Loading...
HomeMy WebLinkAbout0120 BUNKER HILL ROAD - Health 120 Bunker.:Hill Road Osterville, r ll A = 095. 024 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 004120 Bunker Hill Road � Property Address Charles Sabatt Owner Owner's Name , information is required for every Osterville MA 02655 May 25, 2021 page. Cityrrown 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 A. Inspector Information filling out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating __ _ use the return Company Name key. PO Box 89 ®ICI Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 _ S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. 0 Passes 2. rj Conditionally Passes 3. M Needs Further Evaluation by the Local Approving Authority 4. LD Fails May 28, 2021 Insor's Signature Date pect 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is required for every Osterville MA 02655 May 25, 2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary ' Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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 pas/dh Check the box for"yes", "no" or" mine " (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and ove d* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infi xfiltration or tank failure is imminent. System will pass inspection if the existing tank is rith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inif it is structurally sound, not leaking and if a Certificate of Compliance indicating that the ta than 20 years old is available. ❑ Y ❑ N ❑ ain below): t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 5 , c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt . Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every — — page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. b rvation of sewage backup or break out or high static water level in the distribution box due ❑ O se g p 9 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 r replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a ye r due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the B and of Health): ❑ broken pipe(s) are replaced Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the and of Health: ❑ Conditions exist which require furth evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 < Commonwealth of Massachusetts s, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � / 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is required for every Ostervill„' MA 02655 May 25, 2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 abs rption system (SAS) and the SAS is within 100 feet of a surface water supply or tributa to a surface water supply. ❑ The system has aseptic tank and SAS nd the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S Sand the SAS is within 50 feet of a private water supply well. ❑ The s tic tank an SAS and the SAS is less than 100 feet but 50 feet or system has a septic more from a private water supply w I**. Method used to determine distanc : **This system passes if the well w ter analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absen and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided at no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 El due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 16 I c Commonwealth of Massachusetts � Title 5 Official Inspection Form �n cial i, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 120 Bunker Hill Road v Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 belowahigh 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. supply ® Any portion of a cesspool or privy is within a Zone-1 of a public water pp y Elwell. ❑ ® 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 2000 gpd- ❑ ® 10,000 gpd. El ® 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. 5) 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 indi/ora " es" or"no"to each of the following, in addition to the questions in Section CA , Yes No ❑ ❑ . the system feet of a surface drinking water supply a� ❑ ❑ the system0 feet of a tributary to a surface drinking water supply ❑ ❑ the system a nitrogen sensitive area (Interim Wellhead Protection Area—IWped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments v / 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is required for every osterville MA 02655 May 25, 2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® El available 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 ssachusetts Commonwealth of Ma p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt _ Owner Owner's Name information is required for every Osterville MA 02655 May 25, 2021 - page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 460 GPD Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to'. 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 2019= 162 GPD Water meter readings, if available (last 2 years usage (gpd)): 2020= 183 GPD Detail Sump pump? ❑ Yes ® No Current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 AA, Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road v Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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., tc.): - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: --- Industrial waste holding tank pr sent? ❑ Yes ❑ No Non-sanitary waste discharg d to the Title 5 system? ❑ Yes ❑ No Water meter readings, if a ailable: Last date of occupancy se: Date Other(describe below): 3. Pumping Records: Source of information: Owners records: Pumped Oct. 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons - How was quantity pumped determined? ------- Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 I ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known) and source of information: Tank installed 1982. Age of home. D-box and SAS installed 06/1812003. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 2.8 Depth below grade: feet Material of construction: ❑ cast iron ® 40�PVC ❑ other(explain): - L ` Distance from private water supply well or suction liner feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form G I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .......... 120 Bunker Hill Road _ Property Address Charles Sabatt Owner Owner's Name information is required for every Osterville MA 02655 May 25, 2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 2'2" Depth below grade: feet Material of construction: ® concrete ❑ metal []fiberglass ❑ polyethylene. ❑ other(explain) J If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5' x 4.5'x 5' 1000 gallons Dimensions: Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 32 2„ Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13" Dip tube and tape measure 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.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Both covers are under patio stones removed by landscaper proir to inspection. Recommend maintenance pumping every two years with full time use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every _ y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 outle ee or baffle Distance from bottom of scum to botto of outlet tee or baffle - Date of last pumping: Date Comments (on pumping recomme dations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet i ert, evidence of leakage, etc.):. 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade:, Material of construction: ❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ---- Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 120 Bunker Hill Road Property Address Charles Sabatt _ Owner Owner's Name information is required for every Osterville MA 02655 May 25, 2021 — page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float s/hes, tc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): One inlet, two outlets. Speed levelers in place. H-10 D13-3 3' below grade. Light corrosion. Riser brings access within 10" of grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is required for every Osterville MA 02655 May 25, 2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: , ❑ Yes ❑ No* Alarms in working order, ❑ Yes ❑ No* Comments (note condition of pump chamb r, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 1.1. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-500 gal unitsw/3' stone. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — -------_--- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt Owner Owners Name information is Osterville MA 02655 May 25 2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers located and inspected with camera. Liquid level 1.5+-' below invert. Light staining 2" above current level. Three rows of clean stone visible in sidewall holes. No sign of past hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inl/invert — Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater ❑ Yes ❑ No Comments (note conditioraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25 2021 required for every Y , page. Cityfrown State Zip Code Date of Inspection .D. System Information (cont.) 13. Privy (locate on site plan): ` Materials of construction: — --- Dimensions Depth of solids Comments (note condition of soil, signs of ydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ill Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25 2021 required for every __ — � page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 1 00 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i f � y t J r I 1 t ' e z�c 10 0 J S f J 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Bunker Hill Road v Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5feet 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: 1981 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation.. Test hole in 1981 found no ground water at 144" (elv= 22). Base of units at elv= 29.6 per engineered plans. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `...........� � 120 Bunker Hill Road Property Address Charles Sabatt Owner Owner's Name information is Osterville MA 02655 May 25, 2021 required for every Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: l ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank-:-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of,estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 { 1 TOWN OF BARNSTABLE LOCATION 120 BUNKER HILL ROAD OSTERVILL SEWAGE # 2002-379 VILLAGE OSTFRVILLF ASSESSOR'S MAP & LOT b� l ELLIS BROTHERS CONST. CO. 508-362-6237 INSTALLER'S NAME&PHONE NO. �• SEPTIC TANK'CAPACITY. 1000 , l LEACHING FACILITY: (type) 4 500 GALON LEACHING CERS NO.'OF BEDROOMS E r: BUILDER OR OWNER M` .M CHARL S SAB ATT , PERMITDATE8/30/02 COMPLIANCE DATE o� a Separation Distance Between the: X Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet *; Private Water Supply Well and Leaching Facility (If any wells{exisi t �-. on site or within 200 feet of leaching facility) . 3; Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished 6y _ . Lq bit C- - .ITS � fly 6 I 0 Gt No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Miopaal *pztem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(v)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Ow�` �'s Name, ddress and Tel No Assessor's Map/Parcel ,V/A Installer's NaZe,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 9 �� /, Dwelling No.of Bedrooms— Lot Size /' sq.ft. Garbage Grinder Al Other Type of Building X2—y No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title A�v Size of Septic Tank ,�� e Type of S.A.S. Aj Description of Soil � � 4001 t' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to a the c4ctio maintenance of the afore described on-site sewage disposal system in accordance with the provis' s o itle5oental Code and not to place the system in operation until a Certifi- cate of Compliance has i d by this B ne ® ate b Application Approved by Date 9, C Application Disapproved for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' VYes PUBLIC HEALTH DIVISION - TOWN. OF BARNSTABLES MASSACHUSETTS Zpp icatiou for Mi.5pogaV*p.5tem Cottgtructiou Permit Application for a Permit to Construct( . )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Own 's Name,Address and Tel.No. Assessor's Map/Pazcel,:,...— ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4Type of Building: % f a. Dwelling No.of Bedrooms- -4 'Lot Size sq.ft. Garbage Grinder Other Type of Building i'Lf — No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow '� � /' gallons. ter_ Plan Date 5� - w �- Number of sheets Revision Date Title IXZ�_,d 1 � eNell4A/Z0&1VIZ—A;ii 10 Size of Septic Tank ,/'t`>� Type of S.A.S. Description of Soil f-O I`'; A A/- t ,(n Nature of Repairs or Alterations(Answer when applicable) t j Date last inspected: [t E Agreement: The undersigned agrees to ens qrthe cjare, ction and maintenance of the afore described on-site sewage disposal system in accordance with the provisi s�ofbitle 5 oE °nmental Code and not to place the system in operation until a Certifi- cate of Compliance has�Si b issuy this BI th. ne m Yin. Dates b Application Approved by ./ �f �Date f Application Disapproved for the following reasons / Permit No. Date Issued ------------------------------------- 3 THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS O T _CERTIFY, that the On-site Sewage Disposal S stem Constructed( )Repaired( )Upgraded( ) Abandoned( )by L G�-/ -5 e-v_;---5 • L--�`� �' - at E---.-)(. /j ` 11 ha b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '07"dated Installer ��<4- . C_-, -Designer--I - IVThe issuance oft s fe shall not be construed as a guarantee that the system tll r�ct` s tie �e Dater I D� Inspector /� 1 — —---------------------------- � No. �L --�'+ Fee r" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migo!gai *pztem Con5tr A I n Permit Permission is hereby granted to Construct( )Repair( - )Upgrade( Abandon ) System located at / ` y 4+G l �-A c 5)5 a,=" and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty-to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must e� 1 te`d v Within three years of the date of thisWit Date: �V V Approved by i TOWN OF BARNSTABLE LOCATION 120 BUNKER HILL ROAD OSTERVIL.L SEWAGE # 2002-379 VILLAGE neTFRU T l I F ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE N.O. ELLIS BROTHERS CONST. CO. 508-362-6237 SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) 4 500 GALON LEACHING CtERS NO.OF BEDROOMS BUILDER OR OWNER MIM CHARLES SABATT 22 PERMIT DATO/30/02 COMPLIANCE DATE: �7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leacldng facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by V. � w� t i 1 V 6 �� � � 72 . f OCATION SEWAGE PERMIT NO. -:VJI L L AGE yy iN i is s I.NSTA LLER'S NAME i ADDRESS �✓, C�s�' e UILDE R OR OWNER DATE PERMIT ISSUED 7 DATE COMPLIANCE ISSUED y f' to f� � ' ` ' o 341 VYxs. ..... THE COMMONWEALTH OF MASSACHUSE BOARD,,,OF HEAL � < ......_...................oF..... . . .- Appliratiou for Uispwi al Application is herebyZrpade for a Permit to Co s uct or Repair ( ) an Individual Sewage Disposal System at ............... ...: .......-----.............A�l ...... e - ......r.....-..o % ....._......... LocatifAr. s or Lot o.._---.•.. - -- ...................... ...� ..d� _.OAddress ....................... = —... ...................... --•---...............••............. .s......... Installer Address % Type of Building Size Lot T..:'Zr ............ t U g— Expansion Attic Garbage Grinder (��g vDwellin No. of Bedrooms.............................. a`4 Other—T e of Building No. of persons............................ Showers YP g ---•----•---•--------------- P ( ) — Cafeteria ( ) Otherfixtures ..__..... ............................................................................................................................. w Design Flow.............................7� gallons per person per day. Total d ll��iow.._............ .........-. 4lon�,. WSeptic Tank—Liquid'capacity.. ._......gallons Lengthl.-.6...... Width_.y-:1-_---.. Diameter____--__----_- Depth-------------- x Disposal Trench—No..................... Width........I----------- Total Length........... Total leaching area.__.._.............sq. ft. Seepage Pit No.___-___-/:_--____-. Diameter......1e-_-_-_- Depth below inlet.......`t' Total leaching area., ft. z Other Distribution box (� Dosing to Percolation Test Results Performed b / \a Y------ -�1---�y�� ----- Date.---�.��'._.�.���{••--------- / Test Pit No. 1------- -....minutes per inch Depth of Test .... Depth to ground 44 Test Pit No. 2................minutes per inch Depth of Test Pit___:..f.--7...... Depth to ground water..__._`-`................ O Description of Soil------•-•. :=y1 L � �L' ------r -7--- �`�7 x w 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 THTITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation a Certigoate of Compliance has b ssued the bo d of lth. �r Signed -------------- ................................ D e Application Approved BY .... ...,. , ................................... D e Application Disapproved for the'f ollowing reasons-----------------------------------------------------------------------------------------------------------•----- ----...-•------------------•-----------.......----------------------------•---•---------.....------------••---•-•--••------•---------••------•-•-- Date PermitNo......................................................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH OF C3p ) tf t Appfiratiou for Disp.aiittl Works Tnnitrnrtion Fumit '.. Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal 'System at• / /j�� Loca�ta.........P)........................................... ............................................................................ pn d ss l / E or Lo N v Ow Address .......................... ���. . .. �': `.. ..---•••.............•-••••••. •••---••••--------•-•-••••-•----•---......--•-••........................._..... - •- Installer r Address Type of Building t; Size Lot........................... v Dwelling—No. of Bedrooms......:: :'..............................Expansion Attic.4h Garbage Grinder Other—Type of Building '9 No. of persons............................ Showers — Pa YP g = --..._ P ( ) Cafeteria ( ) Other fixtures ......... W E 'D�sign Flow.............................} ..'......__gallons per person per day. Total daily„flow............... ©..............gallons. G: Septic Tank—Liquid*capacity..t�ggallons Length'F.=�...... Width.'.O...._. Diameter................ Depth_:C1_ Disposal Trench—No. .................... Width.. ............. Total Length..................... Total leaching area.......... _..sq. ft. Pit No ..._ _.... iameter......; ._._:_ Depth below inlet..... 4- Seepage. .... .. Total leaching area_ 7r: :_ ' �� P g sq. ft: Z Other Distribution box (�'i) ``Dosing '" Percolation Test Results Performed by.------- .....................T1 �.� ` �.r.��.....' �'f_j'�! �. .. ---•--•-----•-- Date---••---=,. --P---- --- ----------- � Test Pit No. 1___________.....minutes per inch Depth of Test Pit.'_./.. Depth to ground (� Test Pit No. 2................minutes per inch Depth of Test-Pit.....,. ._/._...... Depth to ground G4 ------ -- f �-----r�-`-�--- ------water�....._ - ..... - r ......-_-.•__-_-_--..-_-_-_-__.- Description of Soil----.._..•_._._�, �.-----=�- __�....: :.. :.. � ---------- -- ' ---------------------------------------------------------------------------------------------•------------------------------------------------------------•-----------................................. 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 E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in open tio; uptil a Cert• to of Compliance has b ssued Lthe bo, d of ealth [� Signed............. -- •• --•-• .. --- ...•-------------•---• ................................ D Application Apprdved By, `- ,e. t... .. ......................................... .... -------- Date Application-.Disapproved for the following reasons--------------------------- ----------------------------------------- ----------------------------------------- -•..........-•••-•---•----....••••••--------•---------••--••----•--••-•---•-----••----......••---•----•-•-•----•-s--------------------------•--------------•--••------•----•----------•--•----•--•---••- Date PermitNo................. .. Issued-------•------•--------•----------•--•----••--•-•-----• ..,. Date i 'THE COMMONWEALTH OF MASSACHUSETTS r BOARD .OF" HEALT14 ........................ 'rrtifiratr of Tomp ianrr THIS IS TO CERTIFY, Th t t Individual Se e' Disposal System constructed ( ) or Repaired ( ) by------------------------------------------------------------ -'-.................................................................................. Installer/ r ?' at....... • " --�" 1 -- ---------------------•------------•-----------------.......---------- has been installed in accordance with the provisions of TITL: 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No::.8�� d 7-1............... dated................................................ THE ISSUANCE OF THI CERTIFICATE SHALL NOT BE CONSTRU A G RANTEE THAT THE 3 SYSTEM WILL FUNCTI N ATISFACTORY. /D l fi1- Inspector:.:.......DATE...................:.. ...._.. ..................••• •••.--•-----_-•--- ---------•••............••--••-•..... r THE COMMONWEALTH OF MASSAC USETTS BOARD OF, HEALTH - f ...............:.OF..-.- ............................. No._.... FFE...)..49............. Disposal ki n, ion rrntit Permissio is hereby granted -----=---------•--.---•-•...........------..._------._...----------------.............----................•--- to Construct or Repair ( ) a ndividu Sewa a Disposal System at No. ��° Street as shown on the application for Disposal Works Construction Permit No..................... Dated_..,-----------------.-----------........ / Board of JOSItE DATE > ......... ---------- t FORM 1255 HOBBS,"& WARREN. INC.. PUBLISHERS 0)g. Ai'i'[.1CATiUi• FUR PERCU[,ATIuN TEST A;11'') OBJERVATIOZJ PlT,; „ s � +!.00ATION _ r )Ulf� tAiu_ �'—'�'.��— �, � Ct�i(Alc 6f5(S1.D€" NO. P i !1II,T.AGF. \PPLIC'ANT C Si9( 1�'C�` FEF/ -0_ f�RDDRESS TELEPHQNE NO. -1�?� -v2�7�Non-rer:u: :. j'.NGINEER E i CS�,>� TELEPHdNE NO. (�Zg'- 4)ATE SCHEDULED i' (Applicant's signature ) - . . . . . . . .. .. . .. .. .. .. . . .. . . . .. :.... . . . . . .... . ... . .. .. .. .. ...... . . . . . . . . . . . . . . . i SOIL LOG 'SUB—DIVISION NAME C�1`i K. DATE its � TIME (�`. �U� t XPANSION AREA: YES ENO i :�OWN WATER 4-PRIVATE WELL7�G' BOARD Oi 74:�:>1_ L - EXCAVATOR :SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in pr ' imi_ty to test holes ) i I / NOTES I E :PERCOLATION RATE: ' ;TEST HOLE N0: ELEVATION: TEST HOLE NO: Z_ ELEVATION: 2 i 3 3Inc ' 5 i 5 - 6 6 �. AS 9 D 9 10 10 111 11 . 12 12 13 � �a ,;. 13 e 14 14 15 15 1:6 16 ! SUITABLE FOi SUB-SURFACE SEWAGE: LEACHING FIELD 1,1, ACIJING PITS Z ' LEACHING TRENCHES/ UNSUITABLE .FOR SUB-SURFACE SEWAGE. REASONSi ^Tr E LNG I4E:ERING PLANS MUST SHOW NUMBER ASSIG2JEDi. ON PERC TEST APPLIC\'?' v'; `.)R1GI`\L: . �!CCMPLFTETI TEE ENTIP.F.T H P AN R lj1_ F.D TO BOARD OF HF.:1jI,Tf{ fJ t i _ r }{r � � Est, fit► ^� - ,. R9.7 g"�•7 "'` CIO Zcz, l d Ol C=y TEAT` T-F+E 1 a G\ r- U vjr= t 5eroAr-v u- t LQ ti to OF,Ai WUlfAM C. Ma, 193U NZ Z5, use QF \k3 " ..; ./ ? "`_, Ac.4N ^ i r SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER IS WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) To ENGINEER: BAXTER AND NYE 37.50' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM BARNSTABLE HEALTH DEPT. 35.0' WITNESS: I Locus RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE DATE: 10/16/81 FOR FIRST 2' 4 < 2 MIN/INCH EXISTING_1SZ00 3 MAX. PERC. RATE _ 3�Exs GALLON SEPTIC 34.13' 32.50' CLASS i SOILS P# 781 TANK (H- 1O ) GAS C: 0 �:33.0'BAFFLE 32,90 --4:� CJ C7 C] I� 0 0 C7 CI 31.67 aMCJM M CO [� � M 3' ATSIDES 6" CRUSHED STONE OR MECHANICAL Eo Cl C� Cl CJ C� O Cl 2.5' TEND i ELEV. ELEV. '�D I COMPACTION. (15.221 [2)) �$g 2 � Cl C� C7 � Cl CD L� Cl d 29.67' p" Q 37.5' p^ Q DEPTH OF FLOW 4' SLOPE) ( 7 % SLOPE) " LOAM TEE SlzEsc 3/4 TO 1 1/2 ' DOUBLE WASHED STONE LOAM INLET DEPTH = 10" SUBSOIL SUBSOIL OUTLET DEPTH = 14' LOCATION MAP NTS FOUNDATION- EXIST. SEPTIC TANK 41 ' - D' BOX 20' LEACHING .0 zoL14 5 ASSESSORS MAP 95 PARCEL 24 FACILITY 7 67' / CONC BND FND MED. SAND / MED. SAND a oPo / 22.0 FND CONC BND 144 22.5 144" 22.0' CONC BND UG UTILITIES TO FRONT +3 .42 . / FND OF DWELLING (INCL. \ NO WATER NO WATER 0° WATER) ��O NOTES: o° Qb > '�9 SEPTIC DESIGN:' (GARBAGE DISPOSER IS NOT ALLOWED ) 1 . DATUM IS APPROX. MSL .29 DESIGN FLOW: `�_ BEDROOMS � 1 1U GPD) 440 GF'D '-2.' MUNICIPAL WATER iS i r i, 1,. / GRAVEL DRIVE. P S 3.30 + 1.44 USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. CONC BND FND \ , . Fh3.9 SEPTIC TANK: 440 GPD (2) = 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-10 EDGE of 5.' PIPE JOINTS TO BE MADE WATERTIGHT. SPRINKLERED a.27 USE A In(!- GALLON SEPTIC TANK (RE-USE EXISTING) LAWN6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. \ v 36 3a,s 3z.7a LEACHING: ENVIRONMENTAL CODE TITLE V. ,S EXISTING 6.16 �' �� SIDES: -2-(� + 10.8�2(,74.) - 147.5 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 0Op DWELLING \. CONC BND - 312.5 TO BE USED FOR ANY OTHER PURPOSE. FND`,� \ BOTTOM: 39 x 10.83 (.74) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40•-4" PVC. 2 .3 DECK 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT PATIO j.2151,s �R � \ : TOTAL: 621 S.F. 460 GPD 6 \ \ USE (4) 500 GAL, LEACHING CHAMBERS ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED + FROM BOARD OF HEALTH. \ �s � 30_9�1 . 2 EQUAL, WITH 3' STONE AT SIDES AND 2.5' AT ENDS 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING LEACH PIT s 37.« �¢�� PNE 11 . CONTRACTOR REQUIRED TO CONTACT DIG-SAFE PRIOR TO EXCAVATION GAR TH1 PINE BENCHMARK: PATIO AT BULKHEAD 37.51 CORNER ELEV. TH2 37.3' LEGEND TITLE 5 SITE PLAN �I 10p.0 PROPOSED SPOT ELEVATION OF 120 BUNKER HILL ROAD LOT 76 100x0 EXISTING SPOT ELEVATION 1.81 AC IN THE TOWN OF: 100 f PROPOSED CONTOUR (OSTERVILLE) BARNSTABLE 100 EXISTING CONTOUR PREPARED FOR: M/M CHARLES SABATT o a 40 0 40 80 120 BOARD OF HEALTH APFaOVED DATE MA SCALE: 1 " = 40' DATE: MAY 21 , 2002 off 508-362-4541 fax 508 362-9880 down cape engineering, inc. ���" Of � �� A H. OF` CIVIL ENGINEERS OJALA Z9 NE H. J LAND SURVEYORS �o N ' ,� H ,�' z JZ6 z- 939 main st. yarmouth, ma 02675 O I (o AR OJAL E NG DA TE