HomeMy WebLinkAbout0047 CAILLOUET LANE - HealthF'47 Cailloulet Lane
Osterville
A= 141-098 002
r
• Engineering &
S U I I iva n , Consulting, Inc.
(508)428.3344 • P.O. Box 659 • 7 Parker Road, Osterville, MA 02655
seci@sullivanengin.com • www.sullivanengin.com
June 22, 2015
Health Division
Town of Barnstable
200 Main Street
Hyannis, MA 02601
RE: 47 Caillouet, Osterville
To Whom It May Concern:
Sullivan Engineering and Consulting has been asked to review the existing septic system for
the dwelling located at the above referenced property, and the implications of any future
proposed renovation or addition thereto. The following summarizes our findings:
• The existing system was designed and installed around 1984 for 3 bedrooms with a
garbage grinder. '
• The property is listed as having 4 existing bedrooms by the Assessor's Office.
• The area of the lot is listed as 1.37 acres (59,677 square feet).
• The property is located within the Estuaries Overlay District only.
• The existing septic system was inspected on May 6, 2015 and passed.
• The S.A.S. is listed as 2—600 gallon leaching pits with 4' of stone.
• Calculations showed that this S.A.S. has the-capacity for 967.4 gallons per day.
We believe the existing system can support the 4th bedroom with a garbage grinder.
We believe that the present Health Division policy would allow the owner to go forward with a
renovation or addition for a 5th bedrooms, with no change to the existing septic system, as long
as the grinder were removed.
I trust this meets your present needs. If you have any questions or require any additional
information, please feel free to call.
Very truly yours,
`0 V
J�h O'Dea, P. E.
Sullivan Engineering & Consulting, Inc.
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osteryille MA 02655 5/4/15
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 James Ford
use the return Name of Inspector
key.ICI Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
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 Furth r Evaluation by the Local Approving Authority
5/6/15
Inspe or's ignature Date
The tem inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
ID Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
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
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
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
❑ ® 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
M El ® or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
l5ins•3113 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
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
P. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. CityrFown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of.liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ 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): see below Number of bedrooms(actual): 4 per town
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 967.4 G.P.D
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
per design plan, system was designed for 3 bedrooms with a grinder. but can take 967.4 G.P.D.
system will take more bedrooms without a grinder installed
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: unknownDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: unavailable
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
_ r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•''� 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
system installed - 1985 per as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 16"feet
Material of construction:
®concrete El 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 gal.
Sludge depth:
2
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
G - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•'" 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Cityrrown State Zip Code Date of Inspection
D. Syst'em Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
6
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. There was no sign of leaks e.The covers are 16" below grade.
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
N/a
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth f Ma
ssachusetts
assachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
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 even
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.):
The D-Box was normal and the cover was 26" below
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
2-600 gal.with 4
® leaching pits number: 'stone
❑ 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.):
The pits were dry. The scum line was 2' up from the bottom. There was no sign of failure. A camera
was used.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
4 u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every osterville MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
4 . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
re 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
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
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v tit
yf! $7
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
1 Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•''�t 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
page. CityrFown 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: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on recprd
If checked, date of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Topo and water contours map
❑ Checked with local,excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
water was observed at 12.5' at test holes when installed
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
C
S
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•''` 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is required for every Osterville MA 02655 5/4/15
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
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
k�
Commonwealth of Massachusetts
Title 5 Official ' Inspection Form
Subsurface Sewage Disposal;System Form-Not for Voluntary Assessments
r 47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owners Name
information is
required for every Osterville MA 02655 5/4/15
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.
f,.
Important:When filling out forms A. General Information
on the computer,
he tab, I l O
P f
use only the tab 1. Inspector: `
key to move your
cursor-do not James Ford
use the return key. Name of Inspector
QCompany Name ;
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
Telephone Number J; . License Number
u i3 f
of
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 Furth r Evaluation by the Local Approving Authority
5/6/15
Inspe eV nature Date
The tem 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 1 0,00 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.
i,
ti
****This report only describes',conditions at the time of inspection and under the conditions of use
at that time.This inspection''does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
it '
i .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address j
John & Barbara Blaze Trust
Owner Owner's-Nameinformation is
required for every Osterville MA 02655 5/4/15
page. Cltyrrown 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{.
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in': 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. :
Comments: I
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. Th'e 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 andiover 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. ;S
*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.
is .
❑ Y ❑ N ❑ ND (Explain below):
I
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
li
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c �^
Z\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposai System Form Not for VoluntaryAssessmen
ts
.•y�. 47 Caillouet Lane Ir
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is
required for every Osterville i MA 02655 5/4/15
page. City/Town I 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 1 asses (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).-
El broken pipe(s) 'irre replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box i:fs leveled or replaced ❑ Y ElN ElND (Explain below):
f
i
i.
I
❑ 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):
is
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
�i
,
i
,r
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 unlIess Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy,is within 50 feet of a surface water
❑ Cesspool or privy:is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13
{; Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
li
{
Commonwealth of Massy'achusetts
u Title 5 Officia�� :Inspection Form
Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust ;
Owner Owner's Name
information is
required for every Osterville MA 02655 5/4/15
page. CitylTown 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 s' ptic an and soil absorption system (SAS)and the SAS is within
100 feet of a surface wZer 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. t°
❑ The system has a septic"tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private wat' r 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: r
i . 1
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or,�"No"to each of the following for all inspections:
ii
Yes No
El ® 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 n overloaded or clogged SAS or cesspool
❑ ® Static I quid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid cepth in cesspool is less than 6" below invert or available volume is less
than %ciay flow
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
F`s`s
t,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposa System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust '
Owner Owners Name
lug
information is I
required for every Osterville ' MA 02655 5/4/15
page. City/Town f State Zip Code Date of Inspection
B. Certification (cont.)!'
Yes No
ii
❑ ® '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 p9rtion 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.
t '
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from aliprivate water supply well with no acceptable water quality analysis. [This
systerlh 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,boogpd.
stem fails. I h
❑ ® The sy ave 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
neces ary 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 o 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 I:WPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to.a`n Y y y 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 3 0 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. pp priat e
t5ins•3/13 Y'
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
P
Commonwealth of Massachusetts
Title 5 Officia`I Ins ection Form
p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
is
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owner's Name
information is
required for every Osteryille MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the,system received normal flows in the previous two week period?
❑ ® Have lairge volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were a 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?
e
r
it
® ❑ Was thd'site inspected for signs of break out?
® ❑ Were al(�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?
yl
❑ ® Was thefacility 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:
t
® ❑ 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
approxinhation of distance is unacceptable) [310 CMR 15.302(5)]
t.
D. System Information,
Residential Flow Conditions:
I' see below
Number of bedrooms (design): Number of bedrooms(actual): 4 per town .
Ij
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 967.4 G.P.D
i�
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
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Commonwealth of Massachusetts
Title 5 Officidl ;Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 47 Caillouet Lane1,
Property Address
John & Barbara Blaze Trust
Owner Owner's Name {{
information is !'
required for every Osterville MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Informatio''n:
Description:
per design Ian '
P g p system was designed for 3 bedrooms with a grinder. but can take 967.4 G.P.D.
system will take more bedrooms without a grinder installed
l
y
Number of current residentsi; ;
Does residence have a garbage grinder?
❑ Yes ❑ No
Is laundry on a separate selage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? El Yes ® No
Seasonal use? R
1 ; El Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:Detai h
unavailable
4:
tl
�i
Sump pump? ,
l: El Yes ® No
1 .
Last date of occupancy: unknown
I Date
4 :
Commercial/Industrial Flok' conditions:
Type of Establishment: ¢ ;
(
Design flow(based on 310 GMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/prsons/sq.ft., etc.):
Grease trap present? i
t; ❑ Yes ❑ No
Industrial waste holding tank.present?
❑ Yes ❑ No
it
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
,I
Water meter readings, if available:
t5ins•3113 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i, .
I , .
R.
Commonwealth of Massachusetts
G Title 5 Official '
l Inspection Form
Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments
r( 47 Caillouet Lane t
Property Address
Owner Own
John & Barbara Blaze Trust
information is er's Name t .
required for every Osterville �'° MA 02655 5/4/15
page. City/Town ;P State Zip Code Date of Inspection
D. System Informatid`(cont.)
Last date of occupancy/use:;
Date
Other(describe below): (
General Information
Pumping Records:
Source of information: unavailable
Was system pumped as pa of the inspection?- ❑ Yes ® No
If yes, volume pumped: u
gallons
How was quantity pumped d.ptermined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy t
I
❑ Shared syst6rn(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 I) I/A system by system operator under contract
A.
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 '
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
t .
Commonwealth of Massachusetts
H Title 5 Official . lnspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3'
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owners Name
information is
required for every Osterville MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Informati®n
Approximate age of all components, date installed (if known) and source of information:
system installed - 1985 Per as-built
Were sewage odors detected when arriving at the site? El Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
t feet
13 ;
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
i
Septic Tank(locate on site pla'n):
Ci .
Depth below grade:
16"
i;
feet
Material of construction:
it
® concrete ❑ metal ❑fiberglass ❑ pol eth lene
I Y Y ❑other(explain)
i
t
e .
If tank is metal, list age:
I : years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal.
Sludge depth: 2
t5ins-3/13 t
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I!
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i,
3 .
Commonwealth of Massachusetts
Title 5 Offici 'I ;Inspection Form
Subsurface Sewage Disposa, System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze T rust
Owner 's
information is Owner Name l
required for every Osterville i9 MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) a
Distance from top of sludge!fo bottom of outlet tee or baffle 30
Scum thickness '+ 1
r: ;Distance from top of scum to;top of outlet tee or baffle 6
Distance from bottom of sc m�to bottom of outlet tee or baffle 10
EI
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. There was no sign of leaks a The covers are 16" below grade.
I,
is
i II
' k�s
1'
Grease Trap (locate on site plan):
Il
Depth below grade: it n/a
feet
Material of construction: i
❑ concrete ❑ metal ❑ fiberglass ❑ pol eth lene y y El other(explain):
Dimensions:
r .
Scum thickness �!
Distance from top of scum to`top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Ei
r
fl
Commonwealth of Massachusetts
Title 5 Official ;Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane .
Pro e p rty Address
John & Barbara Blaze Trust l;
Owner information is Owners Name •`
required for every Osterville MA 02655 5/4/15
page. CitylTown State Zip Code Date of Inspection
D. System Information (Cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
F
i
ro:
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
r
i
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
;i
Elother(explain):
N/a
1'
I.
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ;: ❑ Yes ❑ No
I•
Alarm level:
Alarm in working order: El Yes ❑ No
�l 3
Date of last pumping:.
i. Date
Comments (condition of alarm and float switches, etc.):
•
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No
l5ins-3/13 !
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 17
it
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal xSystem Form-Not for Voluntary Assessments
•'" 47 Caillouet Lane E'
Property Address
John & Barbara Blaze Trust '
Owner Owner's Name
information is
required for every Osterville MA 02655 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Information '(cont.)
Distribution Box(if preseni must be opened) (locate on site plan):
41
Depth of liquid level above outlet invert even
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.):
The D-Box was normal and'the cover was 26" below
E .
ii
Pump Chamber(locate on site plan):
is
r.
Pumps in working order. ' El Yes ❑ No'
Alarms in working order; El Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
r,
h
Is
If pumps or alarms are not iryn working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
i! ..
If SAS not located, explain why:
Q
f
t5ins•3/13 �{. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
s
t
`I
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & BarbaraBlaze Trust :
Owner Owner's Name
information is
required for every Osterville MA 02655 5/4/15
page. Citylrown
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits►! " number: 2-600 gal. with 4
i
'stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching tren4es number, length:
r :
Elleaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
c
Type/name of technology:
ii
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The pits were dry. The scum line was 2' up from the bottom. There was no sign of failure.A camera
was used. ,
i-
1
4
Cesspools (cesspool must bye pumped as part of inspection) (locate on site plan):
Number and configuration
i
Depth—top of liquid to inlet ih vert
h :
l+ .
Depth of solids layer i
Depth of scum layer j
Dimensions of cesspool '
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 k Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
1:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Caillouet Lane d
Property Address
John & Barbara Blaze Trust t
Owner Owner's Name
information is
required for every Osterville i MA 02655 5/4/15
page. Cityrrown
State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of din condition
etc.): !; pon9, of vegetation,
'j
i
i ,
4
Privy (locate on site plan): I
Materials of construction: !
k
u .
Dimensions s;
Depth of solids
j
Comments (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
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I.
a + ,
t
t5ins•3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
lil •
i
Commonwealth of Massachusetts
Title 5 Officia�'I Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner Owners Name
information is
required for every Osterville 0 MA 02655 5/4/15
page. City[Town I+ State Zip Code Date of Inspection
D. System Informati6h (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:
v �I
® hand-sketch in the area below
❑ drawing attached separately
4
Piro
v tit
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lt4 s7
fS -7r
7s
� 78
/ 7Y
t
s
E'
15ins•3/13 li I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
4 Title 5 Official : Inspection Form
Subsurface Sewage Disposal;System Form -Not for Voluntar
y Assessments
it
47 Caillouet Lane
Property Address
John & Barbara Blaze Trust
Owner information is Owner's Name
required for every Osterville !. MA 02655 5/4/15
page. CitylTown b State Zi p Code Date of Inspection
ti.
D. System Information.(cont.)
Site Exam: �h
5•
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
I;
Estimated depth to high ground water: 12.5'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on recprd
y . .
If checked, dateof design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
i'
® Checked with local Board of Health -explain:
Topo and water contours map
❑ Checked with local,excavators, installers-(attach documentation)
❑ Accessed USGSdatabase-explaln
You must describe how you established the high ground water elevation:
water was observed at 12.5'at test holes when installed
i
8, .
l;
r.
Before filing this Inspectiorr'Report, please see Report Completeness Checklist on next page.
i!
t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
h
Commonwealth of Massachusetts
Title 5 Officia![ Inspection Form
Subsurface Sewage Disposal:System Form -Not for Voluntary Assessments
47 Caillouet Lane
t+
Property Address i
John & Barbara Blaze Trust
Owner Owner's Name
information is
required for every Osterville ' MA 02655 5/4/15
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist ,
® Inspection Summary: A; B, C, D, or E checked
Inspection Summary D;�(Sy'stem Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
1 :
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
ti
• 1`
•
• e
t5ins•3/13 I' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
-#4"� 1 41 el 9- Z
LOCATION SEWAGE PERMIT NO.
(yo` LL OU
V I L L A G E
6 � r ✓ I Atl +l ®qB 0®Z
INSTALLF. R'S NAME & ADDRESS
BUILDER OR OWNER
I
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED f-Z'Z Q`
i
1 y,�
• / y r
No.. ..__.3�- i I ` Fss........ .........
•M , •THE COM ONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... w/V.......OF.... 9, .vsT .4'-..
Appliration for Disposal Workii Tattstrudiun jrrm t
Application is hereby made for a Permit to Construct (tXor Repair ( ) an Individual Sewage Disposal
System at:
�'�giLG�.Y✓��? �/-�i►��' G�T�7Z 1�iceC �T'��
�,r a DLLogcatioZAddress or Lot No.
................"T..........................._.......................................................... ..-----...------.......................... --.....-•----------.....................-----
Owner Address
.....---•------•............................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............. ........................ Attic ( ) Garbage Grinder (�f
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................... ...
W Design Flow.............15a. .............._......gallons per person per day. Total daily flow............s3v................•....gallons.
G; Septic Tank—Liquid capacity. gallons Length._4. ...... Width..¢6..__. Diameter_............. Depth.S. ....
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--___•_------____.---sq. ft.
Seepage Pit No........�________- Diameter....�'`x'--------- Depth below inlet..._..3.......... Total leaching area..;.Ie_!.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by.__.0 ............... Date....i�AJV81!----------
.
W
,.4 Test Pit No. 1_ ._ -.._.minutes per inch Depth of Test Pit---- 4`Q_.__... Depth to ground water........................
fXq Test Pit No. 2..5L .._.minutes per inch Depth of Test Pit.... .".. Depth to ground water.........
pa ....................•--•------------•---.............•..------....--•----•----................••.---........•-•••-•••--•-•••---••--................---.......
O Description of Soil........0.:..lz....................................0 , -........ sv#
cs
y S „ �_ Z ✓Zc..
�.vC S47--,0 Z- . �-a��•.�i� r---�ir,..b......V : 1.�Q. .... ._.... F �
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
...-•--•----------------------------------------------------------------------------------------•--------------•----------------•--•--•-------•-------•--------------------------------...------.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een issued by t and of 1
S . -- - -- ---------- --•- ----- ---------------------•--•...-•--
.
Date
Application Approved By--•••-•-•-•-...�------•--- ..._�..: th.......................... --------- l- 9.5
D e
Application Disapproved for the following reasons---------------••----•-----------------------------------------•------------•---•-------------------------------
•-----------••••--••................•--..............--------...--••--•-------•-.............•--------•••••....-•-......----------••------••--------••-•-•-•----•--------•--••------••--------•.........
Date
PermitNo... = a.Z.............-_._ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..70Irv�/------oF...f3l�.r�.c�sr�1 ..-----------------------------------
Applirtttion for Uispnottl Works Tonstratrttnn Prrutit
Application is hereby made for a Permit to Construct k ,.}' or Repair ( ) an Individual Sewage Disposal
System at:
LovGG-.. �/ iG. G5T4?z�/ic tG.....................................40T
..... ......... ----••• ---•-------------••------------•--.........._---•--
/� Location-Address or Lot No.
...... .." .L .z L.............................................. -------------•-•-----•--•-•--• -•-----•--....._....._............._...-•----.
Owner Address
-----f hF:.... - --------------------------------•--------- ------------......---------------------------...-------:..------------------------•---•---.._.....
4.4 Installer Address
.-Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic Attic ( ) Garbage Grinder (L..-�
'C14_l Other Type.of Building No. of persons............................ Showers — Cafeteria
Other fixtures ..........................................
W <' Design Flow____._:___�� _________________________gallons per person per day. Total daily flow_......___30________.____..._____.gallons.
7W Septic Tank—Liquid capacity!SQ .gallons Length.h!�'�__.. Width.' ....... Diameter................ Depth4::`6"
x Disposal Trench—No. .................... Width.__........_...... Total Length.................... Total.leaching area•____---__•_--I......sq. ft.
Seepage Pit No.......Z.......... Diameter----/^a.......... Depth below inlet.....J_........... Total leaching area.&74_(.__sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by....cr'l�V.G:.__ ................. Date.../_-?A-191—............
aTest Pit No. ......minutes per inch Depth of Test Pit._-/ ?:_:=____ Depth to ground water.......
{i, Test Pit No. 2.5.Z-__••minutes per inch Depth of Test Pit... __'..... Depth to ground water.___....:.":__.__-____
PG ....................................------•----..........------------.....-••-...----.......-•---•--.........................................................
0 7 �p/�Y �i ss
Description of Soil----•--�----1�:.-•-----------=-�--��----T??�C�..�a!�=---------��---"-5�'--------*S-G�',,`-!�- --� ----�5•�.�.:,FacS..�.
x �?......Viz¢............................................................ G /�7cs' G z'--------.1_ +_:'-..� Tis✓G:..__Stz...
U
W
VNature of Repairs or Alterations—Answer when applicable._..............................................................................................
...-••-•-......----•••-•--••-••••-...•-•--••----••-•--•-.....---•-••.--•----••••••--•..............••••...••-•-•---••--••-•-•--••-•---•••--•---•----•-•---•--•••-•--••---•-•......•-•----.......__-••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI:j 5.of-•the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by t oard of '
Sig .,
Date
Application Approved. By..... •..... . . . .. . r0,___- ..... _t_r..............
.............. --------
D to
Application Disapproved for the following reasons:-•-••-•-----••••••••••-•••-•--•-••-••-•••-•-••••--••--......••-----•----•......................................
......................................................-..................................................................................................................................................
Date
Permit No...... / '� ' _ Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............7�4"0/ ...........OF.... •-' �.:f .Ti 'G ..............................
�rrti�irtt�e of f�ua�t�littnr�
THIS IS T CERTIFY, That the Individual Sewage Disposal System constructed ,(.'j or Repaired ( )
1r t } I Installer / -
t .:
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod as described in the
application for Disposal Works Construction.Permit No.........< -j... ........ dated......6_. _. .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
r r
DATE.................1 13 es.--•---------•---------------------- InspectorA........ " ..............................
r THE COMMONWEALTH OF MASSACHUSETTS
�ti
a BOARD OF HEALTH
k
......��. . .........OF._......�/�z�t,/..... ..............
Now
�--'-•-•-- x FEE........ .n..........
x
'Piaposal Norks .Tonstructiall "Pamit
Permission is hereby gfanted....................
------------------------------------------------------••----_.._--_-...---------...... ---------
to Construct (� or Repair\) an Individual Sewage Disposal System
atNo................................................----------------------------...................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No. "-�__r 1�-Dated.._,-.��/I.a)t
•-"'•--•••..........
Board of Health
DATA 1✓�� �. AA y
FORM 2551 A. M. SULKIN, INC., BOSTON /'"^'�.r��G'1C•� y rnwST ;E-. T_ c^,r.A,51F /�IJRJ
EDWARD E. K ELLEY
REG. LAND SURVEYOR
CUMMA4UID, MASS.
02637
TEL : (617 ) 362-2266
December 23 , 1985
Town Of Barnstable
Board of Health
Hyannis,lilass .
REF: Lot #. 14
Cailloulet Lane
Osterville ,Mass,
John Blaze ,Owner
The Sewage System that was installed. on Lot # 14
conforms to the elevations shown on the submitted
plan and the location varies only slightly. The
system conforms to the Town of Barnstable Health
Regulations and Title V.
X`kk OF�P�%S�C'
o� E4�WAR �G
j' E.
KELLl-Y
20
Reg. Profdsslo �' °' Q
. ��ana yor
Permit Number: Date:
fr Completed by
®`�e .HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Ca l� Lance U, _69 Lot No.
Owner:
_ Address: T5�/` M-6
Contractor: Address:
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. . . . . . . ... . .. . . . ... . . . . . . . . . . . . 2/Co .
date
STEP 2 . Using Water-Level Range Zone '
and Index Well Map locate
site and determine:
A) Appropriate index we]
B) Water-level, range zone � . :�. . .
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
water level for index well . . . f
mo y r
STEP 4 Using Table of. Water-level
Adjustments for index well
STEP 2A current d&pth to
water level for index well
(STEP 3), and water-level
zone (STEP 2B) determine-
water-level ;
adjustment . . . .. . . ... . . . .. . . . . . . . . . . . . . . . . . . . . . . . .
STEP 5 Estimate depth to high water
by subtracting the water- 1
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
l
-BLAZE ,
RESIDENCE x
47CAI LLOUET LN'"
7 OSTERVILLE,MA bk55
A 1+
f R s
' - 100 l^ca2
�oTt:s �;LOOD P.al
c',.EYATION .7
i. ALL°ROPERT'f UNa &ND 's TED
'.IT-- IN.OR\\1TtoN 1vaS TAY-cti iR,4,\1 a ?11.N 1Q
P2EP&a_-O Fjf CAP% CO'D l.=4aY !A>�'JLTANTS, .. \ -
DARED OCT.IS,19b1-
2. ALL \V021. y.IAti... 6E PER--OQMEO M �bTRIGT
OA\PLIAN6E \VITN TUE bARNaTAC`E N \�
7
�. AI-L Woo SLIALL bE PE2pOaA%D 5TalcT
COA\"UaNCE \V7-LI I 2a¢N6TAPbLE TAbI;NCa
BITE PLAN iNDIGOS'— ONLY APPQOXIAWT-
UXATION OP FAWE ..\VOIZVc. PlaloR TO PRoCeEOINC-� / \\ \ \\ \\ . . .
``VITLI ANY P2oJEGT NORK (O-Ott.7lNA7c /.. \ \\ \ \ \
ACUAL EXTEST OF SITS CLEARINU AND Ac1UAC
- LOCATION OF ALL SITTE \VORIL,LOL IumoASLON
6E\VACaE D"0O,AL co SIA\I L tAwizov&
A\ENTS WITµ ADCµITE�7 AND PAYE SAME
DZ/PFW-r LAID DDT 4ND yAK.ED Pzr .AW5'P
_REU15TEV-D LAND..SURV°YOR. .. I—b�MAU R" O1A:KORp�r}T
4. --mA\GE DY'�P.05AL -JT`3TSM 1_4ALL ba AS r�T 51DE Cr.CAI LLOULET
INDICATED ON T}.II^-> DPAVINEa, D("oYaNED AND A-HS 07'tYOITC IOT J¢
E -OJPFn ETf E4.U5 $TWULIN,�IHG. ._'.18.9SI. �1`�3(\
5. PaIOR
O-7.OG-c£DI\I."-a \V1113 ANY c,ITL\NORK
COK'RppGTCQ 444ALL DIC N'\V Ob.,E.2VA7I�ON PIT
IN C.L09E PROX AU tY RJ OR;GLVPI_ _ST
PIT P3 TO r)ETE2N\INE ACTUAL 6ZOUNDNATER
LEVcL AWD NOTI P-r SL.I� 4 74JLIU,INC.
ACL02OI NChLY.
Cm I.G.
SIGN PIT.
N10 1,'EL
\ BUMP T ARE \OF
SCRE PIED
POP-
EXPgN toN
i 72 C�aa' LOL1 .mP/.La s+Tu _ 3 J @"i.Vj :�D \ ,� sx
EL.:19 92
q �
.HOU6 /
, . MART 1 N Y
F f'
DESIGN
61 7 • 2E33 . 4104
PROJECT NUMBER:
rT: O�?i � \� .. RESEKVE � .(�+`ub •r/. i. :cr d /�4 / / / / � / DRAWN BY:GM
wAap
DRIP:\YaT p� .."� � :� I _,y /.• h 'R'�'tr / j�aUPso� TE/ �£✓:N _.s.5 ' G
ROA`TVA7 DATE.13 JANUARY 2015
' W
r
1
Op
' \VETLAND
>ITE PLAN I� _
TITLE .
SITE NORTH BLDG NORTH. - SITE PLAN
e
0
EXISTING SITE WITH AREAS OF HOUSE ADDITION SHOWN SCALE:?°=20'-0°
BLAZE ;.
RESIDENCE
,,47 CAILLOUET LN ,
OSTERUILLE;;MA 02655
PEN WALL FOR
NEW WINDOW
REMOVE EXISTING WINDOWS
AND DOORS QrGP:
oB os +z FOP=;�Fj
LIVING ROOM ROOM DECK �Q�i nj1
R-D p COUPOSRE OECR
REMOVE EXISTING SCREEN
PORCH AND ROOF,WEST
WALL TO REMAIN FOR INFILL
REMOVE KITCHEN CABINETS, / / //
FIXTURES AND FLOORING.
TEMPORARILY SUPPORT
/j/�/�/j //
EMOVE EXISTING FLOOR ABOVE FOR WALL //
WINDOWS REMOVAL AND INSTALLATION /
___----- Vo OF NEW BEAM / //� '
M.BEDROOM
Wpp�gpp / /. /SCREENED PORC
CLOSE '
/ r
'A ROOM_;XTGURES,
FLOORING,DOORS AND
souTH WALL /'/I// r / ��/ i•/ %� �„ r//,,./'i
�IED
ON MARTI NY
DESIGN
l l 617 293 4104
PROJECT NUMBER:
PEN WALL FOR/ � WINDOW
/ NEW WINDOW DOORXN AND
WIN WINDOW FOR
P PORCH NEW S1NNE %': / // DRAWN BY:GM
/'' / / / / REMOVE CLOSET
DOORS.SHELVING
AND WALL TO SCALE:AS NOTED
RIGHT DOOR JAMB
DATE:13 JANUARY 2015
r————__——___ r___—___————T r ____-I
PEN WALL FOR
NEW BUMPOUT REMOVE BATH
REMOVE EXISTING FIXTURES,LAUNDRY
CLOSETS,FLOORIn CLOSET/COUNTER I I I
AND WINDOWS AND EXPAND DOOR
OPENING,REMOVE I I I I
FLOORING
I I I I I I
HATCH INDICATES -
EXTENT OF WORK
?ITLE
EXISTING"FIRST"FLOOR PLAN"'
■
EXISTING FIRST FLOOR PLAN W/ DEMO NOTES SCALE:114'=1'-G-
BLAZE
RESIDENCE ,-
47 CAILLOUET LN
OSTERVILLE,MA 02655 .
FOP=-�5
EMOVE EXSTING
iSKYLIGHTS
I
Py j 't i
/ ;
1sx
OPEN LO F PLAYROOM ———— OVEN LOFT OFFS / i// /
/ / I
Wl
MART 1 NY
EMOVE EXISTING
WINDOWS FOR NEW
DESIGN
6 1 7 • 2 EI 3 • 4104
✓/,i i/ �/ %/// / / / ///% /„i,//- / j // //%///' REMOVE EXISTING
ROOF PROJECT NUMBER:
I
DRAWN BY:GM
I
I / I
-MOVE EXISTING SCALE:AS NOTED
WIINOOWS,WALL
AND ROOF FOR
——————— NEW DORMERS DATE:13 JANUARY 2015
I
I
I
I
HATCH INDICATES
EXTENT OF WORK -------------- ---- -------------------------
TITLE
EXISTING:SECOND FLOOR PLAN'.
■
EXISTING SECOND FLOOR PLAN W/ DEMO NOTES SCALE:1/4'=1'-0'
BLAZE
RESIDENCE
W®
47 CAILLOUET LN'
OSTERVILLE,MA 02655
I
------------Q-----------u------------- —u
DECK
�06 �O6 com—E WE
LMiG ROOM DINING ROOM �I\�-'
� xowoao �ow000 Q�P:' ,
s D.
----------
SOB 1111L:—dI m-
M.WORD I 11 I I 11 I 1 SCREENED PCRCH
O
g� MASTER�CLLOSET �04 i.SX' -
KROn I -
II /ll Ill 111 III I I
---------�. IIIi1l1111LL1 r1 - I I
—J
m .FRRY'S CLOSET BEDROOM ENTRY ————————
0 MG �ow�o
HANGING ——on MAR,
F2
S.D. I N Y
RuI} 11 u_ NG Tu ® O 0 s
`II III 11I \II ill VI SHELVES SHELVES + S.C._ I I I I I I REAR HA D E S I G N
o renreoxaao 6 1 7 • 283 • 41 04
\ / y-4 02
21. W/O ^^9 PANTRY _ - PROJECT NUMBER:
6`g FRONT PORCH
SHOWER Ea SforvE y� DRAWN BY:OM
/ M BATH i E
/ \ _ POWDER
/ G - niF SCALE:AS NOTED
BENCH FAIY FAIT
❑ ❑
DATE:13 JANUARV 2015
r—_---__-----I r-----------1 r-----------1
I I I I I I
I I I I I I
I I I I I I
I I I I I I 1
I I I I I I
1 I I I I I
I I I I I I
I l l I l
TITLE
RENOVATED�1 ST FLOOR PLAN`::.
Al al
a
RENOVATED FIRST FLOOR SCALE:1/4"=1'-0• ,
BLAZE
RESIDENCE '..,
M �47 CAILLOUETLN
OSTERVILLE,MA 02655
------------------------------I
I
I
----- ------------ ----------------- N\\�'
I
NEW CEILING ciO•��31
RAFTERS TO r�CJ� 11
CREATE \✓j
CATHEDRAL
CEILING IN LIVING
ROOM
'REPLACE EXISTING
AWNING WINDOW .
WRH DOUBLE HUNG
WINDOW
I
1 sx•
---------------------------
I O� CUPOLA 202
OPEN LOFT��LAYROOM /' `\ ABOVE OPEN LOFT OFFICE
— — I
on
NEW WINDOW
NEW WINDOW
t
_ I o EH _f MARTI NY
`X' DESIGN
I I F ~ 4
b s a s17 . ZE13 4104
3•-1'
PROJECT NUMBER:
IL
NE DORMER KET DRAWN BY:GM
———————
L J i SCALE:AS NOTED
I
DATE:13 JANUARV 2015
---------------------------------------------------------
I
I
I
I
I
TITLE.
RENOVATED 2ND FLOOR PLAN:
Al
2
0
RENOVATED SECOND FLOOR PLAN SCALE:11 =I-D'
BLAZE �;;
R'ESIQENCE
s-
u,®
47-CAILLOUET LN
OSTERVILLE.MA 02655
wvn:o io osrs
sonor,sa�mm:.• oc+o awvoa*�vs.
or 1T.n wrmours
a _ _ Ch —Zi— =�====
't�'
Pg
s:.
ua
I
I
I
1.5x•
I
N �
I
\J °� MARTI NY
/ DESIGN
61 7 • 263 • 41❑4
PROJECT NUMBER:
V' DRAWN BY:GM
4 g \ SCALE:AS NOTED
n ❑
DATE:I3 JANUARY 2015
I I I I I I
ixn Roos � I I I I -
I I I I I I
I I I I I I
I I I I i I
I I I I I I
TITLE
'- RENOVATED,IST FLOOR.PLANsi
i'
e
RENOVATED 1ST FLOOR FRAMING PLAN SCALE:1/4"=1'-O"
BLAZE f
RESIDENCES X `
M 47 CAILLOUET LN
� - 2 6�•
'..OSTERVIL LE,MA 0 6 5..:�
._ .. 1Al
i
-------------------------------I
- I
-------------------•--------
NEW CEILING SJ�O�11��1
RAFTERS TO
CREATE
CATHEDR AL
CEILOYG IN LNIN G
ROOM
III
I
NEW LYL BEAN TO
SPAN NEW OPENING
IN KITCHEN WALL
I i NEW WALLS 0 I
\ —_
I I _ tsx•
I
I _ _
I on I
I I
I
I
MARTI NY
I
DESIGN
0 J;,
617 • 263 4104
-L Li I
I
PROJECT NUMBER:
a I
5 5 a
DRAWN BY:GM
I
I
Iyaxwa+nc Fl.00a1 SCALE'AS NOTED
Mro �ooa AUTn DATE:13 JANUARY 2015
-—————————————— ————————————————————————————————————————————\—
TITLE
,RENOVATED'2ND FLOOR PLAN
r:
Sl m2
a
r �
RENOVATED 2ND FLOOR FRAMING PLAN SCALE:
a
i EL ��•S�,
TOP OF FOUNDATION
+ CONCRETE COVER f
CONCRETE COVERS
4"CAST IRON 2"MAX.
OR SCHEDULE 48 4 «~ / `•
P.V C PIPE SCHEDULE 40 PVC (ONLY) 12"MAX
PITCH I/4"PER. PIPE - MIN. LEACH r
PITCH I/4-PER.FT PIT PRECAST
° QJ LEACHING
INVERT c9 PIT OR
EL. /~-`j INVE T INVERT p
SEPTIC TANK ;�.A DIET. , - ; • 41 �;; EQUIV.
P
EL.. - BOX EL. ,>x �
��
,.. ELNVEt /`:roc GAL INVERT INVERT w W 3A TO I V2
_ EL14 ;/ o WASHED
w STONE
v,' ' '• i� ri% J ,;' I
i .9
PROFILE OF GROUND WATER TABLE \ \
SEWAGE DISPOSAL SYSTEM Herr :r&v </16N -
wnrrr� Ga�vF'z. 11
NO SCALE aa►+P4,TA-naw+S.
p
�Ro eY TY' /.s leae�r6�a 4
SOIL LOG WITNESSED BY : EE�Iv� '�• ''''� '� �~
DATE 141 !>/ TIME ,„/ N G/FJ pd+ta BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 v ENGINEER ~ \ \
t I/7•/u
ELEV (L 8p. ELEV. . . `
DESIGN DATA
Sre.iN�. NUMBER OF BEDROOMS ---.
i
TOTAL ESTIMATED FLOW . . . . . . . . GALLONS/DAY
�;;,• ;�„/,, .;�Q BOTTOM LEACHING AREA �`:S� :� . SOFT. /PIT, P. � �,,� •
SIDE LEACHING AREA SO.FT./ PIT/329 8
GARBAGE DISPOSAL y!� (50 % AREA INCREASE)
TOTAL LEACHING AREA S?/ �- SO.FT
d _
PERCOLATION RATE = '�`''` 'Wr MIN/INCH
WATER ENCOUNTERED
LEACHING AREA PER PERCOLATION RATE
l ,o �!; y �t�.
/ - y NUMBER OF LEACHING PITS
APPROVED / 4G "T
BOARD OF HEALTH . .
OAT
t
AGENT OR INSPECTOR ��� 0
Cq
\ t
,r4 S
N \ ! `
i .f
AAviLC
jr
/ F
Jar
f A``
I �O1V Mq c EDWARD ��S `�' n^LE.
ti
KELLEYmi I J� ` r ,F �,•� / % ;i
No.26100 v,
O
CISTEP
q
l ►'b, ti c s u;�v F�..w�
4.. .. • tire¢
YY VV 1 ._T i