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HomeMy WebLinkAbout0064 CURRY LANE - Health 64 Curry Lane Osterville P A 142 109 o , 6 e o ° ° • K I,A ` �t'ys u Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Vol untary"Assessments - t 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name WV information fo is every 0 terville ►� MA 02655 March 29 2016 require d for page. City/Town }: ,h State Zip Code ;'y 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 / �� � on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return David D. Coughanowr, RS• :;; key. Name of Inspector Eco-Tech Rapid Response r� Company Name 155 George Ryder Road South Company Address Chatham MA-1 02633 City/Town State Zip Code 508 364-0894 1328 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 i aO. A OF MgSs e ❑ Needs F•F�tf�� I the Local Approving Authority, 61 "s D. C ANOWIR N March 29, 2016 Inspector's Sig rr re F�/s T ERA Date ,Sq I N The system Inspec ,r mit 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 64 Curry Lane'= Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29, 2016 page. City/Town `" State Zip Code Date of Inspection B. Certif 6 tion (cont) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is recommended. 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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. r ❑ Y ❑ N ❑ ND (Explain below): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,x �M ,•' 64 Curry Lane-Assessor's Map 142.Parcel 109 1. Property Address Patrick Rondeau Owner Owner's Name T information is Osterville , . , �" MA 02655 March 29, 2016 required for every page. CltyrFown 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) r': ^ ❑, Observation of sewagelbackup or break out or high static water level irrthe distribution box due Jo broken or obstructed pipes) or due to a broken, settled or uneven distribution'box. System will " pass inspection if(with approval of Board of-Health).- El. broken pipe(s) are replaced ❑ Y ."❑ N .-" ❑ N,D(Explain below): obstruction Is removed ❑ _Y '' ,❑ N' ,❑ ND(Explain,below): , El distribution box is leveled or replaced ❑ Y,- j❑ N+° ❑ ND (Explain below): 4 ❑ The system required pumping more thanA times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health);; _ El broken pipe(s)are replaced ❑ Y' [IN El _ND (Explain;below):, ' ❑ obstruction is removed ElY °: ElN ❑^ND (Explain below): r' C) further Evaluation is Required by the Board of Health Ej 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' safety t the environment: is not functioning in.a manner which will protect public health,' • y and �. ❑ -%Cess ool or privy is within 50feet of a surface water* W ,� Y w.. ._ Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh- 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17, n Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29, 2016 page. City/Town 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 99 p ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® cesspool Liquid depth in is less than 6 below invert or available volume is less q P , than /z day flow t5ins•3/13• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r v r-.. • . ha r Commonwealth of Massachusetts W Title 5 Official inspection Foam a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Curry Lane-Assessor's Map 142 Parcel 109 s Property Address Patrick Rondeau Owner Owner's Name information is Osterville MA' 02655 March 29°'2016 required for every 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 privyis 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. h ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 ❑ ❑ the system is within 200 feet of a tributary to'a surface drinking water supply _ r 11 El the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—1WPA) or a mapped Zone 11 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17'- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1,y , 64 Curry Lane-Assessor's Map 142 Parcel 109 . Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29, 2016 page. City/Town 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? ❑ ® Y P ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Z ❑ 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. ® E 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address .. Patrick Rondeau Owner Owner's Name information is Osterville MA 02655 March 29 2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A system sized for three bedrooms was installed by DECO-Joe Di iano in 1997.. 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? µ ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage (gpd)): 186 gpd 9 ( Y 9 Detail: 2014: 44,000 gallons 2015:92,000 gallons Sump pump? m ❑ Yes ® No 1 week ago Last date of occupancy: date Commercial/Industrial Flow Conditions: Type of Establishment: , Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑-Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El"Yes ❑ No Water meter readings, if available: i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29, 2016 page. Cityrrown 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: Owner 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): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,. 64 Curry Lane-Assessor's Map 1142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is Osterville MA 02655 March 29 2016 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 18+ years. Certificate of Compliance for a new system was issued 7/16/1997 (Permit#97-157 at Health Department). Were sewage odors detected when arriving at the site? .+ ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. 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: 10.5 x 5 x 6-1500 gallon Sludge depth: 8 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 " R Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29 2016 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 26 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended within 2 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Removal of garbage grinder is recommended 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 • - Property Address Patrick Rondeau Owner Owner's Name information is Osterville MA 02655 March 29, 2016 required for every page. Cityrrown 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 imust 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29, 2016 page. Cityrrown 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 at outlet invert 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.): No adverse conditions observed. 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: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I , Commonwealth of Massachusetts x l ug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth.—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑, No t5ins-3/13• 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 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29 2016 page. CityTTown 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.): 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 W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Curry Lane -Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every n Osterville MA 02655 March 29, 2016 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 LL Oo CA T§Oo HISS -OF SEPTIC COMPONENTS LEACHING GALLERY —DISTANCES IN DECIMAL FEET A 8 2 Q_0 40 h D—Box 3 l 16 52' 2 r 23 54 O4 1500 GALLON 3 26 49 SEPTIC TANK 4 39 37 A B NOT COX§S#NNG TO DVS gLLUNNG SCALE THIS SKETCH IS ? Q BEST VIEWED IN 3 2 COLOR FORMAT -� ¢Ct .. W , lOJ • Q j - � V L- 508 364-08914 CURRY LANE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is Osterville MA 02655 March 29, 2016 " required for every 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: 1 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: 4/3/1997 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: Approved design plan on file with the Board of Health shows bottom of system is 7.5 feet above the bottom of a witnessed test pit in which no groundwater mottling was encountered. 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 W Title 5 Official InspectionForm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Curry Lane-Assessor's Map 142 Parcel 109 Property Address Patrick Rondeau Owner Owner's Name information is required for every Osterville MA 02655 March 29, 2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B; C,'D,,o'r 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 z GEOHYDROLOGICAL PROFILE NOT TO SCALE Z, 4 a W ,w• PRECAST ' ry Z 4' �Ys r°. O DR YWELLa � ` ? .. BOTTOM OF `a LEACHING PER. DESIGN PLAN LEACHING IS - ABOVE HIGH ' GROUNDWATER NO. GROUND WA TER MOTTLING SEEN t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE 6tLOCATION &4Y CV rr (A(%k— SEWAGE # _ '�f 1 S7 V1LAGE OS et V l ASSESSOR'S MAP & LO ICOI INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S0D LEACHING FACILITY: (type) a G�AM�cts (size) /3 x a S NO. OF BEDROOMS 3 BUILDER OR OWNER PAL)l Mll er-'an PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or wihn 200 feet of leaching facility) Feet Edge of Wetland and Leaching''Facility (If any wetlands exist within 300 feet of leachi g facility) Feet Furnished byT^SAGLiv--% ;--r. pcw/ )) _ - -_.� . �� o i 1 A (3 � �� s� a � 3 a a3 sN y 3 �to �g � 3°I 3� TOWN OF BARNSTABLE LOCATION SEWAGE # `-'/' VILLAGE ASSESSOR'S MAP& OT C® INSTALLER'S NAME&PHONE NO. ►� -32) _ �^ SEPTIC TANK CAPACITY 1, 5VD LEACHING FACILITY: (type) �� � �� (size) Z NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 4C —3_Q COMPLIANCE DATE: 9 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 1U)J4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist �(/ Feet within 300 feet of leaching facility) �p / Furnished by y _ 0 I . t U` t . lit No. •, F, .,w: Fee �� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Miopogal *pgtem Conotruction Permit Application for a Permit to Construct(X Repair( )Upgrade( )Abandon( ) AComplete System El Individual Components Location Address or Lot No. <_4- G u lair l_i✓ Owner's Name,Address and Tel.No. Assessor's Map/Parcel MAr 142 tJZL \Gl ���i Ct M AG 0�?2� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. LD _. J0� VAeAA.Z2. r ,b,_SsCX,_. 4X7 Type of Building: Dwelling No.of Bedrooms Lot Size ``�, C50 sq. ft. Garbage Grinder(Vln Other Type of Building WOOD FAAAe 4 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��J�J. gallons per day. Calculated daily flow 30 gallons. Plan Date 1"14ec-A Z-a 110)9�7 Number of sheets Revision Date Title S t Sr—,1jAr 4l; +� Size of Septic Tank 1500 Gam• Type of S.A.S. 44L.M i0eu-5 Vi ` o �� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ` Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment 1 Code and not to place the system in operation untila Certifi- cate of Compliance has been i e B d of Malt _ Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 9 -7 'I S 2 Date Issued — 7 *^� . No. / .1 a•. �.►d Fee * 0000 w� Entered in computer: i. THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pplication for ;Digpogal *pftem Construction Permit Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) KCompleteSystern ❑Individual Components Location Address or Lot No. G4� G i l!.y l� Owner's Name,Address and Tel.No. +ti A_ pgal.it Gea ,o,aF-. Assessor's Map/Parcel 70 �/1 t<1�1 G1,MGL C .M HA - QV? Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �-e GO — SOe v VAB-L C .4ssc�.. P. o. t3io� 4-17 Type of Building: Dwelling No.of Bedrooms 3 Lot Size 101, OSO sq.ft. Garbage Grinder(oVII) Other Type of Building yi(,, ii &&A,a No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .353, Q gallons per day. Calculated daily flow. 3 3O gallons. Plan Date M AMCA Z811� Number of sheets , Revision Date Title S 1 1 Q Size of Septic Tank 15oa Get.. Type of S.A.S. a.) L W ' e Description of Soil J Yrt` Nature of Repairs or Alterations(Answer when applicable) Date last inspected: r f� Agreement: ,...P The undersigned agrees to ensure the construction and maintenance of the afore described on-site.sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i�red y B d of 1�ealth. s1 Signed Date ,,. Application Approved by - Date Application Disapproved for the following reasons Permit No. 9 -7 / Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS a Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( v�Repaired ( )Upgraded( ) Abandoned( )by \joi_= z)I C//f Am - 6 e co at -# / C� r U'eg� h L UE dS TdE..g V IC L� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.5.2-1S"2 dated V- ? 9 . Installer a.. Designer The issuance of this permit hs all not be construed as a guarantee that the syste will function as designed ,, -Date "'7 - —^� Inspector No. 9 ��7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS wigozal *pgtem Construction Permit Permission is hereby granted to Construct( 4epair( )Upgrade( )Abandon( ) System located at 4 IA (_'y9A Y Lfi AIr !),5 T rf=d J LtE and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thii$-permit. Date: L/ ' 2 Approved by 1 J1 1 f TOWN OF BARNSTABLE 7. LOCATION �U� ` /� SEWAGEI# VILLAGE ASSESSOR'S MAP & O. INSTALLER'S NAME&PHONE NO. 3ag-- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C1f� l8! (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: '3 —Q 7 COMPLIANCE DATE: -.I G...� 97 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ..' Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet.. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished byL—T—el R .. V (r(]�L�`� //���✓ I b,Y* o Z 3 i -- a 3 Y Y? 35 3`,5 ' O o _ _ _ 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROT CTIOLNCEIVED OCT 1 0 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 82 CERTIFICATION Property Address: 64 Curry Lane Osterville MA 02655 Owner's Name: Paul Myerson Owner's Address: Date of Inspection: October 2 2002 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Map; 142 Mailing Address: P.O. Box 49 Osterville MA 02655-0049 Parcel: 109 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 5, 2002 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: 64 Curry Lane Osterville, MA Owner: Paul Myerson Date of Inspection: October 2, 2002 Inspection Summary: Check A,B,C,D or E/:ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.. ND explain: Observation of sewage backup or break out or high static water-level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Curry Lane Osterville AM Owner: Paul Myerson Date of Inspection: October 2, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Curry Lane Osterville, AM . Owner: Paul Myerson Date of Inspection: October 2, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. . _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 Curry Lane Osterville, MA Owner: Paul Myerson Date of Inspection: October 2, 2002 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 Curry Lane Osterville, AM Owner: Paul Myerson Date of Inspection: October 2, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 - Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no) No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend Use COMMERCIAL/INDUSTRIAL. Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persoris/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: { OTHER(describe): GENERAL INFORMATION ` Pumping Records Source of information: New system never pumped Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons.--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soi.1 absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 7116197 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Curry Lane Osterville, AM Owner: Paul Myerson Date of Inspection: October 2, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete metal _fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1 S00 gal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Afeasuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every 3 years GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I ` Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Curry Lane Osterville, MA Owner: Paul Myerson Date of Inspection: October 2, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: - Capacity: Gallons Design Flow: gallons/day Alarm present(yes or no): ' Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level- Clean no solids present. No sign of backup or failure from leach field. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Curry Lane Osterville, MA Owner: Paul Myerson Date of Inspection: October 2, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. chambers 13'x 25'per as-built leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The chambers were located but not dug up. No sign of failure in D-Box.. Bottom to grade was approximately 4. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Curry Lane Osterville,MA Owner: Paul Myerson Date of Inspection: October 2, 2002 Map: Parcel: 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 � I A (3 3 a 013 Sy y 3 c96 yq 30) .37 10 Page 11 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Curry Lane Osterville, AM Owner: Paul Myerson Date of Inspection: October 2, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach field to grade was approximately 4. Using Barnstable Topographic Map and water contours map.Maps are showing app. 20'+/-to groundwater. • s This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 Town of Barnstable P# 74- Department of Health,Safety,and Environmental Services IMF Public Health Division Date N Date Scheduled 367 Main Street,Hyannis MA 02601 = 6ARMABILA • �.f. + r + MASS. 2� et� Time I oclk Fee Pd. rfnna+� 3 Soil Suitabilit0sse S CS 1. t for Sewage;Disposal ��z Performed By: � l � Witnessed By: LOCATION & GENERAL INFORMATION Location Add r ss Owner's Name U CUIZAq Address Assessor's Map/Parcel: Engineer's Name �[ a2� , NEW CONSTRUCTION REPAIR Telephone N �' S �J Land Use t✓ �'`� Slopes(°/.) �2 — Surface Stones°_ Distances from: Open Water Body+ `✓O 11, Possible Wet Aria' ft J Drinking Water Well S1;„rig. 1 l.},�,I;J•7 �� •� N Drainage Way + _R Property Line 1' '. 14R Other ` SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) r S�oa'C 5-4F Parent material(geologic) �x �$ Depth to Bedrock + 11LJLi Depth to Groundwater: Standing Water in Itole: /1, _ Weeping from Pit Face Estimated Seasonal High Groundwater 1`ll ► , DETE MINATION EORSEASONAL IIIGIi W Tt it iA►3Li, Method Used: Depth Observed landing in obs.hole: in. `Depth to soil mottles: in. Depth to weeping from side of obs hole: in. Groundwater Adjustment R. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST' balls 2� �( Time 1 :0d Observation Hole N Time at 9" v In,/ y Depth of Perc - �1� 1� Time at 6" Start Pre-soak Time @ ' r Time(9"-V) End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public health Division . Observation Hole Data To Be Completed on Back-� Copy: Applicant ' ' DEEP 013SERVATION hIOLE LOG Hole# Depth frorn Soil I lorizon Soil Texture Soil Color Soil )thcr Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,° l3oulderes. nGravel) , 3 „ ICUR DEEP OBSERVATION HOLE LOG Hole# Z Depth from I Soil I lorizon I Soil Texture Soil Color I Soil Other Surface(in.) (USDA) (Munsell) Mottling (Struciure,Stones,Bodideres. 5jo ell- O�M7 ,.DEEP OBSERVATION HOLE LOG Hole# Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,l3oulderes. i n ° Gravel) I DEEP OBSERVATION HOLE LOG Hole# Soil I lorizon Soil Texture Soil Color Soil ' Other Depth from rre Stones l3oulderes. p (USDA) (Munsell) Mottling (Structure, Surface(in.) n i enc ° Gravel) N T Flood Insurance Rate Map: Above 500 year flood boundary No Yes " Within 500 year boundary No— Yes Within 100 year flood boundary No_ Yes ✓ Dcpth of Naturally Occurring Pervious Material Does ate least four feet of naturally occurring pervio s material exist"in all areas observed throughout the area proposed for the soil absorption system? .-- t-. If not,what is the depth of naturally occurring pervious material? _ Certification 1 certify that on I (date) I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was perfo d by me consistent with the require ing, exp se a 'ence described in 310 CMR 15.017 I Signature - — ____-- Date Zl Q1 / TEST HOLE LOG CiVq, /ti vTiL.,��G,�, / DATE:: Z7� i 9Y7 ,c::,— 8GJ t 6 ` SOIL EVALUATOR: 27. 1W-q50,J / WITNESS: PERC RATE: Z x-l��/•�%vc.� G V p lv /-� z/•, IV 39 o„ c /.` 0 _ oj DESIGN DATA 0 -� DAILY FLOW: (3)BDRMS.z 110 GPD=336 GPD SEPTIC TANK: 33oGPD z 200%s 6-6-0 GPD Iv Z8 USE: /5 0o GALLON PRECAST SEPTIC TANK > 3 V LEACHING FACILITY: VUSE: Cz� x S,Sx Z"�soa)mac. 0�2y�6crc.5 CAPACITY: SEDEWALL: 7G X z x o,7y_ //Z,S h� BOTTOM: /3'le ' TOTAL: 3 I � NOTES: ol~A M 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. V 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION Q BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. S. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2•LAYER OF 3/3"PEASTONE OVER E 3/4--1 1R'WASHED STONE ALL AROUND TOP OF FOUND- EL. 7 C• b 10- 14- z(;.. C! d 30.so zs v o 30, zs SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 15.00:TITLE V. f��� J� 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE i DETERMINATION. DATE: _ 99,'• z8 /J97 SCALE: 4• ALL DISTURBED AREAS TO LOANED AND SEEDED. S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY j REQUIRED INSPECTIONS. 7- t ice' �9/Zc-� o/c �/ c-yam Co•.J�c�'.✓_ H OF I f4.s9p p DANIEL 1. yG MAMAN 0 cm WELLER & ASSOCIATES A No.32696C�O FT,E1645FALMOUTH ROAD CENTERVILLE, MA. 02632 ?o �'OISIrEL: (508)775-0735 FAX: (508) 775-0754 �Ess APPROVED BY: TEST HOLE LOG �iVA, /�v uTiL,f7�GE, DATE:'. IIAIZ. Z7� / ,FY7 P— 89l SOIL EVALUATOR: ,41 ylySo�J WITNESS: i PERC RATE: Z -1i^/•�%vc.s� 3 Y LY/lp/VN/G 1 00 �v G A Z�y A � g 4— 36MN 2 6� Z 1�' a QopoG�,/CT y�(L Inhp !q.� � ^Z /~ f o _ '' °� DESIGN DATA O DAILY FLOW: (3)BDRMS.z 110 GPD=33o GPD SEPTIC TANK. 33o GPD z 200% GPD Zf3 j 3 USE: /5 0o GALLON PRECAST SEPTIC TANK / 3 V LEACHING FACILITY: i V USE:.�L, S,sn z'�soe)mac. p2ywEc.c.� D CAPACITY: SIDEWALL: 7G X z,X a•7y= //Z,S BOTTOM: /3�� Zs ico.�y - Zyo,5 TOTAL: �\ /;i' it NOTES: Ift~Aum ~ 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. V 2. PIPE TORE LAID LEVEL FOR 2'OUT OF DISTRIBUTION BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEL 2•LAYER OF 3I8•PEASTONE OVER 3/4•-1 112•WASHED STONE ALL AROUND 1 TOP OF L. /FZ a OUND. E 10• 14• 7 -- 30.sa ZR v a v Tom. ,30. ZS SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR G 5" G�2.�Y �:�cJ, TO ANY EXCAVATION OR CONSTRUCTION. /Z 3; 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 15.00:TITLE V. 3. THIS PLAN 15 NOT TO BE USED FOR PROPERTY LINE �7 J DETERMINATION. DATE: 997 SCALE: 4• ALL DISTURBED AREAS TO LOAMED AND SEEDED. S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. OF 9 DANIEL RAMAN Gv, 4 cIVIL WELLER & ASSOCIATES 0 No.22696C H FTIE645FALMOUTH ROAD CENTERVELLE, MA. 02632 A?o��arsTEL; (508)775-0735 FAX: (508)775-0754 APPROVED BY: Fss