HomeMy WebLinkAbout0002 CROSSWAY PLACE - Health 2 Crossway Place
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAItts
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DEPARTMENT OF ENVIRONMENTAL PROTECTIONF`rwF-1VED
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HEALTH KN'sTABLE
DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655 QS —6S S
Owner's Name: MR. HENSON
Owner's Address: 2 CROSSWAY PLACE OSTERVILLE, MA 02655
Date of Inspection: 9/4/03
Name of Inspector: (please print) JOHN GRACI,INC. 1
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
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. 1 am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditional . Passes
_ Needs Furtl e'r Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 9/4/03
The system inspector shall submit a c of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. '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.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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.
Titla S Incnr rtinn Fnrm F/l S U00 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
13. 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 for the following statements. If"not determined"please explain.
n/a 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 irmninent. 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: n/a
n/a 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: n/a
n/a 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
_obstruction is removed
ND explain: n/a
r .
Page 3 of I I
OFFICIAL INSPECTI
ON FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE, MA 02655
Owner: MR.HENSON
Date of Inspection: 9/4/03
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 enviromment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 n/a
"This system passes if the well water analysis,performed at'a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility 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:
n/a
f
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE, MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X An onion of a cesspool
Y P or privy is within
p p vy thm a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X 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 coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility 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.]
NO (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.
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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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
T 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.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2 CROSSWAY PLACE OSTERVILLE MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
Check if the following have been done. You must indicate "yes" or"no"as to each of the following.
Yes No
X _ Pumping information was provided by the owner,occupant, or Board of Health "
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period`? "
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X _ Were as built plans of the system obtained and examined? (If they were not available note as'N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum `'
X _ Was the facility owner(and occupants if different fi-om 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:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):-mir
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establislurnent: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.):n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO -
Non-sanitary waste discharged to the Title 5 system(yes or no):NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a "
Approximate age of all components, date installed(if known)and source of information:
NEW SYSTEM IN 00 IN FROM OWNER
'4 Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
BUILDING SEWER(locate on site plan)
Depth below grade: 22"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: H 10' 6" H 5' 7" W 5181111
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
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: 16"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass ._polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a
I`
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
II
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) ,
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
c
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
R
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
INFULTRATORS leaching chambers, number: 4
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
INFULTRATORS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO
SIGNS OF FAILURE. THEY WERE EMPTY AT TIME OF INSPECTION. BOTTOM IS AT 7 FT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction:n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
Q
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE, MA 02655
Owner: MR.HENSON
Date of Inspection: 9/4/03
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.
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 CROSSWAY PLACE OSTERVILLE,MA 02655
Owner: MR. HENSON
Date of Inspection: 9/4/03
SITE EXAM
_Slope
_Surface water
_Check cellar
_Shallow wells
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12 FT.
11
TOWN OF BARNSTABLE
L(}CATION Z � 1*ce SEWAGE # WeO- y�
VILLAGE l%✓�'7` 'T�✓���� ASSESSOR'S MAP & LOTAf--a -
4..
INSTALLER'S"NAME&PHONE NO. V'011'Ple l 69.167 Z 7/-Zy
SEPTIC TANK CAPACITY l5ev 64L
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 7 -00 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site oc.within 200 feet of leaching facility) c Feet
Edge of Wetland and Leaching Facility (If any wetlands exist ,/
wit Af
un 300 feet of leaching facility) r 114 Feet
'' Fumisaed by b
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33�
P
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TOWN OF BAR NSTABLE S
LOCATION � _ L a—SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT S
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY (1 D
LEACHING FACILITY: (type) 614 (size) et
NO.OF BEDROOMS OZ
BUILDER OR OWNER Cmc.._S Lrzr Wit 92" 4
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any'wetlands exist
within 300 feet of leaching facility) Feet
Furnished by ( �� _
6CA �3
Decl
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A to
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y — -
No. �� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Digpogar Op.5tem Construction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) L Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
k.
Assessor's Map/Parcel 05 Me
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No.
�Br�eGv��C°n�sr.
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Type of Building:
Dwelling No.of Bedrooms t3 Lot Size sq.ft. Garbage Grinder(�
Other Type of Building of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow M gallons per day. Calculated daily flow 131� gallons.
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)��`"%�` Zf Z77
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 Certifi-
cate of Compliance has been issued b this o d o Health.
Signed Date
Application Approved by Date 7--a'-Z, C-(>
Application Disapproved for the follo ing reasons
Permit No. Date Issued �'
46 No. pr°�_. �T a Fee
• F-a
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
r I UB-LIC34HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
�,. yY
0(ppYication for Miooaf 6peum Construction Permit
Application for a Permit to Construct( )Repair V
(./f Upgrade( )Abandon( ) Complete System ElIndividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 7— Ile
Installer's Name,Address,and Tel. o. F Designer's Name,Address and Tel.No. *,r
Type of Building:
as Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( �
`$ 'Other Type of Building / No. of Persons Showers( ) Caf erta( )
4 Other Fixtures
Design Flow gallons per day. Calculated daily flow — gallons.
Plan Date Number of sheets Revision TVe
' Title
Size of Septic Tank Type of S.A.S. ^_
Description of Soil
4
Nature of Repairs or Alterations(Answer when applicable)
v i
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 Certifi-
cate of Compliance has been issued by this Board of Health.
Signed _ Date
Application Approved by Date
Application Disapproved fort o in reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ,)Xpgraded( )
Abandoned( )by
at T � u� has been constructed in accordance
with the p "visions o the 5 and e r Dis sal Sys em Construction ermit No. dated r
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syst will function as designed.
Date E Inspector
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-------------------------------- -' -----
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ligool *pgtem (Con0truction Permit
Permission is hereby granted to Construct( )Repair(..,,,yUpgrade( )Abandon( )
System located at " ,;'
;
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: Approved by
WA
NOTICE: This Form Is To Be•Used For the Repair Of Failed
Se tic Systems Only: _
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUMON PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated concernine the
property located at Z G ro5 5 A✓Q Y Ac--& A*rl4lle meets all of the
foilowinsz criteria: i
}/The failed system is connected to a residential dwelling only. There are no commercial or business
,, /uses associated with the dwelling.
Y the soil is classified as CLASS I and the percolation rate is less than or equal to : minutes oer inch-
The:e are no wetlands within 100 feet of the proposed septic system
Y There are no private wells within 1-40 fee;of the proposed septic system
There is no increase in flow and/or c'aange in use proposed
There are no variances requested'or needed.
Y The bottom of the proposed leaching facility will not be located less than five feet above the.
t
ma�dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimmor
when applicable)/ethod
the S.A.S. will be located with 250 fee,of any vegetated wetlands. the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the masimuan adjusted
groundwater table elevation,
Please complete the following: ,
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation z-a—+the MAX High G.W.Adjustment.
DIFFERENCE BETWEEN A and B 371
SIGNED DATE.
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TOWN OF B"ARNSTABLE "
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LOCATION Z G �'d 33�4 1 )10Ce SEWAGE # ZOO-�yZ
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VILLAGE 6✓74-e1'-4111le ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.. C1n5l. Z�/'
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SEPTIC TANK CAPACITY 1. L
LEACHING FACILITY: (type) �- (size) /d �e)o rz�
NO. OF BEDROOMS.. 3
BUILDER OR OWNER Z�5125ef
PERMITDATE: 7 ` Z-7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist `
on site or within 2,00 feet of leaching facility) / Feet _
Edge of Wetland and.Leaching"Facility(If any wetlands exist
within.300feet.ofleaching facility) !/ Feet
"Furnished b
a,n p
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Commonwealth of Massachusetts
Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
One winter Street'Boston,Ma. 02108 .Jolui Grad
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.wELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI r
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r • ✓gbr
PART A
CERTIFICATION ,,, r5'j 26ip
,d7
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55 Address of Owner: �✓� r
Date of Inspection: 9/24198 (if different)
Name of Inspector: JOHN GRACI ESTATE OF THOMAS LARKIN �t f
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
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 inspection. The inspection was performed baled on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria defined In Title V
Conditio/allyasses code 310 CMR 16.303.My findings are of how the system is
performing at the time of the inspection.W inspection does
_ Needs Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 9128198
The System Inspector shal submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection. .
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:,
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co111pliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04n7)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1 r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124199
— Sew•acie backup or,breakout or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four 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
obstruction is removed
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate elther"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloa!IPd or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124199
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply w.F
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
r
(reYlsed 04127197)
e
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55 .
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x — None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
—x— — The site was inspected for signs of breakout.
x — All system components, excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x — The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x
Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)(15.302(3)(b)]
(revised 0412T197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124.199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0 g•p.d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: o
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy:6 MONTHS AGO
COMMERCIAL/INDUSTRIAL:
Type of establishment: Na
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings, if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) rva
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
We
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: rva
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
x Single cesspool
x Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date Installed(if known)and source Information:
1969
Sewage odors detected when arriving at the site: (yes or no) No ¢
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124198
SEPTIC TANK:
(locate on site plan)
Depth below grade: Na
Material of construction: concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age ma . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: rda
Sludge depth:rda
Distance from top of sludge to bottom of outlet tee or baffle: rda
Scum thickness:We
Distance from top of scum to top of outlet tee or baffle:rda
Distance form bottom of scum to bottom of outlet tee or baffle:rda
How dimensions were determined: n1a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
GREASE TRAP:_
(locate on site plan)
Depth below grade: rva
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rya
Scum thickness:tva
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumping;1a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,'structural integrity,
evidence of leakage, etc.)
We
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2-
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction Ilne:TOWN
Diameter: nla
rNaImments: (conditions of joints, venting,evidence of leakage, etc.)
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
SYSTEM INFORMATION (continued)
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: we
Capacity: rda gallons
Design flow: Na gallons/day
Alarm level:_n1a Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
Owner: ESTATE OF THOMAS LARKIN
Date of Inspection:9124199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type.
leaching pits,number: rya
leaching chambers, number:rda
leaching galleries, number: rJa
leaching trenches,number,length: rda
leaching fields, number, dimensions:rva
overflow cesspool, number:ONE6'xe'BLOCK
Alternate system: rda Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH PR IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION
CESSPOOLS:x
(locate on site plan)
Number and configuration: ONE
Depth-top of liquid to inlet invert: EMPTY
Depth of solids layer: nla
Depth of scum layer: Na
Dimensions of cesspool: e'xs'
Materials of construction: BLOCK
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
nla
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
MAIN CESSPOOLS AND ALL COMPONENTS ARE STRUCTURALL SOUND.RECOMMEND PUMPING SYSTEM EVERY YEAR.
PRIVY:
(locate on site plan)
Materials of construction: Na Dimensions: Na
Depth of solids: rua
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rVa
(reYleedOQV97)' ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
2 CROSS WAY PLACE OSTERVILLE MAP 165J PAR 55
ESTATE OF THOMAS LARKIN
9124198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
Ncc
A
�Q 3�
(reAsed04127197) Page 9 of 10
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
2 CROSS WAY PLACE OSTERVILLE NAP 155J PAR 55
ESTATE OF THOMAS LARKIN
9124199
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation'. .
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
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(revised04)27197) page 10 of 10