HomeMy WebLinkAbout0080 CARLISLE DRIVE - Health 80 Carlisle Drive
Osterville
A= 122 - 130 /
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i
No. Fee &0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pplication for �Digo$aY *pgtem Construction Permit
Application for a Permit to Construct( ) Repair X) Upgrade O Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.96 COAL&IG bfL Owner's Name,Address,and Tel.No. -75�s -ZRj'Z&5
Assessor's Map/Parcel 0 b6 C'6Q \5LE b�L 05WVQ\L"
Installer's Name,Address,and Tel.No. 5o%— 5— %(p(O Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms U/1 10 Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure nstruction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title f t e Environmental d and not to place the system in operation until a Certificate of
Compliance has been issued by this d Hea
Signed Date ;�--
Application Approved by Date
Application Disapproved by: Date
for the following reasons
——— Permit No. dol�- Date Is
- — 26 c———
—
————----
sued -�
No. ?r�7 1 Fee /dam
'tEntered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYtcatton for Migozal. bpztem Cowaruction Permit
Application for a Permit to Construct O RepairX) Upgrade O Abandon O ❑Complete System ❑Individual Components
Location Address or Lot No96 CNIaXL\SLC b(L Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 1 _ Q �jv C(\1USLC 612 OS_-V&LL4 '
Installer's Name,Address,and Tel.No. >�O�_-�-t5_ )�( (� Designer's Name,Address and Tel.No.
()NE 6uatjki-
1 Type of Building: _
Dwelling No.of Bedrooms b Ik2 Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( . ) Cafeteria( )
Other Fixtures
i
Design Flow(min.required) gpd Design flow provided gpd
' Plau .Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) LAC
Date last inspected:
Agreement:
The undersigned agrees to ensure E construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of 1 of t�e Environmental de and not to place the system in operation until a Certificate of
Compliance has been issued by this .o �d �f Healt
-�'� !
Signed Date
Application Approved:bye Date Y`
17—
Application Disapproved by: Date
1 for the following reasons
Permit No. �00 7 _ �� Date Issued 1 v }
- a,--r• THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS -
-�ox Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (✓ Upgraded ( )
Abandoned( )by ULAP..1�-�lr4-c_r �C�C a12 { V fl)1 Q
at 9=D Cws� 0'' r. , has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. a00 7-1 dated 6 ,�
Installer ��vr w� � /(Xwe beiv�li� Designer
#bedrooms Aj Approved design flow gpd
The issuance of this permit sha
llnot be construed as a guarantee that the system -i l functions ass/d�esigne
Date /I Inspector
----- ---- ------ ---- `- ------- --
No w Fee /00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
lwigoml *p!5tem Con5truction Permit
Permission is hereby granted to Construct ( ) Repair (✓) Upgrade ( ) Abandon ( )
System located at yd ('e-_r�,'s v
and as described in the above Application for Disposal System Construction Permit.The applicant reco�izes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction mu t be completed within three years of the date of t ' pe it.
Date ( � Approved by
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Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 16, 2007
Mr John O'Hara
48 Balson Drive
Zalatie, NY 12184
ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5
The septic system located at 80 Carlisle Drive, Osterville,MA, was last inspected on
June 4th 2007,by Jason Burnie, a certified inspector for the State of Massachusetts.
The inspection of the septic system showed that the system"Conditionally Passed"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
The D-box is rotted and need to be replaced.
You have,2 years from the date of the system failure to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable
Health Department.
4BARNST ;HEALTH EPARTMENT
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Thomas A. McKean,R.S.; C.H.O.
Agent of the Board of Health
- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information VIA �3a
Important:
When filling out 1. Property Information:
forms on the g0 CARLISLE DR OSTERVILLE,MA 02655 '7
computer,use
only the tab key Property Address
to move your JOHN O'HARA t 4
cursor-do not
use the raturn Owner's Name y
key. 48 BALSON DRIVE ---
Owner's Address '
qu(;
4
ZALATI E NY r
City/Town State
i Code
6-4-07 —
Date of Inspection: Date
�n
cut
2. Inspector:
JASON BURNIE
Name of Inspector
D.J BURNIE & SONS bluewater holding corp
Company Name
105 FERNDOC ST UNIT A — ---
Company Address - MA 02601
HYANNIS
City/Town State Zip Code
508-775-0139
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000)'.The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-4-07 —
Inspector's Sign of Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
se'
Subsurface Sewage Disposal System Form
B. Certification (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655
Property Address 02655
OSTERVILLE MA —
City/Town
State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
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 t any failu� htena not evaluated are ilure criteria described
03 i
in 310 CMR 15.3 or in 310 CMR 15.304 exist. Any e c
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass. -
Answer yes, no or not
�determined (Y, N, ND) in the [-Ifor the following statements. If"not
determined," please explain.
❑ The septic tank ismetal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
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B. Certification (cost.)
80 CARLISLE DR OSTERVILLE,MA 02655 --
Property Address
55
OSTERVILLE MA Zip Co
City/Town
State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
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
❑ obstruction is removed
® distribution box is leveled or replaced
ND Explain:
DISTRIBUTION BOX IS ROTTED AND NEEDS TO BE REPLACED
❑ 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 pipes) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will puss unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety,and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
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B. Certification (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655
Property Address 02655
OSTERVILLE MA
City/Town
State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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.
E
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS,and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.'
3. Other:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (co'nt.)
80 CARLISLE DR OSTERVILLE,MA 02655 _
Property Address
OSTERVILLE MA 02655
City/Town State ZipCode
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 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
of 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.
Yes No
❑ ® The system fails. I have determined that one or more of the above failure
"criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure. ;
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (coat.)
80 CARLISLE DR OSTERVILLE,MA 02655
Property Address 02655
OSTERVILLE MA —
State
Cityf town Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
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.t
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
❑ El Area
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,
large system has failed. The owner or operator of any large
or answered"yes" in Section D above the
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.
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Commonwealth of Massachusetts
1
Title 5 Official Inspection Form
Not for Voluntary Assessments
• Subsurface Sewage Disposal System Form
C. Checklist
80 CARLISLE DR OSTERVILLE MA 02655 —
Property Address {
OSTERVILLE MA 02655
City/Town State Zip Code
JOHN O'HARA _ 6-4-07
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
1
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 bre9k out?
® ❑ Were all system components, 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
® El 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
El ® approximation of distance is unacceptable) [310 CMR 15.302(5)]
F
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
80 CARLISLE DR OSTERVILLE,MA 02655 —
Property Address
55
OSTERVILLE MA Zip Code
City/Town State Zip Co
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Residential Flow Conditions:
3 2
Number of bedrooms (design): Number of bedrooms (actual):
total design
DESIGN flow based on310 CMR 15.203 (for example: 110 gpd x#of bedrooms): &443gpd
0
Number of current residents:
Does residence have agarbage grinder? El Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] El Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
05= 87gpd
Water meter readings,iif available (last 2 years usage (gpd)): 06= 3 gpd
El Yes ® No
Sumppump?.,
within 2 weeks of
Last date of occupancy: inspection
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?i ❑ Yes ❑ No
Industrial waste holding tank present?
El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings., if available:
Last date of occupancy/use: Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
5 e,, Subsurface Sewage Disposal System Form
D. System Information (cont.) ,
80 CARLISLE DR OSTERVILLE,MA 02655
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
i
{ General Information
Pumping Records:
Source of information: ' NONE PER BARNSTABLE BOH
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? --
i
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1980 PER PLAN ON FILE AT BARNSTABLE BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Asslessments
iV^M
Subsurface Sewage Disposal System Form
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655
Property Address
OSTERVILLE _ MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
12"
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):
7"
Depth below grade: feet
Material of construction:
® concrete j❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
----certificate)- -------------------- -----------------------------
1000 GAL _
Dimensions:
6"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle —
4" -
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
i SLUDGE JUDGE
How were dimensions, determined?
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
a°
Subsurface Sewage Disposal System Form
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655 ---
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
THERE ARE NO PUMPING RECORDS ON FILE WITH THE TOWN SO I RECOMMEND THE TANK
BE PUMPED OUT FOR MAINTENANCE
Grease Trap (locate on site plan):
{
Depth below grade: feet
Material of construction:
Elconcrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
i
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as relatedio outlet invert, evidence of leakage, etc.):
I
t .
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):
i
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655 --
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Tight or Holding Tank,(cont.)
Dimensions:
Capacity: gallons
i
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ElYes ElNo
Date of last pumping: 'I Date
Comments (condition of alarm and float switches, etc.):
1
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
THE BOX IS ROTTED AND NEEDS TO BE REPLACED THE WALLS OF THE BOX ARE
CRUMBLING ---
Pump Chamber(locate on site plan):
r
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655 —
Property Address
OSTERVI LLE MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
1- 4'with Son
® teaching pits number: stone around
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
4
Comments (note cond i ition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
THE PIT HAD 5" OF STANDING WATER IN IT ----
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655 --
Property Address
OSTERVILLE _ MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
i
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
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.),
i -
back up 1.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA' 02655 —
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07 —
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building. I
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back up 1.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
, M
D. System Information (cont.)
80 CARLISLE DR OSTERVILLE,MA 02655 -
Property Address
OSTERVILLE _ MA 02655
City/Town State Zip Code
JOHN O'HARA 6-4-07
Owner's Name Date of Inspection
Site Exam:
Slope ycs C/0,it{l0
Surface water
Check cellar. /� S
i
Shallow wells A10
Estimated depth to ground water: )y` -t h��� 'PjAr4 ON r'Ie, c't
/SRO
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
1980
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:
❑ Checked with local excavators, installers-(attach documentation)
® AccessedUSGS database-explain: ,
SDW-2531 ZONE C 3-4 WATER LEVEL 47.3 2.0 X 12= 2'ADJUSTMENT
I
You must describe how you established the high groundwater elevation:
SEE ATTACHED:
back up 1.doc.doc•03/2006 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
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LOCATION SEWAGE PERMIT NO.
VILLAGE
(` A= 12z i `3 ® •
I N S T A LLER'S N A W A ,ADDRESS
8 U It DE 9 OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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'3 �] THE COMMONWEALTH-OF MASSACHUSETTS
3(�` BOAR® F" HEALTH
.............OF.................0.,YL.........................................................i
Appliration for Disposal Works Tonstrnrtion rami#
Application is hereby made for a Permit to Construct (� Repair ( ) an Individual Sewage Disposal
System at: --
, . ..... .. -----------------------•----
- - ----- ----- ---- -- -----
r L n-Add ess o Lot No.
...............
�••--.....--- --------- ------------------ ���.�1_. �...`�+�s..�.�Gr9..�✓.�.�
Owner A dress
.................... .....�.. ----•-• .. . ...... ............ � :.- ...... -/-__.1.. �t..
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a In al r Address
Type of Building Size LotpAo D7—e------Sq. feet
U Dwelling No. of Bedrooms.-------a.... ...............Ex Expansion Attic a g— ------•--••- p ( ) Garbage Grinder ( )
WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Oth, , 2f tures --------------------
WDesign Flow...... :.:...............................gallons per person ej jay. Total daily flow......3?D.........................gallons.
WSeptic Tank—Liquid*capacity.. gallons Length... .......... Width..Y..;!'.. Diameter................ Depth5�.&_'/.
xDisposal Trench—N ..................... Width................... Total Length..........;- Total leaching area....................sq. ft.
Seepage Pit No........ :.......... Diameter.........' . .... Depth below inlet.......C.......... Total leaching area...R4.C�...sq. ft.
Z Other Distribution box ( LK Dosing tank ( )
aPercolation Test Results Performed by...... -4--- ------------------------------- Date/Q/i.)./m...............
Test Pit No. Lj�: .n....minutes per inch Depth of Test Pit....,1.-.L ....... Depth to ground water...-->, -
0� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------------------------------------------••-...------......------.....-----•......----..---.......-
0 Description of Soil----..C?' l�a� L' .�..-•-•--Z ' ' `-•- ------•-----------------•-----------------------
x
c,
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 TITLi- 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 b the board of health.
Signed-•-•.-- .................. ...... ~
Date
Application Approved BY �:.., --- ................................ All, ° � ---------------
Date
Application IfisILpproved for the fojjowing reasons:............ .. ..
Date
Permit No._.
........................................-------•--- Issued..- ................................ r
Date #
h
.............................
'd THE COMMONWEALTH OF MASSACHUSETTS
BOARD�,?F HE.SLTH
x)
..................................j....... ...................................................................................
Appliration for Disposal Work, Tonstrurtion famit
Application is hereby made for a Permit to Construct (e-'-) or Repair an Individual Sewage Disposal
System at:
G7
R_ b
.................................... ............................................................ ..............
Loc s or Lot No.
................... ..... .................... ..D _IC_........ ....... ......
......................
---- . Address
------ --- --- ....3.. ... "�).p--------Address ;
-
-Type of Building Size "'IR11- -------Sq. feet t
Dwelling—No. of Bedrooms__.____.:::..................................Expansion Attic Garbage Grinder
Other—Type of Building ............................gNo. of persons._.___._________._.__.__.__. Showers Cafeteria
Other` tures .. .............................. .....................................................................................
.........................:.........gallons'�Xll/ ..............--------------
Flow....... . per person day. Total daily flow....... .I
..................................gallqns.
........gallon Length..e�........... Widthr-_::::.�-�� Diameter________________ DeptO...
9 Septic Tank—Liquid capacity.. S ----------
Disposal Trench—No_.................... Width_____..___._.____.__ Total Length.......... ...... otal leaching area....................sq. ft.
Seepage Pit No......j------------- Diameter......'L/........ Depth below inlet___ :__:__._._..._. _!�22.....sq. f t.
................. al leaching area.��..
-,Z Other Distribution box
Percolation Test RAQ�j Performed b ................................. Date/
y ----------------------------- -------------------------------
Test Pit No. I________________minutes per Inch Depth of Test Pit._._._.___.__._.._.. Depth to ground water ...........
44 Test Pit No. 2................minutes per inch Depth of Test Pit__.____._._.______.. Depth to ground water...____.._..___.__.__...
r
7----------------------- ----------
P4 -,A .........Z.�'
oDescription of Soil....................................................................................................w...................................................................
U ...........................................................................C...................................... ......................................................................................
.............................................................I...........................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i�. 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 be issued'Ib the d oLAeAh.
Signed.
....... .............
Sighed. .... ............... ........... ............. ..................
Application Approved By..._*_J9-X ........ . . .. ..................................... .... ...... ...............
Date
Application Disapproved for the following reasons:................................................................................................................
...................................................7....................................................................................................................................................
Permit No. I--------------- Issued_....I — 'I — I Date k" I
0 ......d ),...........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
\.........
OF.........................................
..
......................... ..................
%TWrtifiratr of Toutpliatta
THIS IS TO CERTI Y, That the Individual Sewage Disposal System constructed or Repaired
�bY.....................................................................................................................................................................................................
Installer
at.....................................................................................m..................................................................................... .............................
has been installed in accordance,with the provisions'of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated..............._....____._....____.____.________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILI, FUNCTION SATISFACTORYj .
VDATE............ji�)........ .............4........................ Inspecto* n...d�� ........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR HEALTH
......... ........OF....................................I.......I........................................
No......................... F2 ....................
Map
..........
ianstrudion "pantit
Permj&sieh is hereby granted.....do QW, T
............................................................................................................
..
to Con ( ar?RepaiR�* I bidual Sewq0,PjfZW System
atNo...........................................................-................................................................................................................................
Street
as shown on the application for Disposal Works ConstrWT57,ermit N Dated..........................................
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1'e5l a. ............ �11.01
ow .1�0 .....................................................
Board of Healt
DATE...........................................1................................... h.
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