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HomeMy WebLinkAbout0247 CRYSTAL LAKE ROAD - Health 247 (Sys -1)�Crystal 'Lake Rawl O 3teNille P A = 139 051 J i i i� i r� o S Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form,Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property Address i Bullock Owner Owner's Name / information is ✓ required for Osterville Ma 8-20-2020 F every 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 I way.Please see completeness checklist at the end of the form: Important: A. Inspector Information S 5 I $ When filling:out p - • forms on the computer,use Douglas.A Brown only the tab key. Name of Inspector to move your D.A.Brown Inc cursor-do not C Company Name use the return i key. P.o Bok 145 i Company Address Centerville- Ma .02632 City/Town State Zip Code i 508-420=4534 S14297 I r�0 Telephone Number License Number I B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection:I have determined that the system: 1. Passes 2. .0 Conditionally Passes , 3. ❑. Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8-20-2020 7r�ignatur�e ��-�� Date i The system inspector shall submit a,copy of this inspection report to the--Approving Authority(Board ! of.Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to.the system owner and copies.sent to ` the buyer, if applicable, and the approvingauthority.- Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. l5irisp.dac•rev:7126/2018 Title 5 Official Inspection Form:Subsurface sews Die sewage posal System•Page 1 of 18 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not forVolunta A 9 p Y ry ssessments 247 Crystal Lake Rd Systems 1&2 Property Address Owner Bullock information is Owner's Name. required for Osteryille Ma i -20-2020 i every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2,3, or 5 and all of 4 and 6. 1) 'System Passes: ® 1 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: At time of inspection this property had 2 septic system that met all minimum passing,requirements. This report can not predict the future performance under the same or increased usage.This report is not to be.used for bedroom count determination. Both systems appear to be older but hotoriginal. { (There were very limited records available on thesesystems).As a note there is a slop ink in the basement that runs into a drywell that takes water from a de humidifier and a.condensor of some sort on the furnace this does not go into either septic. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be I replaced or repaired.The system, upon completion of the replacement or repair, as approved by i 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. I The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurallyunsound, 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. t *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of 1 Compliance indicating that the tank is less than 20 years old is available. i i ! ❑ Y ❑ N ❑ ND(Explain below): I i i t t5insp.doc•rev.7 MX118 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System-Page'2 of 18 Commonwealth ofmassachuset Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 w i Property Address Owner Bullock information is owner's Name required for Osterville Ma 8-20-2020 every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 2) System Conditionally Passes(cunt.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Ipumps/alarms are repaired. i ❑ Observation of sewage backup,or break out or high static water level in the distribution box due I _ to brokenor obstructed pipe(s)or due to a broken, settled or;uneven distribution box'. System will ,pass inspection if(with approval of Board of Health): l ❑ broken pipe(s)are replaced- ❑ Y' ❑ N ❑ ND(Explain below); 1 ❑ Y ,❑ N ❑ ND(Explain beiow) obstruction is removed'-_ a .distribution box is-leveled,or replaced ❑ Y -'❑ N ❑ ND(Explain below): f - t - e _ r . ' ❑ 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): ' t ❑ broken pipes)are replaced' ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑' ND(Explain below) i - 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if i thesystem is failing to protect public health, safety or he environment. a a. 'System will pass unless Board of Health determines i ' 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:- 15insp:091.•rev.7126/2018 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 3 of 18. i ltx Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property Address Owner. Bullock Information is Owner's Name required for Osterville Ma 8-20-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt.marsh b. System will fail unless the Board of Health(and Public Water Supplier,If any). determines that the system is functioning in a manner that safety and protects the public health, environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 4 100 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: i I This,system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are.triggered.A copy of the analysis must be attached to this form. c. Other: 4 S Failure Criteria) stem Y Applicable to All Systems: You must indicate."Yes"or"No"to each of-the following for all inspections: Yes No ❑ IE 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 t5inop.doc•rev.7/26/Z1118 Thle 5 Offidel Mopedron Forth;Subsurface Sewage Disposal System•Page 4of18 I 1, Commonwealth of Massachusetts. i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property.Address Owner Bullock information is Owner's Name required for Osterville Ma 8-20-2020_ every page. City/Town State Zip Code °„ Date of Inspection C. Inspection SUMMA p rY (cont.) - 4) System Failure Criteria Applicable to All Systems: (cont) '? Yes No , ti Static liquid le4 in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6°below invert or available volume is less than %day flow - ® 'Required pumping more than 4 times in the last year NOfidue to clogged or ..obstructed pipe(s). Number-of times pumped- ❑` Any portion of the SAS, cesspool or privy is below high ground water elevation. i ❑ Any portion of cesspool or privy is within 100 feet of a surface,water supply or tributary to.a;surface water supply. Any portion of a cesspool or privy is within a:Zone 1 of a public water supply well. "❑ ® Any portion of.a'cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100'feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,-for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, ' provided that no otherfailure criteria are'triggered.A copy of the analysis { and chain of custody must be attached to this form.]. - ® The system is a cesspool serving a facility with a•design flow of 2000 gpd- 10,000 gpd. 0 ® 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.. 61 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 imSection 0.4. Yes. No r j ❑ the system is within 400 feet ofa surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply i �. ' ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well - t5lrlsp,doc-rev:.7@6R018 Tape 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 or 1 o Commonwealth of Massachusetts c Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `247 Crystal Lake Rd Systems 1&2 Property Address Owner Bullock information is Owners Name required for 0sterville Ma 8-20-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section 0.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact-the appropriate regional office of the Department. I 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ Z Pumping information was provided by the owner, occupant, or Board of Health t ❑ 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) E ❑ Was the facility or.dwelling inspected for signs of sewage back up? 0 ❑ 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? ❑ E 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: 9 ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7126=18 Title 5 official Inspection Form:Subsurface Sewage Disp osal posal System•page 6 of 18 f c �L\ Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 247 Crystal Lake Rd Systems 1&2 Property Address Owner Bullock. _ information is Owner's Name re quired wired for � a Ostervllle Ma 8.20-2020 every page- Crty mown State; Zip Code Date of Inspection ,D. System Information 1. Residential Flow Conditions: 4, Number of bedrooms(design): 4. Number of bedrooms(actual): 4- DESIGN flow based on;310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: This property has 2 systems system one one the left side of the property according to previous inspection report consists of a 1,000 gallon tankd-box and 5 infiltrator chambers. System 2 on the right. side of the property consists of a 1000 gallon septic tank a d-box and a 6x6 pit. On both systems we located and opened p the tanks and distribution u Ion boxe s. ( ,n is not required see page 13#11) of the soil absorbtlon systems as excavation Number of current residents: I I Does residence have a garbage grinder? ` El Yes ❑ No l' Does residence have a water treatment unit?Y Yes .❑ No If yes, discharges to .Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter,readings,`if available(last 2 years usage,(gpd)): f 237 gpd%2yrs i Detail: j average water readings for the last 2 years averaged 237 god.Sykims are not designed for arba a dis osai: Sump pump? ❑ Yes ❑ No Last,date of occupancy; _ Date 3 - . r t5insp.doc•n3v.7/26P2o78 Title 5 Official Inspection Forth:Subsurtace Sawa e 8 D isposal system•Page 7 of 18 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not,for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property Address Owner Bullock information is Owners Name required for 0sterville Ma 8-20-2020 every page. City/Town state Zip Code Dateof Inspection D. System Information (cont.) Z Commercial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): - Gallons per-day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes Q No Water treatment unit present? ❑ Yes ❑ No i I If yes; discharges to: Industrial waste holding tank present? ❑ Yes ❑ .No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: no records at Board of health at time of inspection Was system pumped as part of the inspection? ❑ Yes J No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doe•rev;712612018' Title 5 Official Inspection Form:Subsurface sewage Disposal system,page a of f8 k I • Commonwealth 'of Massachusetts Title 5 official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 ? t Property Address owner Bullock i 'inforrnatiori is Owner's Name required for Osterville: Ma 8-20-2020 i every page. Cityfrown. State Zip Code - Date of Inspection D. System Information (cont:) 4. Type of System: a Septic tank, distribution box, soil:absorption system 4 ❑ Single cesspool - f ❑. 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 I s .maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract i ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: System 1 and 2 according to previous inspection report states 1994 but there were no permits'found' at Board of Health to verify. System 2 seems to be older than system 1 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet_ Material Of.Construction: ❑east 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.): I piping is pvc not sure if sch 40 or not 4 _ i t6insp#c-rev.7/iwia, Tige 5 Official inspection Form;Subsurface Sewage Di z 9 Disposal System•Pege 9 of 18 i G Commonwealth of Massachusetts Title• 5 Official Inspection Form . s Subsurface Sewage.Disposal System Form-'Not for Voluntary Assessments 247 Crystal Lake.Rd Systems.1&2 Property Address Owner Bullock { information is Owner's Name required for Osteryille Ma. 8-20=2020- every page. Cityrrown State Zip Code Tat of Inspection ' D. System Information (cons} 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑metal ❑fiberglass ❑'polyeth lene Y ❑other(explain) I ` Iftank is metal, list age:. years i Is age confirmed by la Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No :Dimensions: both stated to be 1000,gallon i Sludge depth: Distance from top of sludge to bottom of outlet tee baffle j Scum thickness Distance from top of scum to top of out tee or baffle Distance from bottom of Scum.to bottom of outlet,tee orbaffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc:):' System 1 tank has a riser on inlet with a plastic`cover and no riser on outlet tank is;about:3 ft down tank is in good shape and was functioning property at time of,inspection. System 2 tank has concrete, risers on inlet and outlet this tank is showing some exposed aggregate but is functioning properly. This tank is not in as good:a shape as.tank 1.AIso`in area of system 2 tank there is a;live gas line and an electric line and also:a.white pvc pipe going over the top of the outlet cover caution.should'be.. taken when working in this area: t5insp:doc•rev.7/26/2018 Tide 5 Official Inspection Fort:Subsurrace Sewsga Di„sposal System•page 10o118 Commonwealth-of Massachusetts Title 5 Official Inspectiofi Form- Subsurface Sewage Disposal System Form Not for Voluntary Assessments I - } 247Crystal Lake Rd Systems-1&2 t Property Address Owner Bullock .r ,information is Owner's Name required for Osterville' _ Ma' 8-20-2020 every page. Cdy/Town y State Zip Code,, -Date of Inspection I D. System Information (cont) "f �I 7: Grease Trap`(locate onsite plan) 4 1 - , - a Depth below.grade. f ,-feet - g ` - Material of construction .. ; - '- D concrete :. Q metal. `fiber iass , ❑ g Q polyethylene Q other(explain): Dimensions Scum thlckn"'s. Distancefrom top of scum to top of outlet tee orbaffle } Distance from bottom of scum to bottom of outlet tee or baffle. Date of last pumping Date t Coirments(on purnping recommentlations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as,related to outlet invert,evidence of leakage, etc.): 4y r e y , " 8 Tight or Holding:Tank(tank must be'pumped at time oflnspection)`(locate on site plan):• , , - ,e { Depth below grade. } Material of construction:,., Q-concrete _° ' . , S i 1 Vw Q.metal, , ' Q fiberglass ❑polyethylene. Q other(explain): I' µDimensions. `= Capacity: 1 gallons Resign Flow: , j gallons per day t5kmpAoc•rev.7r2 wit; T Ti11e 5.006al Inspection Form:Subsurface sewage Disposal System-.Page 11016 Commonwealth of Massachuseft. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property.Address Owner Bullock information is Owners Name required for Osterville Ma 8-20-2020 every page. Citylrown State Zip Code Date of Inspection D. System information (cont.) 8. Tight or Holding Tank(cont) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date. Comments(condition of alarm and float switches, etc.): r i "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes- ❑ No ti 9. Distribution Box(if present must be opened)(locate on site plan): t Depth of liquid level.above outlet invert o" 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.): Both d-boxes were functioning properly at time of inspection with liquid levels at outlet inverts.The d- box on system 1 was in better shape than the d=box on system 2 which is consistent with.the. conditions of the septic tanks. t5insp.doc rev.7/26/2018 Me 6 Official Inspection Form:Subsurface Sewage oisposaLSystem•Page 12 of 18 IL Commonwealth of Massachusetts Title 5 Official Inspection Formm Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 - a Property Address Bullock Own er Owner's Name, 9 t ,information is required for Osterville Ma '• t:'8 20-2020 every page. CityfTown State Zip Code. Date of Inspection _ D. System Information 10. Pump.Chamber(locate on site p lan Pumps in-working order: es ❑ Y ❑ No* I AI arms-in working`` " order : [J Yes Q N o- t Comments(notercondition.of um 4 p p chamber, condition of pumps and appurtenances, etc,)`. < w i a t - e 'If`.pumps or alarms are-not•in working order, system is a conditional pass:.' * _ 11. Soil Absorption System*S)(locate on site plan, excavation not required): If SAS not located,'explain why:. The s:a.s on system 1 was not located due toahe:depth and'the as-built'measuremerits did not seem to acurate. But this could also be due to depth:I did probe to at least 4 ft down according to the,. measurements and didnt hit any components:the s.a.s on system 2 is partially under the shed-- accordingto the as-built card r - 7-7- Type. . . leachirr , . 9.pits4 f nurntierc. h 16x8 . Teaching chambers• " ` number. 5 infiltrators leaching'galleries number; a ;= 0 " leaching trenches number; length: 0 leaching fields' number,°dimensions: I 0 overflow cesspool number:: i 0 innovative/alternative system Type/name of technology: t5insp.doc rev,7262p18 Title 5 t Official Inspection Form Subsaace Sewa Disposal Sy sem pag. a e 13 of 18 Commonwealth of Massachusetts r Title 5 Officia1 Inspection .Form. Subsurface Sewage Disposal,System Fot'm-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property Address _ Owner Bullock information is Owner's Name required for Osterville R every page. City/Town M8- $-20-2020 State Zip code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(coat.) Comments(note condition of soil, signs of hydraulic.failure, level of ponding, damp soil, condition of s vegetation,etc.): In the areas of both leaching systems there were no immediate signs of back up or break out to the surface. The exact level of ponding could not be determined. 12. Cesspools(cesspool must be pumped as part of inspection){locate on siteplan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of Construction Indication of groundwater inflow ❑ ❑Yes No Comments(note condition of soil,.signs of hydraulic,failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form.Su5surface;sewage Disposal;Sysle'-.page 14;of-16 I - , r _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary As 247 Crystal Lake Rd Systems 1&2 Property Address_ Owner Bullock information is Owner's Name required for Osterville Ma 8-20=2020 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) r i 18. Privy(locate on site plan): E Materials of construction: I Dimensions s i f Depth of solids Comments°(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l 1 0 i 15insp,Eoc•rev.7/26/2018. Tltle 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 15 pf ta. I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fa-Not for VoluntaryAssessments ents 247 Crystal Lake Rd Systems 1&2 Property Address _ Owner Bullock information is Owner's Name required for Osterville every page. Ma 8-20-2020. Ciry/Town State Zip Code Date of Inspection D. System Information (cont:) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where,public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately s ' f t5insp.doc•rev.7/26ws Titles Official Inspection Form:Subsufface Sewape Disposal System•Page 16 of 18 I Commonwealth of Massachusetts' Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property Address Owner Bullock information is Owners Name, required for Osterville Ma 8-20-2020 'every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope i ® Surface water ' ► .Check cellar, , Shallow wells Estimated depth to high ground water: :greater than 5 ft n feet 1 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: • i I ❑ Checked with local excavators;installers-(attach documentation) t t Accessed USGS database explain: f r _ l You must describe how you established the high•ground water elevation: 'Property sits at a much higher elevation than the lake in the back of the property.Both.of these systems are in the;front and side areas of the property. -..Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doC iev.7/2612018 Title 5 Official inspection Form:Subsurface S� swage Disposal System•Page 17 of 18 4 1 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 247 Crystal Lake Rd Systems 1&2 Property Address Owner Bullock information is Owner's Name required for Osterville Ma 8-20-2020 every page. Citylrown State -ZipCode Date of inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. B. Certification: Signed& Dated and 1, 2, 3, or checked C. Inspection Summary: 1,2, 3,,or 5 completed,as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D..System Information: i For 8: Tight/Holding Tank—Pumping contract.attached i For 14: Sketch of Sewage,Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included .5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal,System•page 18 of i8 Page 10 of l - Y D-Fe OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE RD OSTERVILLE,MA 02655 ` Owner. MR..H2OLLOWAY v -Date of Inspection: 9/30/02 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.., A - 0 14 r c - 01 A AA q3 C N351 r AC(,oz L�age 10 of 11 z OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE RD SYSTEM TWO OSTERVILLE,MA 0205 Owner: MWHOLLOWAY Date of inspection: 9130/02 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. r i 1 AA 15 A 6 zz OA 113 1 h8 161b t f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION z � . RECEIVED 1.. 1. ZOOL 5�8 ♦ T0Vvr.'rr-BARNSTABLE . TITLES HtALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ,. CERTIFICATIONS Property Address: 247 CRYSTAL LAKE RD SYSTEM TWO OSTERVILLE,MA 02655 Owner's Name: MR. HOLLOWAY Owner's Address: PO BOX452 S. HERO VT 05486 Date of Inspection: 9/30/02 Name of Inspector: (please print) JOHN GRACI Company Name: i SEPTIC INSPECTIONS 100' Mailing Address: {` `} P:O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813',FAX 508=564-7270 CERTIFICATION STATEMEN' 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 maii-aeriance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340�`ofTitle 5(310 CMR 15.000). The system: X Passes '0': _ Conditionally asses _ Needs Furt Evaluation by the Local Approving Authority Fails �5 Inspector's Signature: `s'= Date: 9/30/02 The system inspector shall submi 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 stall°subunit the report to the appropriate regional office of the DEP. The original should be sent to the system owner an&copies sent to�the buyer, if applicable,and the approving authority. ♦ „ Ky . Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. .e ****This report only describesWednditions 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. Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t�. G CERTIFICATION (continued) Property Address: 247 CRYSTAL LAK'E.RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWA'Y Date of Inspection: 9/30/02 Inspection Summary: Check A,,B,C,D or,-E/ALWAYS complete all of Section D A. System Passes: ;S X I have not found any informationlwhikh indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMIt 15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. �? B. System Conditionally Passes: y _ One or more system componentAs described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,ras approved by the Board of Health,will pass. Answer yes, no or not determined(YA,N®) in the for the following statements. If"not determined" please explain. n/a The septic tank is metal,and over 20 ye'ars'old* or the,septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 6z61tration 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: n/a n/a Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled.or,' neven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(§)are replaced ,.p obstruction is,removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping rnore.than 4 times a year due to broken or obstructed pipe(s). The system will pass ` inspection if(with approval of the iBoard of Health): bioken'pipe(s)are replaced _obstruction'is�removed ND explain: n/a s +1�KITr , Page 3 of 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A : . .CERTIFICATION(continued) Hi Property Address: 247 CRYSTAL;LAKE.RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 p C. Further Evaluation is Reguired'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: I. 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: a�f . 3• _ Cesspool or privy is within 50t feet'of a surface water _ Cesspool or privy.is within 50 feet of a bordering vegetated wetland or a salt marsh Ilk •.� -. A 4..'8 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 se pt c,tank Fan'd soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface"water supply. .k _ The system has a septic tank.and.SAS and the SAS is within a Zone 1 of a public water supply. _ The system has aseptic rankand SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tankl`and SAS and the SAS is less than 100 feet but 50 feet or more from a private water 1l ,: t;; supply well**. Method used to'determine distance n/a . ,,d I. **This system passes if theswell water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds`indicates�that the well is free from pollution fro���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. � 9 3. Other: n/a t, ,•l� • , y Page 4 of 1 1 { OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r. Property Address: 247 CRYSTAL LAKE•RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no'to each of the following for alLinspections: Yes No r �t _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of e,ffluentto the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than.6"below invert or available volume is less than ''/z day flow X Required pumping more,,alian'4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 5 YEARS BY OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. `' tributary to a surface water supply. ce water Supply or t b� _ X Any portion of cessp`bbP'o�r'pti-ivy ►s within 100 feet of a surface pp y y _ X Any portion of a cesspool.,',q�orivyllsgwithin a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coli form bacteria and volatile organic compounds indicates that the well is free from pollution from thatja. ility 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 forma _ (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 syste►p fail,sjhe,�,ystem owner should contact the Board of Health to determine what will be necessary to correct the failure: '' ',',;: ' E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either."yes"'or"rio"to each of the following: The following criteria apply to large systems in addition to the criteria above) yes no t X the system is within 400 feet•of a surface drinking water supply X the system is within 200 feet pt a tribpttary to a surface drinking water supply t X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered 'yes"yto anyquestion in Section.E the system is considered a significant threat,or answered yes" in Section D above the Lu&,Sysi4ni h,is Failed. The owner or opernlrn'i�f any I u'ge sy5teni ctmsidered n si f!nificnnl thr�ttt under Section E or failed under Sec tion'D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. °s:p� � t w Page 5 of -t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 4' CHECKLIST Property Address: 247 CRYSTALLAKE RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY,, Date of Inspection: 9/30/02 Check if the following have been`done YO,U must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system comtponents pumped out in the previous two weeks`? X Has the system received nonrial flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or'dwelling inspected for signs of sewage back up? rA w,s u X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X Were the septic tan nlo k mal`es uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner''(a4occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the tSoil'Absorption System(SAS)on the site has been determined based on: a Yes no ,R F X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]" , 1�,Y 1IN. .. i d i. Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 247 CRYSTAL LADE RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (Ior,example: 110 gpd x 4 of bedrooms): 440 Number of current residents: n/a Does residence have a garbage grinder'(yes or�no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required) Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):jiLa 0 t , 2-71ou� Sump pump(yes or no): NO Z,A`60 0 Last date of occupancy: 8/31/02 `t COMMERCIALANDUSTRIAL` ` r Type of establishment: n/a �«� Design flow(based on 310 CM 15:203):'.a/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes br no): NO Non-sanitary waste discharged to the Title'5 system (yes or no): NO Water meter readings, if available: n/a,. Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records , Source of information: 5 YEARS BY GWNER Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a 'y TYPE OF SYSTEM X Septic tank,distribution box;soil absorption system _Single cesspool ri _Overflow cesspool , _Privy 4 x f ` _Shared system(yes or no)(if yes,attach,previous inspection records, if any) Innovative/Alternative technology..Attaca a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a ; Approximate age of all components,date in stalled(if known)and source of.inforrriacon: 8 YEARS BY OWNER i Were sewage odors detected when arriving at the site(yes or no): NO TF r, Page 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE RD SYSTEM TWO OSTERVI:LLE, MA 02655 Owner: MR. HOLLOWAY , Date of Inspection: 9/30/02 BUILDING SEWER(locate onsite,plan) Depth below grade: 30" Materials of construction:_cast iron,=40 PVC•X.other(explain): ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER ° SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age'confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 2" ' Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to lio`ttom of outlet tee or baffle: 17" How were dimensions detennined:`MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural`integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction: ' concrete',.metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recomm``endations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc..1: n/a , - e, , a i ('1V � < l.' 7 i`' F ` Page 8 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL'LAKE)ID SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 r TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a ' Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a N._` F° `g Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in work ing'order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float swatches,etc.): n/a DISTRIBUTION BOX: X(if present.inust be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level,and.distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED(AND APPEARS TO BE STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO , Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): I n/a ► t � ; • c .Page 9 of . r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) { Property Address: 247 CRYSTAL LAKE RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) `A, , If SAS not located explain why: n/a Type 1000 GAL 6' X 6' ; leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a ieaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a ; ,:innovative/alternative system Type/name of technology: n/a Comments(note condition of�soil,'signs of•hya'raulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PIT. LEACH PIT APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 10 FT. CESSPOOLS: (cesspool must be pumped,as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet iiivert`. n/a. Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):''NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a . PRIVY: (locate on site plan) . l �t Materials of construction: n/a Dimensions: n/a r Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a , Wage 10 of I I { OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 247 CRYSTAL LAKE RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 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. AA Is ` A Fp 2� AC 25 13 An 3 ee � 1.0 • i�} 6 . 7 t y I -�T Page I I of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE'RD SYSTEM TWO OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 SITE EXAM _Slope _Surface water _Check cellar ' Shallow wells Estimated depth to ground water`12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting.property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local ex&: vafors, installers-(attach documentation) NO Accessed USGS database-,explain ',n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. F•{. t;'fit. } COMMONWEALTH OF MASSACHUSETTS 4,�ia ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS F DEPARTMENT OF ENVIRON7E;NL PROTECTION ECEi�lED 4 f nrT 3 1 2002 iV�M SJ4�. ia.1' r!'.• Tr"av h;1h BA: NSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM • PART A �-� CERTIFICATION Property Address: 247 CRYSTAL LAKE RD OSTERVILLE, MA 02655 Owner's Name: MR. HOLLOWAY Owner's Address: PO BOX 452 S. HERO,VT 05486 � Date of Inspection: 9/30/02 Name of Inspector: (please§print) . .JOHN GRACI Company Name: SEPTIC INSPECTIONSL.• Mailing Address: t v t':{'zf':b. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813.FAX 508-564-7270 CERTIFICATION STATEMENT 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: X Plass'es - _ Conditional) Passes _ Needs Fur r Evaluation by the Local Approving Authority Fails P Inspector's Signature: 1, � Date: 9/30/02 The system inspector shall'submi a,copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this,inspe, tion. I f 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 andacop es sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V`INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. i ****This report only describes r'610itiotis at the time of inspection and under the conditions of use at that time.'Phis. inspection does not address how-t,he system will perform in the future under the same or different conditions of use. itt , Titlr 5 1111CnOrti Nl I,rn•m 6/1 5/3hoo ?' 1 Page 2 of 1 1 ` ,z OFFICIAL INSPEi 'IONY• FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A +: CERTIFICATION (continued) Property Address: 247 CRYSTA:L.I,AKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D . k A. System Passes: + 1 X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes.:. ; _ One or more system comporieAis'-as"described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacemeritl'or_repair,as approved by the Board of Health, will pass. Answer yes, no or not de'tennined'(Y N,NC) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20-years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is 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 oid is available. ND explain: n/a t , n/a Observation of sewage backup orybreak out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): %;- broken pipe(s)are replaced _ obstruction is removed _ distribution,box is leveled or replaced ND explain: n/a n/a The system required um m T3moie than'4 times a year due to broken or obstructedpipe(s). The s stem will ass Y q p p ' " Y Y P inspection if(with approval of the Board bf Health): _.broken,,,pi0,e(s)-1are replaced obstruction i ,removed ND explain: n/a , s F j,I� . ,y •st � , .: i. Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A "CERTIFICATION(continued) Property Address: 247 CRYSTAL`LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY, i Date of Inspection: 9/30/02 C. Further Evaluation is Requir;,ed*,by the Board of Health: _ Conditions exist which requi.re,1',further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the�en'v:iromnent. I. 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 x .e t 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is,funyctioning hi 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`tank1!and SAS and the SAS is within a Zone I 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 tanka�,d,SA,S and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance n/a **This system passes if the we`ll water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic coin pounds indicates that the well is free from pollution fron,that facility and the presence of ammonia nitrogen and nitrate nitrogen is;`ecual 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. y LS- 3. Other: ? t n/a I , rr. - t',it; .Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE1SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 247 CRYSTAL'LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY ' 0 Date of Inspection: 9/30/02 ' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no—to each of the following for alLinspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or pond.ing of effluent tothe surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool I ' X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped FIVE YEARS BY OWNER. _ X Any portion of the SAS,cesspool o'r privy is below high ground water elevation. X Any portion of cesspool&pri`vy'is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cessp6o-j.;or,privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, forlcoliform 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 forma (Yes/No)The system fails. It have determinedthat 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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"pr"no"to each of the following: (The following criteria apply to large systems)n addition to the criteria above) yes no F� + . X the system is within 4,00 feet of a surface drinking water supply. X the system is within 2'00 feet oEa tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II of a public walei•`siipply well If you have answered"yes"ito-any question in Section E the system is considered a significant threat,or answered 1: 7;; "yes" in Section D above Ihe. large s1' ' "I "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 CM 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 1 4 t. OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 247 CRYSTAL LAKEZRD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY ! Date of Inspection: 9/30/02.i' Check if the following have been done. Yoii must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information-was provided by the owner,occupant,or Board of Health X Were any of the system.com'ponents.pumped out in the previous two weeks X Has the system received'`iiorinal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage backup? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? „ X Were the septic.;tank,manho.les'urcovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different 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 X Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if ariyWithe.failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. . ri r a , Y Page 6 of 1 l 1'i t4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C ',SYSTEM INFORMATION Property Address: 247 CRYSTAL LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of'bedrooms(actual): 4 DESIGN flow based on 310 CMR'15.203 (fonexample: 1 10 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):°NO Seasonal use: (yes or no): NO (] 0 Water meter readings, if available(last 2 years usage(gpd#-a. n 0 l' Sump pump(yes or no): NO Last date of occupancy: 8/31/02� t t COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR(1.5203):-n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no),r:NO Industrial waste holding tank prey ent'(� e's or iio): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a,", Last date of occupancy/use: n/a ti t OTHER-(describe): n/a t +,tGENERAL INFORMATION Pumping Records .;', Source of information: FIVE YEARS BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons.;;;How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM ` X Septic tank,distribution box,soil absorption system _Single cesspool y'ty _Overflow cesspool _ Privy rr Shared system(yes or no)(ifwyes;,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) ,{ _Night tank Attach a copyt of the DEP approval Other(describe): n/a rk=.. VN Approximate age of all componentst date installed(if known)and source of information: 8 YEARS BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO eta . i� r, Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'S WAGE DISPOSAL SYSTEM INSPECTION FORM PART C F SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 i BUILDING SEWER(locate on site plan) i 4 Depth below grade: 22" Materials of construction:_cast iron X40'PVC�_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER t,. SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcfete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age Coii°finned by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom 6 outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY,TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a t a Material of construction: coucrete'iJnetal_'fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of'.outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a '. Comments(on pumping recommendations,.inletand outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc): n/a t• 4t 1 7 'IA•; Rl Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL{LAKE;RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete ..metal fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present•must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY`SOUND t icy . PUMP CHAMBER: _(locate on site plan)., Pumps in working order(yes or no): NO Alarms in working order.(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a t , D5 R s Page 9 of I I A OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 fi SOIL ABSORPTION SYSTEM (SAS): X,J(locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a INFULTRATORS ° leaching chambers, number: 5 n/a leaching galleries, number: 0 0 leaching trenches, number, length: 0 0 leaching fields, number: n/a n/a overflow cesspool, number: 0 n/a ,.a innoyative/alternative system Type/name of technology: n/a Continents(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE INFULTRATORS, PROBED DRY. INFULTRATORS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. I CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) AT, V, ! Number and configuration: n/a Depth—top of liquid to inlet invert: n/a' Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a , Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a i , Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL.LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY , Date of Inspection: 9/30/02 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. . 4 4 i + .'!5A. �t i0l AA C13 AC (eZ �h 3S i gage I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 247 CRYSTAL LAKE RD OSTERVILLE, MA 02655 Owner: MR. HOLLOWAY Date of Inspection: 9/30/02 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells ,F Estimated depth to ground water.12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO , Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with Iocal,;Board of Fealth-explain:n/a NO Checked with local,excavators,•iiistallers-(attach documentation) NO Accessed USGS database=c:xpl.aan: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. ( x 1 , s TOWN OF BARNSTABLE ' A 0 5 1 LOCATION SEWAGE # f3 �`� VILLAG 40,c4 v J 14 ASSESSOR'S MAP Cz LOT d INSTALLER'S NAME & PHONE NO. Ca f , tj S � SEPTIC TANK CAPACITY S y 0 LEACHING FACILITY:(type) / n (size) NO. OF BEDROOMS. PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: P"' l DATE COMPLIANCE ISSUED: � �� '" �`�� VARIANCE GRANTED: Yes No r, a� jS 'b' U 0 ��r c� 05 ( No....il5 YP3 .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Alip iratiott for Db3pvii al Work.6 Tomitrurtiott ramit Application is hereby made fora Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ............... ,a� � L .... non-Address or Lot No. ---------- --------- owner Address W Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms----------- ------------------------_----.-Expansion Attic Garbage Grinder aOther—Type of Building ---------------------------- No. of persons------------------------ Showers ( ) — Cafeteria ( ) Q' Other fix es .............. . ..... . ........ d - • ------------------------------------------------------ -----------••-t 1. ................................... W Design Flow........ j�_-��___7gallons per person per day. Total fdaily flow.._....... . ..........................gallons. P4 Septic Tank-L Liquid capacrtv_f'._;alIons � ength---0---.---- Width---lam---------- Diameter.---- .......... Depth.............. Disposal Trench— No.S — Width.....------------ Total Length...3-0......... 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........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•-•---••--------•-•--------------•----•-----------••--------------------------------------------......................................................... 0 Description of Soil......................................................................................................................................................................... x U ..................••-------•-----•----------•-----------------------------------------------------------------------------------------------------------•----------•------------.....--------------.---• ----------------- ----------------•--------•-•-------------.. ------------------------------ ---------------------------------------- - ---_-------- U Nature of R pairs or Alterations—Answer when applicable.._ �!�5 :7v�.._-1 (J� & .(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 f rther agrees not to place the system in operation until a Certificate of Corn71i een board health. SignedApplication.Approved By .......... r- ..-- 4{ '"` ---- ---- ... - -^ a 7" e� J Date Application Disapproved for the)11owing rearonf- ------ ------------------------------- --------------------------------------------- ------------------------------ ...................................._.._.........._................_....--..,....._........................_...._..---..........._.......-_.-_......_......_...._.................................. ---------------------------------------- Date Permit No. �� . ®.. Issued ........ ....�../.7 c��� -- - -------- Date ©5 =' No....7 :.. :b7 F/ics.,,,_ . .... THE COMMONWEALTH OF MASSACHUSETTS d BOARD OF HEALTH r TOWN OF BARNSTABLE Appliration for Di-tipoittl Works Tonitrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ............... .... o alion-Address \ or Lot No. .� to ✓I:? --•-•------------------------------ = Vit!-�!F� x Owner Address ..........................•-•-•--••-•------- Installer Address UType of Building Size Lot............................Sq. feet ►, Dwelling— No. of Bedrooms---------- ----------------_-___..___.-Expansion Attic ( ) Garbage Grinder ( ) a Other—Type T e of Building •____________________--_- No. of ersons.-.-_--__--___--__-----.-.-- Showers yp g p Cafeteria ( ) Otherfixxtt res -----------------------------------------------------------•--------------------------- ---------------•- -- ----•-------- ....................... Design Flow-------- per person per day. Total daily flow-__('.(.�_��.........................gallons. W -- 7 WSeptic Tank-L Liquid capacity. �SW4alIons Length---[Q------- Width---(n._._.-.__ Diameter---------------- Depth................ x Disposal Trench—No. Width___---7.-.-..-_---- Total Length___36..__...-- Total leaching area---____-•-_----____sq. ft. Seepage Pit No..................... Diameter--------------.----- Depth below,inlet................ ... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-----------------------------•----------- -----._........._— a Test Pit N:). 1----------------minutes per inch Depth of Test Pit.__ ._.._.______.___ Depth to ground water----.-._-------------__. fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....................................................... ............................. -..............------.......................•-------•...._•••--•••-•-__•-. DDescription of Soil.---•-----------------------------------------------------•------•--------------------------- '' V ---•-•---•--------------------•-----------••----•--••--•-•-----•-------••---- ----•--•--•-----------•-••---..........-.=--------------•---•---••-----•-----••------•••-----------...--••-----•-•••--- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable- ------ --------- f jr'1= r �'G-f Y 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 fPrther agrees not to place the system in operation until a Certificate of Comp�ce-h een issueD the board- health. Signed --------- -- -- I'-- ........ ......... 1 ,�, D�ae Application.Approved By .............. . ............:` - - --------.........---------...------------------------------- .... 1 7 �- Dare Application Disapproved for the following reasons: -------------------.--------------- -------------------_---------------...----------------------------................... . ....... .. ..............._............._........ .. ...... .... .. ......----------------------- Dace Permit No. -- G o---7-------------------- Issued ------- ...:<.../.7...-d�S.:----------- Dare ..n THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Telrtifirate of Complianee THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by _ ..... ..:� ... - ............ ................. .... �- --------------------------....._.---------------------------------------- i ❑scauea ea A at -------------------------..-------�--q -- -----..�.4. �>`t. L=- ._ ._ :.------- ------------------------------------------ --- ` ------------....-- has been instal_ed in accordce with the rovisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit NO. ..._...... — �_'..]....._... dated .............: . .... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSIRUEID AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. /........ Ins ecto ..... - - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q _ TOWN OF BARNSTABLE Uislima1 Workii Tonitrurtion "permit s-- Permission is hereby granted---------------------- � � ------------- �- . ---....................................................... to Construct ( ) or Repair ( n Individual Sewage Di sal System at No------------- ---------_-------_-- _. � �V�� +�.c�.--Y�.`o . --•---------.... ----------------------•. . Street as shown on the application for Disposal Works Construction Permit Noy�".�n7__ Dated------- -------------- ------------------------------------------- Board of Health DATE........ ---•-•---------------------•------•- FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS