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HomeMy WebLinkAbout0017 CROSSWAY PLACE - Health 7 ross ay s en i c A= ,.��5 - O(ON TOWN OF BARNSTABLE LOCATION (7 6R4Q -N V—J ('LjtCa SEWAGE# -461 CC) VILLAGE QS'�i� tJt L_4 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. J-3-G• 1• SEPTIC TANK CAPACITY EF4YJ b'-�-Znf , tC66 4 AJ_ LEACHING FACILITY:(type) ?, F-{— (size)NO.OF BEDROOMS OWNER uz _ r r" PERMIT DATE: I- 3-1� COMPLIANCE DATE: b Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) A— Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 14 p4- Feet FURNISHED BY J a .y N .26 6 - Sep ..n`. ir No. � Fee a2 THE COMMONWEALTH SACHUSETTS Entered in comp ter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitotion for -Misoos&Y *pstpm �tCO strUttlott 1Prmit "A i Application for a Permit to Construct( Repair( ) 'TJpgrad�( ) Abandon( ) plete System El Individual Components Location Address or Lot No. i 7 &oSS G44 v/ •, Owner's Name,Address,/and Tel No. Assessor's Map/Parcel ``� O Installer's Name,Address,and Tel.N10. Designer's Nam Address,and Tel.No. 4(VZ. :n1 A C�;rJ " -7-7 Type of Building: Dwelling No.of Bedrooms Lot Size 1 3,3,X sq.ft. Garbage Grinder( ) Other Type of Building tfe3' S'o C1._ r-%?,%-e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uir d) y/ gpd Design flow provided W9'7 gpd Plan Date /Number of sheets j Revision Date Title Vnk �l`c e��al /`E�6 e ,Bq 3 Size of SepticC�,'S i7 d' 10049 Q 4 Type of S.A.S. 5W, .1 411a Description of Soil -7 0^ , e—f Sq 4�M ZY-37—�� Q t/`e -f-C 60q,,he J�n or ._ Nature of Repairs or Alterations(Answer when applicable) 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 Environmeriiat.Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health:, Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued °w,. ti...w+• ¢.-. _ ,.�.. - •,...h ,."Fr'.' __. F: °5 No. 1 / �} �J ',�,)',�/ Fee V t THE COMMONWEALTH .F MASSACHUSETTS THE in computer: 4�k. Yes PUBLIC HEALTH,DIVISION -�OWN OF BARNSTABLE, MASSACHUSETTS �Rppliration, for Misoosal 6pstem Co 'strUctlon Permit Application for a Permit to Construct(vy'�Repair(. )dJyad . ) Abandon( ) ram : plete System. ❑Individual Components Location Address or tofNo. 1`77 Cro5,4A4 a d l "E'q Owner's Name,Address,and Tel.No. ,e� C1�r Pu,°fie r✓�cr� l'7mP l Assessor sMap/Parcel l"A/C)t�,v t / Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: 4- Dwelling No.of Bedrooms Lot Size }'� %� sq.ft. Garbage Grinder( ) Other Type of Building RCS. S;',vrle rQ^i No.of Persons Showers( ') Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 9, ! gpd Plan Date f/�/' ��� Number of sheets Revision Date Title for c Owf e+4' Size of Septic r:X,'-541 r 10ra 0 Type of S.A.S.Ue Description of Soil k-/ h 7 A 6z w e 6q", '` + i 3?_ Nature of Repairs or Alterations(Answer when applicable) F Date last inspected: f -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 Environmenta Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Si` ed ,( Date Application Approved by ,,,G � ,/ Date Application Disapproved by Date for the following reasons r.— )) cry Permit No. ( ,� Date IssuedL L1 I s THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the O siz Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) < Abandoned( )by U I•J f' at l rep 5 fi r! l���i�e ��S-�vl G.. �/ has been cons cte -in actor= c e- r - AlIq with the provisions of Title 5 and the for Disposal System Construction Per N� dated Installer f. w r �lrt-f-ix Designer ,�u,���fi� �t-itvii��C,`t°►f -.;f.,�p(; #bedrooms y Approved design flow ff' ' gpd The issuance of this permit shall not be construed as a guarantee that the system will=function's designed. , Date :?4,-�,b h _ Inspector No /�41 / / . .._ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Mispo$aY *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( / ) System located at j' (, '6-,0 Luoy t, f t/, #40 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with 9 Title 5 and the,following local provisions or special conditions. Provided:Construction must st a completed within three years of the date of this permit. .-- Date Approved b rj PP Y a December 24, 2018 Town of Barnstable Health Department 200 Main Street Hyannis, MA 02601 RE: Travis Cundiff 17 Crossway Place, Osterville MA 02655 Bedroom Count Septic Design Dear Health Department, Please IV advised that on Tuesday December 6, 2018 Sullivan Engineering & Consultingiffic. inspected the dwelling located at 17 Crossway Place to do a bedroom analysis. T s was done to facilitate the design of a system because.my existing one has failed. The Assessors Department has the dwelling listed as 4 bedrooms. Although there are 4 bedrooms the inspection of the system stated it was only a 3 bedroom system. This house was listed as a 4 bedroom house with 4 bedrooms in existence at the time my purchase of the property to present day. We intend to install a newly designed 4 Bedroom septic system. We purchased the property on June 30, 2008 without any construction on the property to alter bedroom counts in the time we have owned. Although the Protection of Saltwater Estuaries, which limited the bedrooms in'this area was adopted the same day we bought the house(June 30, 2008), we inspected the property prior to this date when the house was on the market. I trust this meets your present needs. Very truly yours, Travis Cundiff -05-2019 05:28 From: To:15087906304 Pa9e:1/1 : ; Town of.Barnstable: Inspectional Services i 3 Public Health Division ,W Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 r' Office: 508-86 4 Fax: 508-7.9"304 Installer&Designer Certification Form Date: Sewage Permit# Assessor's MapWarcel� Designer. 1 Wq Installer: Address: I611�1 S1Tf& Address: r On ���y �bns c '"was issued a permit to install a '(date) (installer) septic system at CN S based on a design drawn by ddress) dated 2 esigner � ✓ I certify that the septic system referenced above was installed substantially,according to the design, which may include,minor approved changes such as lateral relocation of the distribution box and/or septic°tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that ste fereneed above was constructed in compliance with the to rms of the roval ers(if applicable) (Installer's rgnature) NO ;1 1y XD es�gner s ignature) (Affix signer's Stamp Here PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVI N. 9ARTLFICAxE i OF COL CE NOT BE� UNTIL BOT T S FO AhIA AS- -BU CARD ARE RECEIVED Y THE BARNSTABLE PUBLIC HE TH D SION. TH f YOU. Nwaldo u*iFnL M LIWER oonnotaEP71COuipei Cenlfieadoa Form Rev W-13,00C Town of Barnstable P# / Department of Regulatory Services Public Health Division Date e19.a�� . 200 Main Street,Hyannis MA 02601 Date Scheduled Time Fee Pd "'' Foil Suitability Assessment for S�ema e Disposal Performed By: Witnessed By: LOCATION& GENERAL INFORMATION Location Address ?1 <- Owner's Name T r-a,/t s q � � el C r®ss�r g Address Q W Fie. Assessor's Map/Parcel: 5 ®t0 Engineer's NageSV—ffV"te—, cooly inefo n NEW CONSTRUCTION REPAIR t.� Telephone# Land Use R�J WPy1�/�C1 Slopes(%) a~ S Surface Stones Distances from: Open Water Body ® ft Possible Wet Area Z�/U t ft Drinking Water Well ft Drainage Way 2 So+ ft Property Line ® `_ ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) A :A je g17 t3 a Parent material(geologic) y.4 s 4 Depth to Bedrock 5 y + Depth to Groundwater: Standing Water in Hole: .441 d we. Weeping from Pit Face 4 of d—r-e_ Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil.mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date I! /3 Time l/ Observation Hole# s2 Time at 9" Depth of Perc T D ! Time at 6" Start Pre-soak Time @ p� Time(9"-6') ' - - End Pre-soak 17 Ott Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Mottling Surface in. (USDA) (Mansell) gStructure,Stones,Boulders.( ( ) Consistency. %Graven 32 DEEP OBSERVATION HOLE LOG Hole# . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.°°Gravel �o 132 'C A Son 7�6 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Graven DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel)_ ._ J d Insurance Rate Ma Flood 0: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Devth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the _ .. area proposed for the soil absorption system? V', S If not,what is the depth of naturally occurring pervious material? Certification I certify that on 7/1. Z©/Z (date)I have passed the soil evaluator examination.approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required traininpk expertise and experience described in 310 CMR 15.017. Signature 4 d r Date A Ca l Q:\SEPnC\PERCFORM.DOC COMMONWEALTH OF;MASSACHUSETTS.. t, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT.OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM -`PART A CERTIFICATION' Property Address. 17 Crossway Place Ostervtlle:MA 02655 Owner's Name: Bob Shorb' �' s Owner's Address. { "Date of Inspection ^ March 1, 2008. Dame of Inspector: lease Print James M',, Ford ' `" '' P (P ) c Company Name: James M.Ford, c Mailing Address: P.O.Box 99 Osterville.MA 026554049 Telephone Number:. _(508)8624400 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., .I am,:a DEP, approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).,The system:_ ✓`° Passes : . Conditionally Passes ' eds.Further Evaluation by'the Local Approving_Authority.. Is g Inspector's Signature: Date: March 20 2008 The system inspector shall sub it a copy of t is`iiispection 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. Notes`and Comments re s: ****This port•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.` N Tiile 5.Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: 17 Crosswau Place Osterville, MA Owner's Name: Bob Shorb Date of Inspection: March'1, 2008 Inspection Summary. Check A,B,C D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. .Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es n or not determined 0 o dete ed Y N ND in the for the following statements. If not determined 1 Y ( ) g ,pease 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.Compliatice indicating that the tank is less than 20 years old is"available. ND explain: 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,: 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:, 17 Crosswav Place Ostendle. MA - Owner's Name: Bob Shorb Date of Inspection: March 7. 2008 . C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further evaluation by the,Board of Health in order to determine if the system is failing to protect public health,safety or the:environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 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 aseptic lank 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen aiid'nitrate nitrogen is equat to or'less than 5 ppm,provided that.no other failure criteria are triggered. A copy of the arialysis must be attached to this form. 3. Other: ._ 1. 3 Page 4 of 11 OFFICIAL INSPECTION FORM_-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A' ,' CERTIFICATION (continued) Property Address: 17 Crosswav Place Osterville, MA Owner's Name: Bob Shorb Date of Inspection: March 1, 2008 D. System Failure Criteria applicable to all system'': You must indicate either"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`'/Aay 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 cesspoolor privy is within 160 feet of a surface.water supply or tributary to a surface. water supply.. ✓ Any portion of a cesspool or privy is within a Zone d 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 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 System: - Y 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 systems in addition to the criteria above) . 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.ILof a public,water supply well -z 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 CV1R . 15.304. The system owner should contact the appropriate regional.office of the.Department. 4 i, Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Crosswav Place Osterinille, MA Owner's Name: Bob Shorb Date of Inspection: March 1, 2008 Check if the following have been done: You must indicate"yes"or"no as to each of the following: Yes F 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 interiorof the tank inspected 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: Yes No ✓ 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(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:, 17 Crossway Place Osterville. MA Owner's Name: Bob Shorb Date of Inspection: . March l: 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 3I0 CMR 15.263(for example: 110,gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes,orno): Yes Is laundry on a separate sewage system(yes or no): n/a . [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes orno):. No Water meter readings, if,available(last.2 years usage(gpd)): Undvailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment':,. Design flow(based on 310 CN IR 15.203.): - gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no) Industrial waste holding tank present(yes or no). i Non-sanitary waste discharged to the Title 5.system.(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 4 yrs. Ago.-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How.was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM , t ✓ Septic lank,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 r . 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: Date o installation 41120192 Were sewage odor`s detected when arriving at the.site(yes or no 'No . • Y 6 ' t- Page 7 of 11 y OFFICIAL INSPECTION FORM-NOT FOR VOLU NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION-(continued) Property Address:. 17 Crosswav Place Osterville, MA Owner's Name: Bob Shorb Date of Inspection: March], 2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40.PVC other,(explain): Distance from private water supply well or suction line: Comments,(on condition of joints,venting;evidence of leakage,-etc:): SEPTIC TANK: ✓ (locate on.site plan) Depth below grade: 24" Material of construction: ✓ concrete metal _fiberglass._polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: '1000.gal. s Sludge depth: 2„ Distance from top of sludge to bottom of outlet.tee or baffle:: . "-30" 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: ]off How were dimensions determined: . Measurinz stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,.liquid levels, as related to outlet invert,evidence of leakage,etc.):, Tees were present. The liquid level was even with the outlet invert: There did not appear to be any sikns of ieakage The inlet cover was 10"below.Qrade. GREASE TRAP:' 'None locate.on siteplan) Depth below:grade: Material of construction:_ concrete `_metal filierglass _polyethylene _other'. (explain); — Dimensions: Scum thickness: ` Distance from top of scum to top'.of outlet tee.or.baffler Distance from bottom of scum.to.bottom of outlet tee or baffle:. Date of last pumping:' Comments(on pumping recommendations,inlet.and outlet tee or baffle condition,structural integrity;liquid levels as related to outlet,invert,evidence of te'akage,etc.):; T - 7, , - ri Page 8 of. 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Crosswav Place Osterville, MA Owner's Name: Bob Shorb Date of Inspection: March 1, 2008 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or.no): Date of last pumping: Comments(condition of alarm and float switches,etc:); DISTRIBUTION BOX: ✓ (if present must be'opened)(locate on site plan). Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover;any evidence of leakage into or out of box,etc.): .'The D-box was clean..No solids were t resent. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or nb) Comments(note condition of pump chamber,condition of pumps and appurtenances.,etc.): 8 Page 9 of 11 OFFICIAL.INSPECTION FORM' NOT FOR VOLUNTARY;ASSESSMENTS : SUBSURFACE.SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) L Property Address: 17 Crossway Place Osterville..MA Owner's Name: Bob Shorb Date of Inspection: March k2008 SOIL ABSORPTIOMSYSTEM(SAS): ... ✓ (locate on site,plan,excavation not required), i < . If SAS not located explain why: u Type _. leaching pits,number: leaching chambers,number: 3-infiltrators F leaching'galleries,number: . _ leaching trenches,number,length. leachingfields number .:dimensions: y , overflow cesspool,number..- F Innovative/alternative system Type/name of technolog y:, Comments(note condition of soil,signs of hydraulic failure;level'of ponding,danip soil,condition of vegetation, etc:): The infiltrators were dry: There.did notatiear,to be any signs of failure.` CESSPOOLS`:. None : (cesspool must be pumped as.part,of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert:` Depth of s.olids.layer: ..Depth of.scum layer: Dimensions of cesspool: Materials of construction.:,, . Indication of groundwater inflow(yes or no): Comments'(note condition of soil;signs of hydraulic failure,level of ponding;condition'of vegetation,etc): ' PRIVY:. None (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.): 9 41 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INS]PECTION FORM < 'PART C SYSTEM INFORMATION(continued) Property Address 17 Crosswav Place' Osterville, MA Owner's Name: Bob Shorb Date of Inspection: March 1. 2008 . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties tout least two permanent reference landmarks or' benchmarks..Locate all wells within 100 feet.,.Locate where public water supply enters the building. � r / 4 . 'b 1 3 a� 3 _ r. Page I.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 17 Crossway Place Osterville;MA Owner's Name: Bob'Shorb. Date of Inspection: March 1, 2008 SITE EXAM Slope Surface water y Check cellar Shallow wells Estimated depth to groundwater 35+/- 'feet Please indicate(check)all methods used:to determine the high ground water-elevation: Obtained from system design plans on record-If checked,'date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) . " ✓ Checked with local Board of Health-explain: Topo&aphic and water contours,maps Checked with local excavators,installers.-(attach documentation) e ; Accessed USGS database-explain: You.must describe how'you established.the high ground water elevation: Using Barnstable topographic and ivater contours maps the maps were showinQ'approximately 35'+/=to'groundwater at this. site. T This report has-been prepared only for the septic system and components described herein. This septic system has been. inspected and passed as;of the date of inspection..This report is not a warranty or guarantee that the system will function properly in the future: There have been no warranties or guarantees; either expressed,written or implied relating to.the septic system, the inspection, this'.report and/or any components of the septic system`which have not , been located and inspected: 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 17 Cross Way Osterville, AM Owner's Name: Carol McLaren Owner's Address: P.O. Box 686 RECEIVED Osterville, MA 02655 Date of Inspection: August 9, 2001 AUG 1" 5 2001 Name of Inspector:(Please Print) James M- Ford . Company Name: James M Ford ` ,TOVW0O BARNSTABLE LTH DEPT, Mailing Address: { P.O.Box 49 Osterville,MA 02655-0049 Pa_rcel: 064 Telephone Number: (S08) 862-9400 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes " Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: August 9, 2001 The system inspector shall subnQ 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; _ . Notes and Comments *.***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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION; (continued) Property Address: 17 Cross Way Osterville. MA Owner: Carol McLaren Date of Inspection: August 9, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the".Conditional Pass"section need to be replaced or repaired:- The system;upon,completion of the.replacement or ,repair;as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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: __..- The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass_inspection if.(with.appr(?val ofthe Board of Health). broken pipe(s)are replaced. obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION' (continued) Property Address: 17 Cross Way - - - -- ' Osterville. MA _M Owner: Carol McLaren ' Date of Inspection: August 9, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. , 1. System will pass unless Board of Health determines in accordance with 310 CMR 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'uiiless the Boar_&6f Health(and Public Water Supplier,if any)determine's 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 coliform bacteria and volatile or 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Cross Way _.... ........_A__..:.'_:� :.`.._.._._ Osterville, MA Owner: Carol McLaren Date of Inspection: August 9, 2001 - D. System Failure Criteria applicable to all systems: You must indicate either`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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is 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 portionI 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 burgreater 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'coliforih 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 System: 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . CHECKLIST Property Address: 17 Cross Way Osterville. MA Owner: Carol McLaren r.� •> w 1., Date of Inspection: August 9, 2001 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility'or dwelling inspected,for signs of sewage back up?.(Owner twas not home) ✓ Rr^ a 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: Yes No } ✓ 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 CNM 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 0 -". �; ` '= SYSTEM INFORMATION Property Address: 17 Cross Way Osterville. MA L Owner: Carol McLaren 4 Date of Inspection: August 9, 2001 _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 4(per owner-rooms not inspected) 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 or a separate sewage system(,yes or no): Nb [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)): 2000-132,000 gals.; 1999-171,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCULANDUSTRIAL Type of establishment: Design flow.(based-on 310 CMR.15.203):...-__. _.. _._._,...___.... Basis'of design`flow(seats/persons/sgft;etc.) $ •.r^ ; Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no):._ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on Sept. 27100-per treatment plant Was system pumped as part of the inspection(yes or no):. No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any).. Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank : Attach_a copy.ofthe DEP approval other(describe): v - "Approximate age of all components,date installed(if known)and source of information:.... November 20 1992-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM'1NF:ORMATION (continued) Property Address: 17 Cross Way _ Osterville. MA Owner: Carol McLaren Date of Inspection: August 9, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40:PVC other(explain): Distance from private water supply;well or suction.line: Comments(on condition of joints,venting,evidence of leakage,etc): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 24" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) }� If tank is metal list age- _Is age confirmed by a Certificate of Compliance,(ye .or no):,. r,(attach a copy of certificate) .f5 r. Dimensions: 1000 gal. ;'; Sludge depth: 1" _ Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness: I" r Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present The liquid level was even with the outlet invert There were no signs of leakage. The inlet cover was 6" below grade GREASE TRAP: None (locate on site plan) Depth below grade: 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: - , ' Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity;liquid,levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cross Way Osterville. MA A Owner: Carol McLaren , Date of Inspection: August 9, 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): _...,DISTRIBUTIONS BOX: ✓__-.(if present must be opened)(locate on site plan) Y Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level There was no leakage or solids present There were no signs of backup or failure from the leach field. The outlet invert was 42"below grade PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR'MATION (continued) Property Address: 17 Cross Way Osterville. MA Owner: Carol McLaren Date of Inspection: August 9, 2001 ' SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: :.; Type leaching pits,number: - ✓ leaching chambers,number: 3 infiltrators-per as built card leaching galleries,number: " leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number-:- -Innovative/alternative system -Type/name,of.technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The infiltrators were not dug up.' There were no'si;offaihu;e or bdckup'in'the`D-box.. Tlie bottom to grade was approximately 54': , CESSPOOLS: None (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: a Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9+ Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Cross Way rtw. Osterville. MA } Owner: Carol McLaren Date of Inspection: August 9, 2001 Map: 165 Parcel: 064 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. t O O o C-IL 3 BC A3- aG �33- 3a 10 Page i l of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION,(continued) , Property Address: 17 Cross Way Osterville, MA -- t Owner: Carol McLaren - - x Date of Inspection: August 9, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:. You must describe how you established the high ground water elevation: The bottom of the infiltrators to grade was approximately 54". Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 40'+/-'to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 ' r TOWN OF BARNSTABLE 4'L�t"CA ION !7 CrOSS WA SEWAGE # C a 1�LLAGE O S T e r o l�- ASSESSOR'S MAP& LOT 1405 114STALLER'S NAME&PHONE NO. G. I�UM,pVS SEPTIC TANK CAPACITY d� LEACHING FACILITY: (type) //1 A 449 S (size) NO. OF BEDROOMS-3 BUILDER OR OWNER CAM-] PERMIT DATE: // qa COMPLIANCE DATE: p a0 qa. 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 1 aching facility) Feet Furnished by SY T L. A eclT,0 nJ• i' si- 35 r �1 r Aa- - a ► nsa- 3). cD AS- (o a s . x s' TOWN OF BARNSTABLE LOCATION � � C'ecr�S (y/9-1 _SEWAGE # `ss` N� / VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 6 r'puem CSSEPTIC TANK CAPACITY 0 - LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER,OR OWNER ( f , DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:// c'9,0- VARIANCE GRANTED: Yes No -35 t 3 � ) t No.. Fiz$..... ..-. THE COMMONWEALTH OF MASSACHUSETTS APPR BOARD O HEALTH 80rastabie Conservat on Department TOWN OF BARNSTABLE Appliration for Did usa1 Works Towitrurtinn Date Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ....� .1. ? . ................................. -----••----.....----•-.._.........----.....------.........----------........-•-----------------•-- Zocation-Address i ... �L.�{ -------------------••----...._...------------------------•---- W Owner Addr ' ...Lam. ------------------------------------------ Installer � Address f ing ype o_ Build Size Lot............................Sq. feet aDwelling—No. of Bedrooms.___..�_____________________________________Expansion Attic ( ) Garbage Grinder ( ) W Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 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—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ a .---•-•••---------------------•--•-•---•-•-•••---•------....-•-----•••••-•-----.......................... .. - -------- •--_-_----------------- -......... ... 0 Description of Soil------------------------------------------------------------------------------- ----------------------------------------------------------------------••-•••----•-_--•-- x V ......_.....-•--•-•-•--•-•--•-•---•-•---•------------•-•••-•-----•-••-----•--•••--•-------...•-•--._...-•----------------•---•---•-••-•-•----•--•--•-•--•-••-•- W ----------- x •---•-•----•-------------------------------•----------•-•------------•--•-•---------------•--••----•-------- •-•- - -------•--- - ----------------- -------- -- --- U Nature VR, enappli bl _____e -- -f____._j ___d_._ .r?..._.- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued byAe board of health. r Signed ...... � ...- -- ---..--.. .. ��-`�-..�oa ��� ApplicationApproved B ...................----------- ..... ..............-!�- ...... ------------------------------------------------ ---- -1,: `7" Dale Application Disapproved for the following reasons- --------------------- --..--.....- ---------------- ------------------- -- ---------------------------------------------------- ------------------------ -- -'------------ .............. Date .. Permit No. ------ -...�. -...:� �-- - Issued ------- ................... 1� Date -------------- -- No — Fzz '0! - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE rpl ratuan for Bispood Works TonsumdWn Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: e f 7 Lion-Address .._ or .... owner 04 fInstaller Address Type of Building Size Lot-__ -Sq. feet .-� Dwelling—No. of Bedrooms------ ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T ype of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------------------------------------------------------------------------------------ ---- W Design Flow-------------------------------------------gallons per person per day. Total daily flow----------------------------------_-----gallons. WSeptic Tank—Liquid-capacity------------gallons Length---------------- Width---------------- Diameter----------------Depth-------------- x Disposal Trench—No--------------------- Width--------------------Total Length--------------------Total leaching area-------- ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet------------------- Total leaching area---------•___sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------ -.----_---------- 1.4 Test Pit No. 1________________minutes per inch Depth of Test Pit__-____---_--_•---_ Depth to ground water-___-____________--_-__. G4 Test Pit No. 2_--------------minutes per inch Depth of Test Pit__-___-___-____-_-_ Depth-to ground water___________-_---________ a ------------------------------------------------------------------------------------- --- -_-_- -- — --- --- - 0 Description of Soil------------------------------------------------------------------------------- W _x -------------------------------------------------------------------------- ---------------- -----------------------------------f - -- - _--- -----_ _/ ---- - - U Nature of Repairs or Alterations—Answer when applicable________ 1_,�"________�jf_______�eoc G-_l+ I ------ Y;c ^� 4-Y------------- T J ;!o��, t9 ?_&---------------------------------------------------------------- Agreettlent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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. Signed--- .�.rL - �L�"�'�''o /J�� --------------- -------------------------------- ----- ------ Application Approved By ....---G% - - - -�/' '�� ----------------------------------- - c:�+�^ j nay Application Disapproved for the folloiuing reasons: - ----------------------------------------------------------------------------------------------------------------------- ------- ------------ / - _--------------------------------------------------------------------------------------------------------------------- --------------------------------------=- Permit No. ------- - -------------------------------- ---- Issued --------------- --��` Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (gertifirak of (gomplian e T IS IS TO CE IFY, That the Individual Sewage D po a Syste constructed ( ) or Repaired ( Installer at -- ---1------ -------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as described inti the application for Disposal Works Construction Permit dated ---------- ----------------------- THE ISSUANCE OF_THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONgSATISFACTORY. DATE - �-- -�--...................................-......... Inspector --- _r�-� ;} THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE � No._.... ..... Disposal Work Cho� nation rrrrmft Permission is hereby granted..........C___gos ___-__-- --------------------- ............................................................---- to Construct ( or ,Repatr ( k an In di i u Searage Di posal-S, ste i� M VP atNo..--,/• --------------•-----•-•-. ...._•-- --- -------------------------------------------------------------------•-------•------------------------- Street yy��nn as shown on the application for Disposal Works Construction Permit Nq(S_`r!e�� ated______-/___ ___._.._�_/___.__._.. -------------------------- ------- ��./ Board of Health DATE......= •---• --------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS '_w PERC TEST. 15,850 DESIGN DATA ZONE: Bench Mark PERFORMED BY:CHAPLES ROWLAND,PE- SULLIVAN ENGINEERING f To of Bound Tree to be &CONSULTING,INC. Single Family RC P -4 Bedroom @ 110 GPD r r Area min. 43,560 SF " E/ev. 49.1T Removed SOIL EVALUATOR NO. 15850 (min.) � No Garbage Grinder . .. r Frontage (min) 20' 8 WITNESSED BY:DONNALD DESMARAIS,R.S.-TOWN OF BARNSTABLE ; Total Daily Flow=440 GPD Width (min) 100' December 6,2018 Keep Existing 1000gal Septic Tank n ac Setbks:SITE PASSED Bathroom Front 20' Proposed SAS L "ACHING AREA Side 10' r _ Rear 10' �• �` �° 6S o e See Detail TEST HOLE- 1 EL.47.8 TEST HOLE-2 EL.47.8 440 GPD/0.74(LTAR)=594.6 SF Required ... Sidewall=(30.6+4.0+10.0+33.5+12.83)2'=181.9 SF Bedroom 3 + o� Existing ALAYER IOYR 312....... ... ........A.LAYER I0YR 3!2 Bedroom 4 r :" ..•" 9 Bottom Area= 425.8 SF D-Box to VERY.DARK GRAYISH VERYDARK GRAYISHBRDWN Total Provided=607.7 SF(449.7 GPD) ce 9 be Replaced 24" SANDYLOAM. .... 45.8 22" SANDYLOAM 46.0 \t .. B LAYER.lOYR 6L8 B LAYER.lOYR 6L8 � f Post Fdn .. LEACHING CHAMBER DESIGN . Existing BROWNISITYELLOW. . .. BROWNISH YELLOW ... SheF, G� lity Se tic Tank L.OAMYSAND All Pipes to be Schedule 40. Use 10. Po P 32 .. ... .. 45.1 30 LOAMY SAND.... 45.3 p ' 2.2 J To Remain C LAYER IOYR 7/6 PERC TEST 3-500 Gal.Leaching Chambers in a YELLOW 25 GALLONS GONE IN 10 MIN. Double Washed Stone Field as Shown. SECOND FLOOR PLAN FLOOD ZONE: 132" MEDIUMSAND 36.8 PERC RATE<2 MINAN(LTAR=0.74) LOCATION MAP: NO GROUNDWATER ENCOUNTERED 48" C LAYER IOYR 7/6 43.8 NOT TO SCALE Zones VE Elev. 14', AE Elev. 12, Existing O �LS�. a7 YELLOW X& (0 Annual SAS & D-Box M �, 132' MEDIUM SAND 36.8 (Min Flood Hazard) To Be Removed 1"=2,000f' Existin Sep W' 's` NO GROUNDWATER ENCOUNTERED Community Panel No. ASSESSOR REF.: Per Test 250001 0018 D �+ t } S-- T -2 Per�`Tie d F July 16, 2014 Map 165 Parcels 064 �1 0' 91-558 8.0' Deck` u Season REFERENCES: OVERLAY DISTRICT: � �o� 10.6 Sun Room Deed: Book 1781 AP - Aquifer Protection District I� Q.�o< Elev. 49.3' Sill 50.1' / Plan: Book 178/75 o��ee F w An ® �� SEPTIC NOTES Z 1.Location of Utilities Shown on This Plan Are A rox.At Least 72 Hours Jte Bedroom 1 Bathroom Prior to Any Excavation For This Project the Contractor Shall Make "rpm I W j #1 7 �C6 ��� Mud Room the Required Notification to Dig Safe(1-888-344-7233)and contact �y 1 2 Sty �� Garage Sullivan Engineering&Consulting Inc.(508428-3344). Gas 2. The Contractor is Required to Secure Appropriate Permits From Town w/f D well in g j Garage NSF, Kitchen Agencies For Construction Defined by This Plan. & 3.Wherever Sewer Lines Must Cross Water Supply Lines Both Lines Shall Dining Room Be Constructed of Class 150 Pressure Pipe and Shall be Water Tested to Assure Watertightness. In General,Water Lines Shall be Constructed in Coordination With COMM Water,and Shall be in Accordance I Bedroom 2 With 248 CMR 1.00-7.00&310 CMR 15.00. 4.A Minimum of9"of Cover is Required for All Components. `* 1009' Reserve 5.All Structures Buried Three Feet or More or Subject to Vehicular Traffic to be H-20 Loading.It is the Engineer's Lot Areas FIRST FLOOR PLAN Recommendation that H-20 Always be Used. I 1 3 3 70s f 6.Install Watertight Risers and Covers to Within 6"ofFinished Grade Paved Drive ems, NOT TO SCALE Over Septic Tank Inlet and outlet,D-Box,and One Leaching Chamber. All covers are to be maximum 18"for concrete or24"Cast Iron. I 7.Septic System to be Installed in Accordance With 310 CAM 15.00& N 15' 29' 25"E N 15' 29' 25"E 248 C!MR 1.00-7.00 Latest Revision and the Town of Barnstable I90.00 88.05 U%, Board of Health Regulations. - 33.5' 8.All Piping to be Sch.40 PVC. 9.D-Box Shall Have a Minimum Inside Dimension of 12",and a Minimum Sump of 6". Edge of Pave �+�+ Stone Field 10.The Separation Distance Between the Septic Tank Inlets and CI ro a7 Wa y Place Outlets Shall be No Less than the Liquid Depth.Inlet Tees Shall Extend 10.0' a Minimum of 10"Below the Flow Line.Outlet Tees Shall Extend 14" 500 Gal O Chambers 12,8' Below the Flow Line,and Shall be Equipped With a Gas Baffle. 4•0 / D-Box 30.6' F.F. El. 50.10 Cover to 6" of Grade to be Installed at F.G. EL 28.00 F.G. EL. 47.8-48.2' Time of Construction See Note 6 (typ.) SAS DETAIL EL. 46.30 1 10, Finish Grade Flow Equalizers 3„ Max. € ( ( s ;=. i- € €_( � 3i, As Required 9 Min R EL. 46.40111' q Compacted Fill Filter Installer To Confirm Prior EL. 45.14 Existing To Any Work 1000 Gallon EL. 44.89 Top EL. 45.20 Fabric A Septic Tank INSTALLER TO 44.70 nd/Or to Remain CONFIRM PRIOR D-Box EL. 44.54 2" 1/8" - 1/2" �:. TO ANY WORK ,� � ea Stone 44.20 3 P $ D-Bo to be To Be Installed On Existing Chamber n 3/4" - i 1/2Leaching ���•� '� �� `� Stable Com acted Base o LEACHING Double washed Re ... P placed Bot. E . 4 _0 CHAMBER Stone .. . V. �MOF SS4 Bedding,"T"s !f Encountered Rerrdve & Reploca y , 0 Inspection Port, All (Jr7surtable Sods wrthrn :5' of ::: �r w �G & Baffels The Doter Perrmeter-:of The.:: ys#en 4' - 10'= -� R(3 rD as Per Title 5 12' - 10" ►I CtYil . b No Grob dwater Na. 526 9 Per Test Hole 1 T ION OF CHAMBER °�FSSbNA>. G�`` DEVELOPED PROFILE OF SYSTEM CROSS SEC NOT TO SCALE NOT TO SCALE TI TLE: PREPARED BY: PREPARED FOR: NOTES: Site Plan 1) The property line information shown was compiled Proposed Improvements • from available record information. r0 p p Engineering & Travis Cundiff & Any H. Wrightson 2) The topographic information was obtained from an 17 Crosswo Place Fq t lVall . y on the ground survey performed on December 7, - Consulting, Inc. Osterville MA 02655 2018 using conventional survey method. 17 Crossway Place 3) The datum used is assumed and based on Town (508)428.3344 P.O. Box 659 • 7 Parker Road, Ostervi Ile, MA 02655 of Barnstable GIS Maps Barnstable (Osterville) Mass. seci@sullivanengin.com • www.suilivanengin.com 4) This plan is not to be used for recording purposes 10 0 5 10 20 40 Draft: CTR Field: WHK/JOD/CTR 20 0 10 20 40 80 or a legal lot description. DATE: SCALE: Review: CTR Comp.: CTR January 2, 2019 As Noted Project: 380035 Project: Cundiff ',