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Home My WebLink About0207 CRYSTAL LAKE ROAD - Health .207 Crystal Lake:R��0. Osterville l G II a , Q t 0 i a I • /39-o�-f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary AssessmentsNa 207 Crystal Lake Road Property Address ' Wells Owner Owner's Name c• information is required for every Osterville ✓ Ma 02655 10/17/2017 , page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 67� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection r� Company Name 74 Beldan Ln. Centerville Ma 02632 CitylTown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to•Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ! ' ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by t7710/17/2017 thority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system'is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the."buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 207 Crystal Lake Rd Osterville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 Infiltrators. This system was found to be in proper working condition at the time of inspection. The dwelling also has a separate single cesspool that needs to be abandoned. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System'will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Crystal Lake Road . Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or . . clogged SAS or cesspool ❑ :® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of(Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the.system is within 400 feet of a surface drinking water supply Y 9 pP Y ❑ ❑ 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling-inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ . Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville •Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d p Y(9p ) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is Osterville Ma 02655 10/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town p State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 12-10-92, single cesspoll unknown. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof, tank has 2 inlet pipes. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owners Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank should be cleaned soon and again every 2 years for proper maintenance. tank has 2 inlet tees intact and 1 outlet baffle in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System 'Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01. 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 found in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is Osterville Ma 02655 10/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): Infiltrators were video inspected and found dry with no sign of past overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert dry Depth of solids layer Depth of scum layer Dimensions of cesspool 6x6 Materials of construction block Indication of groundwater inflow ❑ Yes ® No 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .°' 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.). Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): there is a single cesspool that fails per Town of Barnstable regulations and needs to be abandoned. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately n�. jA G i✓�S� � its fno,ut ® Z 3 6 z z3 3 g3 276 57-b 3� 3 , t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of_17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 207 Crystal Lake Road Property Address Wells Owner Owner's Name information is required for every Osterville Ma 02655 10/17/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 `rx Town of Bamstable P o /SZ Dipartatent of RegWatory&Mces h KUL 41 t , >E Public Health Division nate Sep�' R 2A 7 T, sel 200 Main Street.Hyannis MA 02601 X., �. Date Scheduled The Fin Pd.i 10 cti: t. �b ., Soil 5uitabOy Assessment for S e Disposal Pulbraw•Bye ! sU Gl D C D an '+' '1T'S� Whaeased By: LOCATION&GWfMUT.WORMATION o tocauw;Adarcp ;20 Cr` Si{i C_q Ke, owners Hama O�tr; , Q 4 0 5fQr U l He— Address CFO f So n t h Ades W Assosors Mapfparcolt 'Cf• Car"5. Ins o c 3 ,Z¢ Hnpbrcers Na a .� NEW CONSTRUCTION RSPA>st V /Telephoned S d e6 LaadUse �L`1rI�PVLl�tu, Slopes —_ .Lv• 5urrWASoaes n01'1 °L Dbtanew f nu Opw Wag&Body��tt11�V rt. Possible Wet Am& �O, Jt Drinking Vllaier WsR (� -+rt Dnlbaga Way �t/ 'I ft Property Una tl Olhcr it O • ►SMCHt(Bheet name.dimensions of lot,enact lacntloru of test holes&Para seta6 locale vwetlsads{n proslml ty to hates) Q, ' C. CP N �O Parmt malarial(goobglo).0$,C 6 Depih to Bedrock No kic-` _ •v-I-W�3 5 • Deplb to Oroaadwater Standing Wet;r in HWc P/serlt g from Pit Fans &Umatad Seasonal High Groundwater + l h T P - 4 ` D TTON FOR SEMONALMIGH WATM TABLE Method Used- rnOfif PS D Observed staadlog In abs.bale: n o Ke.k:I- l'Z2 la, Depth to toll motUess D to weeping how t{ds cf dw.bolo;+no n e a i l,?ifp la, CmundwUn Adjusbagol 14, tndaa•Wd1A R=uUag Dater tndu Well ipvel.;.___ Adj fholot_AdI.CrmdwwwLoval_ PERCOLATION TIEST Dalo 9 4- t7 um 4 s Pei Ohttxveth n I Hole q Mms,at 9" h DcpthofPam 53�� 55" , 4lmame" to Start he-3wk 7lmo 0 O-00 O-00 h Bad Pna-saa>< Rats Z mPi 2vn pr ';'. i . C4. M iluch SitosultabliltyAsswmenC Sllopaucd ;Slts.FWU'd:' � Addltloaal7tiat(ngNooded(y/1� �0 Odglnat: Public health Dlvlsloa :;,.� Obaervatlon Hn16 Data To Ho Completed oa Hack ***If percolation test is to be coudneted.wi ffiW 1.00,tie wetland,you must first notify the Barnstable Conser+atfon Dtvigton at least ona(1):Weak prior to beginning. Q:lStipTtclPBRt3tORM.Doc .., •• � . , DEEP.OBSEO—ATION HOLi LOG Hula i'F I Depth train S(r1111ndmn Snll'raxlura Still Color Boll• Other Surface an.) (USDA) (Munsell) Mat111rrg (Strurcture.Stand.Buulderx. Cosl,tencv.96 Ctmvell 0- 4 0 Wvoo' L6ftM 10 �V—/z. 'NOWE FRIF*131-� 4- 6 C L06MY SWD lc�"�tR-4/t L1 Laf I-M SW 10-` [O-! _ k-L-3o Q L*MY'SNWD I()qR 54 tt Lc�oSE MeD-CsE�; �o�R 6/3 LOD sc DEEP 011Slr !VATION HOL9 LOG Hole Depth rnuu 9011 Iloilsuu Soll'rexture Soil Color Sell Other Surface(fit.) (USDA) (Mansell) mauling (Structure,Stones,Boulders. 4-5 0• WboD Lolwt L04{R3/z t� Fri Able C.oeMY SA N9 0'?rz, 3/1 rri'ti b le COAV`s�'56ND IogM4 + tt I '' Fri 5l iz-3Z 3 LoAMY 5(-ND LOUR 5/6 t,' L.605-e DEIRP OBSLRVA'11ON HOLE LOG Holo# Depth from Sall Horizon 801111exuue gall Color Sall Other Surface(its.) (USDA) (Muuscll) Mottling (Snalum,atones.Du utdca. �allslslfla&Y-�tlrevell o -3 O Wnod.Ca�M IcyNohe �rl�ble L to�� s l rn�ble 16ct-mySit lOYR �x, F61a4)1e l0'30 ' + ,6 Med ont Sgad 10 Y iZ G `I L ooS e Drow OBSERVATION iioml LOGS halo Depth from Sall Dlurtron SollTextuto ' Sall Color Boll Other Surface(In.) (USDA) (Murisell) Mottling (Stnlolure.Soper.Boulders, • Wo*0A L.oavrn Yii"' Z Nohe �r,able 4-� E CdAt~` Sctn�l 10 Fr;g 6 1 e G-12 Loamy Sand l0 Y R l 2- -R-1 8 4.04tay Sand 10 R w6 1' Loose 3Z� �2g C MRa'w,, Sq A k0 2 6/5 Loose-, Flood Insurance Rate Mail: Above 500 year flood boundary No_� Yes Avilwo 500 year Irnundory No�, Yes.;_,_ Within 100 yatr nool boundary No-,— Yes Nuth uCNa(urally Occurring Varvlous Material Does at least tour feat of naturally occurring pert/ous malorial exist in all areas observed throughout oho area proposed for the soil absorption systom? 25 If not,what Is oho depth of hnlurally occurring pervlous Inatorinl7 a..tificnllo t � . Cr t I certify lent on NO� ails (data)I havo ptui b valuator examination approved by Iho Department of Briv)runmontal Proleotlon and d S Is wits porformed by ilia conelstcat with . the required training,oxilardso d paricn rit? t 15.017. nturc �� SignbLj WUUMANDWR c5S. 0� `1014/ I:N � Q:�gnrrlc,Nrsnc�oltlt.uoc ��•�;,, AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION a C7 C '►N SEWAGE # F,2-,!591 VILLAGE [j75 l E.2v l IF ASSESSOR'S MAP � LOT � �/- 05 INSTALLER'S NAME & PHONE NO. (So SEPTIC TANK CAPACITY LEACHING FACILITY:(-, e) in,-/T-o./2 .j (size) x 7 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 16 /7 DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes - No l/. G 4.� C,"T °x s http://issgl2/intranet/propdata/pre.built.aspx?mappar=139054&seq=1 10/6/2017 TOWN OF BARNSTABLE LOCATION c� 0� C rY:1-6 � L�3�tc i� SEWAGE VILLAGES��(Z U , ��P" - ASSESSOR'S MAP & LOT 1,3T.- 65Y INSTALLER'S NAME & PHONE NO. Go2Ocv��y►�r4v;l LJ�Q,- ��0 SEPTIC TANK CAPACITY /57-0 0 LEACHING FACILITY:(type) (size) q 9 oC 7 NO. OF BEDROOMS.'PRIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNER �t1 /ls " .DATE`'PERMIT ISSUED: IQz yDATE COMPLIANCE ISSUED: ;-VARIANCE GRANTED: Yes No 1,--" e;;4 015 sox r� A(q Paz No... FimzL THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH APPROVED TOWN OF BARNSTABLE Barnstable Conservation Department 442- Apphration for Disposal ork,i Totes rur ' Si Date Application is hereby made for a Permit to Construct ( ) or Repair �,<aan Individ lal Sewage Disposal System at: -- tel..AIA......... le-.-- ......... .... ------------..........------..... ..... . i Location-Address or Lot No. ........................................f S ---••---•---------............................. .................................................................................................. Owner Address a y'j............................................. --•---•...--•-----------•-----•-•-------.....••••....------------..............................--- Installer Address d Type of Building/ Size Lot............................Sq. feet V Dwelling�No. of Bedrooms ..............Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q, 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........................................ 4 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (rq Test Pit No. 2................minutes per inch Depth of Test Pit---:................ Depth to ground water........................ P4 ----•------------------------•--------------•-•---•-------•••-•-----------•-•--••••-----------------...... •------------------------- -..... .----------------- ODescription of Soil...............................................................................----------------------•---------------...-------------------------------•-•............. x U -----• ---- - - ------------- --- ----------------------- ------------- ---- �-f - -------------------------- ..... 0 Nature of Repairs or Alterations—Answ when mica g%1�1 IT/N.-"..._._._.__A...... �...V... 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 b e board of.health. Signed -..��' ---------------- ................................................ ---f/. .�/.............--- Date ApplicationApproved By .......... ...--�. ............................................................... .. ... ... ... ^.1..7:..�.�.:�--... Date Application Disapproved for the following reasons- -------- ---- --------------------------------------- ---- ------------------------- -- ------------------------------- - --- ---------------- ..... A / Date PermitNo. -----{ ( 1---- --_-------------- Issued ........................................... --------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Disposal Varks Tvustuffwfi 11r7aft-1— Application is hereby made for a Permit to Construct or Repair �-ran Individual Sewage Disposal System at: or Lot No. Owner Addrew Installer Address Type of Building Size Lot-- Sq. feet DwelliLng-iNo. of Bedooms,3____ _------------Expansion Attic Garbage Grinder Other—Type of Building No. of persons------------- Showers Cafeteria Otherfixtures ----------------------------------------------------------------------------------------- Design Flow_ ----------------gallons per person per day. Total daily flow------ Septic Tank—Liquid-capacity------------gallons Length-------------Width________------ Diameter---------Depth--- 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_--- Test Pit No. I_______________minutes per inch Depth of Test Depth to ground water------ 44 Test Pit No. 2___________minutes;per inch Depth of Test Pit__._________—_ Depth to ground water- Al ------------------------------------------------- 0 Description of SoiL_____ -—---------- ------------------------ —----------- ----------------------------------------------------------------------------------------------------------- L) Nature of Repairs or Alterations—Answer when applic - ---------------------- ---------- 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 by the board of health. Signed ----------- nm Application Approved By ---------- 17- Application Disapproved for the following reasons- ----------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ------ Permit No- ----- -------------------------- Issued THE COMMONWEALTH OF MASSACHUSETrS BOARD OF HEALTH TOWN OF BARNSTABLE (gertiftrak of (;ffMT1ia= THIS IS TO CER77FY?at the Individual Sewage Disposal System constructed or Repaired by-------------------------- -----------L14VV - ------ ------------ -------- at ,Ro ? -,j-Ti-- .-�,-- Tco; - 04 ------_- ----- r--- ------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application'for Disposal Works Construction Permit No- --------7 5]�,I____ dated ------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. C'\\ DATE------------------------ �- ------------------------------ Inspector i 'd THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Permission is hereby granted-------- —---—------------ to Construct or R kf�, %Individual S System ':m7s, at No.--aq 1- Tff YL 6 'T C) Street as shown on the application for Disposal Works Construction Permit No 0 Board of geaYrh FORM 36506 HOBBS&WARREN.ff4C-PUBLISHERS