x s �.'i �� v SO. FT.GAL./DAY/S. a Z ".`"""w "" �� LEACHING AREA / LEACHING CAPACITY (AREA X RATE) `� �j GAL/DAY .'744i RESERVE LEACHING CAPACITY 'Q `� GAL/DAY ,..own! ! ch a9n .7J -44/.rA ! /DA # I t.• ��. �� �� , , 1' a NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. 46 TITLE 5 AND THE TOWN OF Lj�,F'✓ysrfl:.'L i RULES S ��� t ��`J 'r REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.D ! 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6 OF FINISH s 1 ♦ rr 'r ' ' { �• 3. ALL COMPONENTS OF THE SANITARY NITARY SYSTEM SHALL BE CAPABLE OF rQ� WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 'L .:, 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE I USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4. ANY MASONARY UK S USED TO BRING COVERS TO GRADE SHALL W) BE MORTARED IN PLACE. 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH Or-cn En r%R ZONIN; c.,,, n O 1T ii.,. v.Z � .,c ,r ,..v.ev, � ,v,�. �WA4sf:R Af'Fu Ah T iJ T�1 -- OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. Lin 00_L-D - - ; tt� ' 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR \ ` -, 2 >wtGcsl� IS TO CALL 'DIG-SAFE' AT 1-800-322-4844 AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE. ! 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS , SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. 8. PARCEL IS IN FLOOD ZONE I'j IC► ,"J w '�i .� a 'As �; r`• ''. /, � r . V � 9. LOT IS SHOWN ON ASSESSORS MAP t `� AS PARCEL Q 7 �j �". �.•`/ I .•tr' '� i I / �� �F,✓ ;, J '/ � : .� ? -_-_ _�_.� '~" � SE�. _r i 0,^✓ ! l 7 17�,$ ?—f7 N<tr f'/Z Q� F'1� , �1/�"• !Z>' 4' T<% 13E F?v�`'"t +'P-L3 'J t✓:'" f=I L %. E'L7 �' t .i It 1/J f✓ ✓ % i C /✓+�/ L. w_ 7' F a c m a ti, 4 0 1"tan, W'si re:. µ cD v. ; 3 (, w� r4 A,'v'z)) E P Ti C A nr: x ,�•- .✓ , 7 �` 12 44 .�✓c T�,�� .� f E ! 1 4 R C✓ J t P. Chr i t^1<i M T = i/sra� y T.,;,•. ?` S C©^,J T',E T"ia j H ff i i i 3 7 i<: 41 U r>CaN �7 U c � U N 1 �I.� T� � ° C + � •, + ;"'_--ter---..,_ ,� :i�'i.S 1 APPROVED.` BOARD OF HEALTH t 2 Sep s 1,99 DATE AGENT i ! f i ; PROPOSED SEPTIC DESIGN r FOR A OR , i' 4 01( i PROJECT LOCATION 7,4 € CRAIG R, SHORT508-le PROFESSIONAL,, R 41 PROFESSIONAL ENGINEER i -;>•. '1 385--6530 DENNIS,OMASS. 02638 t °va DATE / 4 SCALE 11 r Jt11 -A 'f ram/ fi I I � ` "" "•..... u i::lVLI,. y�'� 'd i D�� v' _ JI I i '�► .,, . No 27483 l 9 REVISED JOB NO. f I 979 ep f _ I ' y , i ✓ '4 ` ... .,. ��, r �,;' REVISED �'«?3� /-' ! I 1 ° LOCATION MAP [ y ( I SHEET / OF I 1 0 Ai ''�L s 6 ©1996 CRAIG FL SMAT, P.E.