Loading...
HomeMy WebLinkAbout0073 CROSBY CIRCLE - Health 73 CROSBY CIRCLE OSTERVILLE / A= 116 - 017 7 o i ,�� � 7 r NO. v � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for �Mpoga[ 4psStem Con.5tructiou Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑.Complete System AIndividual Components Location Address or Lot No. *73 0;tw4o-f L'�R. VS r Owner's Name,Avress,and Tel.No. PJit,tTTO1V$ �3Y1t1 C•R�X$y Assessor's Map/.Parcel 1 1 lip dS —2y l LCic" Installer's Name,Address,and Tel.No. $102�77'"� Designer's Name,Address and Tel.No. R495v a ova. eZ s. �.E� NIX Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 D tTT(b'T- TES 6N So'n e. SNs-ftec. Naw k-uv D-BBC cad lLiSOR Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date y' Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. ' Date Issued � No. � , } '; ...Fee Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN*OF BARNSTABLE, MASSACHUSETTS Application for Di!5po,!5-al i, 4tem Construction Permit Application for a Permit to Construct O Repair X .Upg ade:� ) Abandon O D Complete System Individual Components Location Address or Lot No. -7 3 R�s �( t p—., Owner's Name,Addre s,and Tel.No. ; r�$t'f T�ri1 k.A3YttJ Assessor's Map/Parcel " '� ( '�, _ P t/ Installer's Name,Address,and Tel.No. ©* ' ><`7? Designer's Name,Address and Tel.No. Type of Building: r Dwelling No.of Bedrooms 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 s Type of S.A.S. r Description of Soil j , Naturoof Repairs or Alterations(Answer when applicable) ���P[�-�- a V ®N L= C- N1� Date last inspected': Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in lx � accordance with the provisions of Title 5•of.the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar -If-Health. -� .r Signed Date � -_ Applicatiorr'Ap rp oved by �l 3 Date 2 Application Disapproved b Date )' for the following reasons Permit No. Date Issued _,i"+�'•"{So�""-" — .ter -�T-`j•'�r�h +^ft'�� � THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS x (Certificate of Compliance THIS IS TO CE TIFY,that the n-site Sewage Dis 1osal System Constructed ( ) Repaired O Upgraded ( ) Abandoned( )by Kop>Eji ca at - i vCd6 fit{ t ac has been constructed'in accordance with the provisions of Title 5 nd the for Disposal System Construction Permit No. dated Installer kooa r ` a Designer N A #bedrooms Approved de si n flo,` IA � gpd The issuance of this `er mi shall.not be construed as a guarantee that the system w 11 fuQliodn.as desined Date - o y� Inspector ———No_� / � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS Digogal �&pgtem Con!6tructton Permit Permission is hereby granted to Construct ( ) Repair O Upgrade ( ) Abandon ( ) System located at *7 3 (2P IP-S-8S C t as described in the above Application for Disposal SystemConstruction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must, e co 4eted within three years of the date/of this permit. i Date i � * � Approvedya `� �f� trkl �i vP 2 Town, of Barnstable saxivsrABM A b� ,�� Inspectional Services Department rF8 MA'S A Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code§360-44 and Title V: 310 CMR 15.000) An"x" marked in the o is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool. ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone l to a public well ❑ A portion of the cesspool'is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally-passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the'invert pipe (per Town Code §360-20 h) O ER go - (�A(/ � e e lA r � �' !c�� fy In Z �!r!il/c k Repair deadline: WSEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 4 Commonwealth of Massachusetts Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 73 Crosby Circle Property Address , Britton�Name Crosby_ _ r Owner Owner's information is required for every Osterv _ — _ MA_ 02655 7-2_-20 •' _ page. City/Town State Zip Code Date of Inspection a r � 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. OF fM lIffIll Important:When A. Inspector Information filling out forms p ��� '• " '••'9p��i� on the computer, isgam; JA M ES • tiN g: use only the tab James D.Sears __ .r„ key to move your Name of Inspector — `— ---- v r.JE7f�rs ; cursor-do not Robert B.Our Co. INC. use the return ---- ------— -- -- -- — — — '•'.�'F •' key. Company Name - 363 Whites Path —---- — — — y N �►�>"` t� Company Address ------- -- — South Yarmouth —_-- MA _ 02664 City/Town State Zip Code 508-477-8877 —__ __ _S 1623 Telephone Number License Number_____------ B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. 0 Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails —_ _ 7-2-20 ector's Signature — Date ----The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts ,m Is Title 5 Official Inspection Form '= I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 73 Crosby Circle V� Property Address Britton & Rob_vn Crosby Owner Owner's Name information is Osteryille MA 02655 required for every _ 7-2-20._ _ page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ 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: Conn Pass- D Box-outlet tee. The systemis a H-20 2000 Gal. Tank D Box and two pits. Note: Outlet cover should be changed and raised. Cover is H-20 at 30" 2) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Rohn Crosby Owner - Owner's Name information is Osterville MA 02655 7-2-20 required for every _. page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ® 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): Need to replace D Box. Need to install outlet tee. ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosby Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every _._ page. City/Town— State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form ;, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 73 Crosby Circle Property Address Britton & Robyn Crosby _ Owner Owner's Name information is Osteryille MA 02655 7-2-20 _ required for every ----_-----.._--- -,.--_-._-- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than 'h day flow Ne%s ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. _ For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Ste, Commonwealth of Massachusetts �n IF Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < � 73 Crosby Circle Property Address Britton & Robyn Crosby _ Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® . ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosses __ _ Owner Owner's Name information is required for every Osterville MA 02655 7-2-20 ----..— ----- -- --- - - page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ---330 _ Description: H-20 2000 Gal. Tank D Box and Two Pit's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to:Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ®'No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c � Commonwealth of Massachusetts �u ,1? Title 5 Official Inspection Form iw � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 73 Crosby Circle Property Address Britton & Robyn Crosby Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every _ _— —_ _ __— page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ---- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): -- -- - --- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: - -- -- -- Industrial waste holding tank present? ❑ 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 below): 3. Pumping Records: Source of information: 2016 Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? - -- Reason for pumping: - l5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 o'18 i� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosby___ Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every ---_------------- --- ---- -- page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval, ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 Permit#86 -796. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): � Depth below grade: 40"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.): Pipeing is 4" PVC SCH _40 & SCH -20. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form -F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 73 Crosby Circle Property Address Britton & Robyn Crosby —_ Owner Owner's Name information is Osteryille MA 02655 7-2-20 required for every --------.---.-- --- - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 30" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal. Precast H-20 Sludge depth: 3 - Distance from top of sludge to bottom of outlet tee or baffle NA -- -- Scum thickness 2, --- - Distance from top of scum to top of outlet tee or baffle _ NA Distance from bottom of scum to bottom of outlet tee or baffle NA_ -- How were dimensions determined? Asbuilt-TapeSludge Judge____________ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): H-20 Tank at working level. Tank and outlet cover at 30" below grade w/inlet at 9". Note: outlet cover H-20. Inlet tee w/no out let tee or baffle. No sign of leakage or over loading_ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosby T _ Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every _. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: --- - Scum thickness -- --- Distance from top of scum to top of outlet tee or baffle — 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 related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: -. - gallons per day 15insp.doo•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosby Owner Owner's Name information is Cisterville MA 02655 7-2-20 required for every -- --- -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -0- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16"-42" below grade w/two lines out. Wall's are gone on box. Need to replace box. t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts I Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >r� 73 C rosby Circle _ Property Address Britton & Robyn Crosby _ Owner Owner's Name information is Osterville _ MA 02655 7-2-20 required for every - -- - -— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields ' number, dimensions: ❑ overflow cesspool number: - ❑ innovative/alternative system Type/name of technology: — t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Ip Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 C osby Circle Property Address Britton & Robyn Crosby Owner Owner's Name information is OSteryllle MA 02655 _7-2-20 required for every -- ---- -- --- - - — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pit's. Pits at 40" below grade w/4' stone, one pit dry w/other pit 1'water. Dry kit due to D Box. No Sign of over loading. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 "IN Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosby __ Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every -- .— -- --- — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. J t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I_ C Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Crosby Circle Property Address Britton & Robyn Crosby Owner Owner's Name information is Osterville MA 02655 7-2-20 _ required for every -- ----- ----- - --- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 R 0 R� f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 73 Crosby Circle Property Address _Britton & Robyn Crosby Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every — -- - - — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 20' 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 record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Lot Higher then abutting property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Crosby Circle u� Property Address Britton & Robyn Crosb ram__ Owner Owner's Name information is Osterville MA 02655 7-2-20 required for every - — - -- — �- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: E A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included L A /6U t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 1�_ >I TOWN OF B.ARNSTABLE IACATION ,;?3 SEWAGE # VILLAGE �S%��v i � ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO2�,y 7s/ -7 a r SEPTIC TANK CAPACITY a O o o 61 LEACHING FACILITY:(typef �L- 9c y ,�iT� (size) � NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER U W i 7 7 oA-1 C 0.5 d DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: - I .7 VARIANCE GRANTED: Yes No �- :�:. C/��.si.3% � i/�c a �� `� � ems. i �i ��� t Y N W e �t7 L.w v�lit� ir.n�r ILV: No 66 'ARCEL N0.: THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ----F-. ---- ..... OF....... ��..1.'.`T.NL�,.:. .......................... �o�� ApplirFation for DispA�aal orks C�nnstrn.rtirrn ramit \\� Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at 1Lc�.e....11,�;Lpm ue.............................. Location-Address or Lot No. .&7.dt",tan--w--..L..RDhryn..R-....C.Las.aY------------------------------- --------•---•--------•--••------------•------------------------------------•------•-••---•----•--- Owner Address a ......................��..�..-•--•-••••••-----•----•-•-•...........--••••••-•-- -•-•..1.4B--•A>L).aWh=d...,.#c L e d� ......................... Installer Address dType of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms._._.___�... ?A ��___ xpansion Attic ( ) Garbage Grinder ( ) Other—T e of Building o, of ersons_________________________ Showers — Cafeteria a —Type g ••--••--•----•-•--••-- P ( ) ( ) Other fixtures -------------------------------- - --- ........•---•- W Design Flow............................................gallons per person per day. Total daily flow----........._..............................gallons. 9 Septic Tank—Liquid capacity2o_,?.'Jallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No--------------------- Width ....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------Z........ Diameter 6�.............. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. l________________minutes per inch Depth of Test Pit.................... .Depth to ground water_---__--_____-____----. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.______-_-..._-._.____. 9 •-••-•----•---------------•-••-•............••..........-•-•-------••--•.................--•------••......................................................... fO Description of Soil........................................................................................................................................................................ x W ••---•----------------••-••----------------••-••-•--------------••-----•----•---•---•-••--..._.---••--•-•••••---••-••---••••••-••--•----------•-•--•••---••--- U Nature of Repairs or Alterations—Answer when applicable.___ _dd_a... ` _T�"! _._ ...DdO_ __. � ---..................-........................................................................................................................................................ ` Agreement: �-- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii i t:a. y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in - operation until a Certificate of Compliance has been i sue y the board of It 8-G-86 Sign . ------ ----- ---- - ----- ---------- -------•----------•• ---_i ----- . 8 Date Application Approved By---•--... ----- ------- .......... .......................... ........... 6- D e Application Disapproved for the following re ons:................................................................................................................ --•-•-•-------•-•-•••----------------------••--••------•-•-...--•---•------•--••-•••..........----••••----------•-------------•-----•-•--------••-•••--••-•----•-••-•-•--•--------•-••-•----••....._..-- Date PermitNo....................................................... Issued-....................................................... Date / I 1 6 N. ........ I L� ' FES .._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF pHEALTH . .► !...................0F......I :/.>.lS.. \.5 ..................... App iration for Biipnoal Works Tnntrurtiun Prrutit Application is hereby made for a Permit to Construct,,(/) or Repair ( ) an Individual Sewage Disposal System at 43 .......--- C._.._... - ..................•----•••......------........---- Loc t;on- r.ss or Lot No. 1�i l .........%t.•-�_... � ..._R_......------.--.... --• -------•--- "-�� -•- a �K C�e�. �-$ d Ss IR� �__g --4 ------------------------•---•------ -- s Installer Address d Type of Building Size Lot____-_------------ -----Sq. feet U e Grinderarba G ion Attic ans Dwelling—No. of Bedrooms..:______ ' ' __________________Expansion ( ) g ( ) pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-__-__-___-_ Depth................ x Disposal Trench— �?o..................... Width....... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..._._..._a7-.._.. Diameter-----...10...... Depth below inlet.................... Total leaching area_....._....:......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY........................................................................... Date........................................ W 4 Test Pit No. 1................minutes per inch Depth of Test Pit..................__ Depth to ground water...................... 1-4 ;%I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ------------------------------------------------------------------------------------•------------- ----------- •......................................................................................... ODescription of Soil........................................................................................................................................................................ W U ---•-------------------------------------------------------------------------------------•-•-•----•---------------•---.....---------------------•-----------------------------•-------•-•-•----------- UW ----••••-•••......................••••-•-----•------•-•------•------•-•.._._..-------•-------------•---••----••••-•-----••-•----•••----------- .........,..........t Nature of Repairs or Alterations—Answer when applicable____ ... ---..._. __fl ............................ ..-- ••--------------------------••----•-••-----•••----••--------•-•----••••-------..........-----••--•---- L Agreement: q- -� - �A_Q_ The undersigned agrees to install the-aforedescribed Individual Sewage Disposal System in accoance with the provisions of'TTL E of the State Sanitary Code— The undersigned 'further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sigtied..................-•-•---�-.--.-,-�--n---.-.-------•--•-------- Date .DAPPlication Approved BY " ---.....---- -- to Application Disapproved for the following r ons:-------••••-----------------•-••--------••-•------••------------•------••-----....•---••......-------••---.----- ..--------•-•••..............•---------•----------...---•-------••-----......-•-------.......------....--•------------------•-•-------•------•-----.................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (......:... .. ...........oF.....:.... ; I`'...:+ V ............................ Trrfifiratr of Tuutplianrr THIS IS TO KTI-E-Y, That the Inaivi ua Sevaa e,D" osal System constructed ) or Repaired ( } (.� .l � -- � —� Installer.. at �:� ----------------------•- has been installed in accordanct with the provisions of T T TIE j 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 HE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... Z.-_. ...S-7---_------------------------ Inspector....----, D. _3 ........................... r THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD ,QOFF(HEALTH 7� .............OF.... U\•(n--: .4�.�..!...1..t,.a. ._............................. FEE .... Disposal �jjrk QUuns#ruan rrut' Permission is herebyranted... __._d '�..C' �- i 0C g -------- . ••---•••-•----•••-•••---•-•--•-••-._......-•--•• ....----•................•.••••- to Construct ) or Repair ( ) an Individual Sewage Disposal System ' Street at No.------�-• .........4-1 I......... ............ `.� U� l-l.�--- as shown on the application for Disposal Works Construction Perm' No.....................� ated------------------------------------------ ...........•- `..... - Q v -------------------•------•------•----------- Board of Health DATE........... ---�• --� FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS L _ �