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HomeMy WebLinkAbout0055 DEERFIELD ROAD - Health 55 Deerfield rRoad ° Osterville <P A = 166 080 o , 1 e : a a _ , ° J m TOWN OF BARNSTABLE LOCATION S� Jrf�,F`/'g-Lb SEWAGE# {: VILLAGE Q 5'V-rzR1a11_J F ASSESSOR'S MAP&PARCEL . oko INSTALLER'S NAME&PHONE JNO. y e'5 rd rJcp IIr>� SEPTIC TANK CAPACITY /,a 0 0 1&L L OA I (type) 0 Cis- LEACHING FACILITY: ahe / NO.OF BEDROOMS- OWNER- AD HILL PERMIT DATE: /&"'Z COMPLIANCE DATE: Separation Distance Be een the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Z , J .� �q tfQ 4Z74 ' �. 9D 1 o c� e vi [l l r T';f y � No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye -- " PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pphtation for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No�,S`✓� LsTC I¢L ID leO4 f* Owner's Name,Address,and Tel.No. Assessor's p/irarcel� ` Installer's Name,Address,and Tel.No. �'U '9 2 7 ;Z r,Na�e,Q(ld �d Te Now rj$ 3 1�17 /Jh G �,/�/ dYGF 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder,(--r Other Type of Building P s L No.of Persons Showers( ) Cafeteria"f,� Other Fixtures Design Flow(min.required)) ?> 37® gpd Design flow provided 7 gpd ' `� /Plan Date / / ee� Number of sheets Revision Date Title i5 5' Size of Septic Tank Type of S.A.S. Description of Soil r / © o L Nature of or Alterations(Answer when applicable) �_ c nod-) &4 L G Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and t to place the system in operation until a Certificate of Compliance has been issued by this Board of Heaftx. Signe Date f 6 Application Approved by 1 t Date �` l Application Disapproved by Date for the following reasons Permit No. a.V - yLj Date Issued12—IA % a. took No. X Fee THE COMMONWEALTH OFMASSACHUSETTS Entered in computerk Yes I ' ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatgon for -Misposaf 6pstem Construction permit Application for a Permit to Construct( ) Repair(t/<Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot Nod S ,rJC�l �rJE y Q /204 P> OvAfiier's'Name,Address,and Tel.No. Assessor'sap/Parcel Q Installer's Name,Address,and Tel.No. �0 y-f 7 1- Des r' Na e, d r ss and TeL No. 7 7 � N Type of Building: Dwelling No.of Bedrooms Lbt Size sq.ft. Garbage Grinder(/) Other Type of Building J T>,Eaky No.of Persons Showers( ) Cafeteria(- -}-Other Fixtures fJ )InL- P t� 7�1 Design Flow(min.required) 3Q gpd Design flow provided �S' / gpd Plan Date / �� Number of sheets / Revision Date Title S 5:o, 6- r' Size of Septic Tank (7� �C Type of S.A.S. r Description of Soil }S r t� S/7/ Co Nature of Repairs or Alterations(Answer when applicable) fw P 5,C/SS�'!/�"� /��/�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and t to place the system in operation until a Certificate of Compliance has been issued by this Board.,of Health?. Signe Date 1 !� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �(� �J — y� Date Issued /1 114 4 ' THE COMMONWEALTH OF MASSACHUSETTS. BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Vr Upgraded( ) Abandoned( )by , at { ` has been constructed in accordance with the provisions of Title 5 sand the for Disposal System Construction Permit No.a -Ll f Aated Installer �( �(� S Designer / #bedrooms Approved design flow —3 gpd The issuance of thi permi shall not be construed as a guarantee that the system wil Dct n esigned. Date / Inspector h/-'. ---- ------ � �----- - ---------------------------------------------- -------------------- ---/lJyi -_---.._ No. Q o Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Co struct( ) Repair( t-� pgrade( ) Abandon( ) System located ata �& /I and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be completed within three years of the date of this permit. Date (Z /�ljJ Approved by z i Twn of Barnstable . Regulatory Services Richard V. Scali,Interim Director t aniwsrns� A`0 Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-63.04 Installer& Designer Certification Form Date: Zo T � Sewage Permit# Assessor's Map�Parcel ` Designer: i Installer: Address: Address: On was issued a permit to yinstall a (date) (installer) septic system at rY;) ` b::fE�LJ;? based on a design drawn by �nA� ,1 ((address) %1 0 r`'I' "`�d dated (designer) I certify that the septic system referenced above was installed substantially according to ' the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the sy tem referenced above was constructed in_cQ reliance with the terms of the IAA a rov letters if applicable) PP ( PP ) At%OF Af4, DAVID r ( s all r S gnature) MASON v No.1066 a (Designer's ignature) (Affix Desi mp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Desiper Certification Form Rev 8-14-13.doc Town of Barnstable P L5 Departiment of Regulatory Services i ZMNAM k Public Health Division Date MAM 1,639. 200 Main Street,Hyannis MA 02601 t Date Scheduled Time— =— Fee Pd.— Sail Suitabili Assessment for Sewage Disposal Performed-By: Witnessed By: 1 LOC N&.CAENERAL INFORMATION Location Address J `1,� s�.M� Owner's Name J Address Assessor's Map/Parcel: ` Ito(9/-S T Engineer's Name . NEW CONSTRUCTION RBPAIR Telephone# Lnnd Use• Slopes(9G) Surface Stones Distancea ftom: Open Water Body ft Possible Wet-Area ft Drinking Water Well ft Dralhage Way i ft Property Line ft Other ft SIKETCH:(Street name,dimensions of lot,exact locations of test holes&.pere tests,locate wetlands?a proximity, to holes) i Parent material(geologic) Depth to Bedrock Depth to Oroundwater. Standing Water in Hole: Weeping frotn Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL-HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _ _ In, Depth to loll mottles: In.' Dellth to weeping from side of obs.bolo: In, Groundwater Adjuslmont ft. — Index Wett-#. __RondingDato; Index Wall level Adj hetbrAtQ.drauntlwatar•1.aval,,,_ PERCOLATION TEST ' Dale,..._,.,_ Time Observation Hole# Time at 9" Depth of Pero � . Time at 6" Start Pre-soak Time 0 Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Slto Passed Si to Failed: Additional Testing Needed(YIN) Original: Public Health Division Observtititin Hole Data To Be Completed on Back-- ***If percolation testis to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(I week prior to beginning. Q;\SEPTIC\PERCFORM.DOC • �b DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil Horizon Soil Texture Sdil Color Soil. Other Surface(In.) (USDA) (Munsell) Mottling (Stnucture,Stones,Boulders. o rsistency.%'Orival) 2J DEEP OBSERVATION HOLE LOG Hole# Depth from Sall Horizon Sail Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 9 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sail Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders., DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sall Color 81311 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,SSooes',Boulders, 0 Mood Insurance Rate Map: Above 500 year Mood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No,,-- Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervlo s�,m'terial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what Is the depth of ha rally occurring per Ions matarial? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ en 1 Protection and that the above analysis was performed by me consistent with . the requig4jEatning,expertise ' nc described in 410 CMR 15.017 Signature Date 1 QN4 EPTIMRCPORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION Lnv PARCEL 004LOT _ "" STABLETITLESPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 Deerfield Road Osterville Owner's Name: Frances O' Keefe Owner's Address: Date of Inspection: 2 d -- ✓ G y Name of inspector:(please print) W i 11 i am E_ •Rob inson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT 1 certify that 1 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 an maintenance of on site sewage disposal systems.lam a DEP approved system inspector pursuant to Sec . n 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: , ,�� Date: /,,)' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanhvr 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. r 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 !!t Page 2 of 11 o OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Deerfield Road Osterville , Owner: Frances O' Keefe Date of Inspection; Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: 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: i B. System ditionally Passes: ; One or m re system components as described in the"Conditional Pass.'section need to be replaced or repaired.The syst m,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or n t determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound,exhibits sub tantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is rcplaceV with a complying septic tank as approved by the Board of Health. •A metal septic tank w 11 pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank s less than 20 years old is available. ND explain: Observation of s wage backup or break out or high static water level in the distribution box due to-broken or obstructed pipe(s)or du to a broken,settled or uneven distribution box.System will pass inspection if(with , approval of Board of H alth): broken pipe(s)are replaced i obstruction is removed distribution box is leveled or replaced ND explain: The system requ ed pumping more than 4 times a year due.to broken or obstruxled pipe(s).The system will pass inspection if(with a proval of the Board of Health): broken pipe(s)are replaced < a obsbuction is rcmovod ' ND explain: r Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) I Property Address: 55 Deerfield Road Osterville Owner: Frances O' Keefe Date of Inspection: — !� C. riher 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 failin to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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 sy em 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 urface water supply or tributary to a surface water supply. The system has a septic.tank 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 tank and SAS and the SAS is less than 100 feet but 50 lector more front a pr vate water supply well•• Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bz cteria and volatile organic compounds indicates that the well is free from pollution from that facility and t4 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other f lure criteria are triggered.A copy of the analysis must be attached to this form. 3. Oth r: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Deerfield Road Osterville Owner: Frances O' Keefe Date of Inspection: ��— D. yslem Failure Criteria applicable to all systems: You ust mdi(ate'�es"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',day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr of times pumped — Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or.privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates(hat the well is free.from pollution from that facility and (lie 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(he analysis must be attached to this form.] (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. Larg Systems: To be con dered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must' icate either"ycs"or"no"to each of tite following: (The follow' g criteria apply to large systems in addition to the criteria above) yes no the s stem is within 400 feet of a surface drinking water supply — _ the sy tcm is within 200 feet of a tributary to a sin-face drinking water supply the sys pm is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Zone ll of a public water supply well If you bavc answe d"yes"to any question in Section E the system is comsidered a significant threat,or answered "yes"in Section D bove the large system has failed.The owner or operator of any large system considered a significant threat u er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: 55 .Deerfield Road s ervi e Owner: Frances O Keefe Date of Inspection:, Zo—`,� 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 lI/Were any of the system components pumped out in the previous two weeks T :Za've Ha the system received normal flows in the previous two week period? large volumes of water been introduced to the system recently or as part of this inspection?_ v— 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? v 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 —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 an of the failure criteria related to Part Cis at issue approximation of distance. — � Y PP is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 Deerfield Road Osterville Owner: Frances O Keefe Date of Inspection: r —D 71 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:_�L_- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no)� [if yes separate inspection required] Laundry system inspected(yes Seasonal use:(yes or no)� Water meter readings,if available(last 2 years usage(gpd)): 2003 - 38, 000 . Sump pump(yes or no): d/ - 55,000 Last date of occupancy: COMMERCIA USTRIAL Type of establis ent: Design flow(b don 310 CMR 15.203): gpd Basis of de ow(seats/persons/sgft,etc.): Grease trap p sent(yes or no):_ Industrial w to holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water me r readings,if available: Last dat of occupancy/use: OTHE (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part the inspection(yes or no):_ If yes,volume pumped:_gallons-=How was quantity pumped determined? Reason for pumping: TYPE S�'STEM _ eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all'components,date installegif kn and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 1 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Deerfield Road Os ervi e Owner: Frances O Keefe Date of Inspection: BUILDING SEA ER(locate on site plan) Depth below gr de Materials of c struction:_cast iron _40 PVC_other(explain): Distance fro private water supply well or suction line: Comments n condition ofjoints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) )1 Depth below grade:_._s_ Material of construction. 1�oncrete metal_fiberglassPolyethylene _other(explain) — _ If tank is metal list uc:, Js age copfrmed•by a Certificate of Compliance(yes or no):—(attach a copy of certificate) ff , w. Dimensions. _ L c Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: •-G Distance from top of scum to top of outlet tee or baffle: I?' t y Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: tT R •v C o y y¢ g Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related too let inert,evidence of leakage,etc. GREASE TRAP:_(locate n site plan) Depth below grade:_ Material of construction: concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scu .to top of outlet tee or baffle: Distance from bottom o scum to bottom_of outlet tee or baffle: Date of last pumping: Comments(on pumpin reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inv ri,evidence of leakage,etc.): 7 Page 8 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Deerfield Road nGtPrvillP Owner: Date of Inspection: 6 °-o e TIGHT or HOLDING T K: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constructio : concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: rallons Design Flow: allons/day Alarm present(yes r no): Alarm level: Alarm in working order(yes or no): Date of last pump' g: Comments(cond' ion oral f alarm and float switches,etc.): DISTRIBU TION BOX: (tf present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 6 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.): PUMP CHAMBER: (loc on site plan) Pumps in working order(yes r no): Alarms in working order( s or no): Comments(note eonditt 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: 55 Deerfield Road Osterville Owner: Frances 0' Keefe Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Typ leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): l CESSPO /na esspool must be pumped as part of inspection)(locate on site plan) a Number ang ation: Depth—toid to inlet invert: Depth of ser.Depth of ser:Dimensionspool: Materials uction: Indication ndwater inflow(yes or no): Commentsondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (loc a on site plan) Materials of co truction: Dimensions: Depth of sol' s: Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Deerfield Road Os ervi e _ Owner: Frances O Keefe Date of Inspection: /G O `7 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. 30 10 Page 1 I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Deerfield Road Osterville Owner. Frances O'Keefe Date of Inspection: 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: C,Iecked with local excavators,installers-(attach documentation) (/Accessed USGS database-explain: You must dgscribe how you established the high ground water elevation: 11 R. A. Bousfield Backhoe Service 17 Burbank Street Sandwich, Massachusetts 02563 name .w AL`j F tR Sewer Permit No. 36 "7 7 Location. _�CtiFZ t=�r\ �-O , L oT D Builder's Name and Address f-)r(-N Date Permit Issued: 1) 1,16 1 `71 Date Compliance Issued: ��;{ • � �" � W d� U c" �:. �� I�, �I; �I i r �,. .. �'� p, �-" � k •r. l 1., A/e v' 190 .77 A� -. 9No...... Qa _� Fx$......�`..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® Qf HEALTH '. ...............OF.....-. ... ... .------ ,Appliration for lhiipos al ,arks Toustxnrtinn rnmit Application is hereby in fo a Permit to Construct �X,) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or t No. Address ........ l�Ct Gf � 1t �. .................... Installer Address Type of Building Size Lot...Za, 6 .: Sq. feet aDwelling—No. of Bedrooms......... ...............................Expansion Attic (—) Garbage Gander p-, Other—Type of Building ............................ No. of persons..........:................. Showers ( ) — Cafeteria ( ) Q' Other fixtures . W Design Flow... _ _.____.gallons per person per,day. Total daily flow...................3.1.0.........gallons. WSeptic Tank—Liquid capacity��Q�.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width............. Length......_.....___..___ Total leaching area....................sq. ft. Seepage Pit No.....1............. Diameter../�t ept�i below i let......_..:.......... Tot lea ing area..................sq. ft. f' Z Other Distribution box (x) Dosin t nk ) v � �� � , Percolation Test Results Performed by... _y/_, ' _._.._.................................. Date...� ____a_mlf17 a a Test Pit No. 1 sl oRle�minutes per inch Depth of Test Pit....la_�........ Depth to ground water........................ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ yy� nn 0 Description of Soil..... "4 V •----------------------- •-•-------- ._.....------ •-------------- ..._..... ------- _--------___------------------------•---•---------------------------•----------------------•---•-••---------------- W VNature of Repairs or Alterations—Answer when applicable................................................................................._.._........... --------••--------------------------------•----...-•----•--•--------------.......-----••----•----------•----....--------------------•------------------•---•----------------------------.._....•--•--••. Agreement: The undersigned agrees to install the"aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...........4 - /� �2 _`�'� � .7 " ... .... Date..7 ---• Application Approved By--------�� 1 " Date Application Disapproved for the following reasons_____________________________ :_. ___�-_::_.___ ............................................... Date MPermit No......................................................... ued_....................................................... Date IN, ; No._.. ..... .... Fus.............. ........ TOME COMMONWEALTH OF MASSACHUSETTS ;. . ' B0.A ALTH ------------ ............. OF.... --- --.•. ................................................. ApplirFation for Disposal Works Tonstrnrtion Vrrmit Application is hereby made for a Permit to Construct`( ) or Repair ( ) an Individual Sewage Disposal System at ............ - ........ .................................................... ------ Address---�.ocation- ,' or Lot No- �-�•r ................... InOstaler .�4� t,�� � ler Address Type of Building a Size Lot./ q ----_"----•Sq. feet U Dwelling—No. of Bedrooms-----------------�---•--................Expansion Attic (--) Garbage Grinder a a Other—Type of Building ............................ No. of persons__..-__..._................. Showers ( ;)..;— Cafeteria, ( ) } r , Otherfixtures ----------------•-•--- --••-•---•---------•------•--•--•----••••-•-•--•----•--••--••--•--. ••`--•.--•------ W Design Floe ' g p p..................:�_............____gallons per person per' day. Total daily flow...............3..3..�1...............gallons. WSeptic Tank—Liquid capacity�022gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... W i d �T�1 Length s ...... Total leaching area....................sq. ft. Seepage Pit No....Z............. Diame --------- . Depiffii below inle ......:_::.......... Total leachingarea..................sq. ft. Z Other Distribution box (k� Dosing tank ( ) d10- a- ;04 e '~ Percolation Test Results,. Performed by.._----- Date_..._....__ �_- '� o!Z fe p p - p ground � �' Test Pit No. 1a......_...4ninutes per inch De ti of Test Pit______f�_.._._. Depth to ound water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w ...y...(_/j._..._�•a_._________•.............................................. _. ...___..._.__. Os...�. e4f -. V '� ........................................ Description of Soil---•- _d.�a.P�,F.. S2-_ -=•• ........................ V -------------- -------• •. • .............-- ....................................................................................... W = 3' •--•----•------•-----•----------••--•....................•--------...-------•-------•-•-••-•-•--••-----•-•. -, .................... 0 Nature of Repairs or Alterations-Answer when applicable_________________________-------_.............................................. ............... Agreement, , The`under,signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued by .he board of health. n_ e C}' igned..................... f -------- ----- -- --------fir---•--•--- Date Application Approved By............. � - a--- j� ---------jp:`........................f ✓ Date Application Disapproved for the following reasons------------------------------------------••----------........................................................ ----...-•----------------------------•--...--•---------------.............------.............------.......•--------------------------------...---"-----------------------------------........................ .,Date "` , •Permit No....:......................`.:. -� Issued.-----•==--•---•----••----------..:. : - -•.... ..........••-•- Date .. ._.__ THE COMMONWEALTH OF MASSACHUSETTS4 ,OARD ..OF EILTH O F Prtifiratr of Tompliaurr T TO C TIFY, T t t ndividuaj,Sewage Disposal System constructed ( ) or Repaired ( ) by ..... •.......- ,_ .... .......... .. = �at W......� ----- ----• '-�. -------:... "'"---- +--T- _. ............. •-- --------------------------------•-----------......--------•------ has been installed in accordance with the provisions of m ^he State Sanitary C s ib in the application for Disposal Works Construction Perini No................. .................... dated .......................................... THE 'ISSUANCE OF"'THIS CERTIFICATE SLL NOT BE CONSTRUED AS A GUARANTEE:THAT THE SYSTEM 1LL,TUNCTION SATISFACTORY. DATE.... - .. Inspector ....._. ----- •---- _.. ._.- Bj .el THE COMMONWEALTH OF MASSACHUSETTS BOARD 9V HEALTH v•"v`..`........OF................................................. ............................... f ; N . • �.... FEE ...... -ins•. ..... tta1 rkono n prrmit Permi'ssioereby r ., grane t ...t to Constru of epair ndl >f spo1 =' at No... ` --•---••---• ---................ ....................................... - ------------------ --- ..... Str t f�� • as shown on the application for Disposal forks Construction PNo 2 r!.. ti .. .. ...__...... . Board of Health DATE--- -•-•----•-----•...............•-• ................._ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS- ` 'rst, _ _ _ uJ rtc. TA► L/ - '3!?D Y. 1S0 �E w4t._t... b2GA = t5o SF y \ t -� 5F � C) ..c7 ��P"D. 4�, sEnrrc M� 57 Al _...""�;� `I7>a.S I!e 1+1 a GL'L�✓ L�•P�,7. � B`'` �o '' F�:..�„�'�ST ( I��I 2. /tom►.! off:. t..�-�,. �'-c-�, �-'��,...f Tip a r y su ..� Top �Nn • /oa,O Tr�"�17 7- Ice. =97 FIST � �P4� ' Box /.Vt/ 9G,a IUD/ "t5.3o a 9 Pi T� 95t3 C-S-IZT11<IaD pL-c6T- L d GAT t o tJ ( 7T=-,,/t : THAT Tt� P4._.,AQ RC-P-Eza�QC : t 1 EQ Er c�►.1 CGvV\PLIf"G V✓t Tta Tt-It= 51 D'E 'LI 1 C--- SET$ACIG %ZGQVIQ-EAAe"TS Of= TNT 1 RE�lSR�iZ�t� t-At.ty SV2v�Yo�z.1 TWI'S FLAW 1> L(OT 13Acit=U 0"4 A.BJ 0STC2!/1Lt-G- v AAAS,,;�, APPLt �b.tJT r ASSESSORS MAP : TEST HOLE LOGS PARCEL: �('SQ __ _.___ ---- -- I) "fire installation sliall corrrpl� wt►li Title V anol 'town 4k4ftfAloard of FLOOD ZONE: /4 _ _ .._.___ �___- WI TNESSALUATC SOIL R : 1 � i', G I Iealth Regulations. t 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE: _ � G _ G ,_.. .._..__.. DATE:_!!� L `' 7 - components prior to installation and setting base elevations. PERCOLATION LATE:: 1 1 '-- 3) All gravity septic piping to be 4 inch Sch ,l0 PVC at I/8" per Fi�ot. "I'he first z�VC 7<0 qp _ .. _� _ � y�' f�l.�y. 11�� 4►� k two leer rnrt of the d-box to the icirchinR shall be level. 4) This plan is not to be utilized for property line determination nor any other TH- I TH-2 purpose other than the proposed system installation. A © 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over I I10 septic components. 7) The property is bounded by property corners and property lines. 8) '['he property owner shall review design considerations to approve of total LOCATION MAP design flow and number•of bedrooms to be considered for design. Receipt ), of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled will) material 1 L ° per Title V abandonment procedures. Those within the proposed SAS shall 2 5-`q7 be removed along with contaminated soil and replaced with clean sand per + A o) Title V specs. 0 10)System components to be 10 feet from water line. Sewer !fines crossing the water line shall be sleeved with 4_inch SCII 40 PVC will) ends grouted if applicable. The proposed SAS is being installed below the water service line. 'file line is to be sleeved as aforementioned and maintained in place. SEPT I C SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. 90.2 7' 14.00 FLOW ESTIMATE ' 12)The histaller is to take caution in excavation around the gas line iI'such o _ exists. 13 OEDR00MS AT M GAL/DAY/BEDROOM •� GAL/DAY 13)Tae installer shall verify the location, quantity and elevrtitiun of the sewer i lines exiting the dwelling'prior to the installation. ' 1`�•3' 14)fl'his plan is representative only that a system can fit on a property meeting ' SEPTIC TANK n (' p Y b A' 10' ro W o, ooD `title V requirements.V11 Q 1 0.3' DECK GAL/DAY x 2 GAYS - GAL 20 ? - USE /LTO GALLON SEPTIC TANK j SOIL ABSORPTIPSYSTEMzo —_ • , SIDE AREA: Z Z , 1�,,: ZX ) �11, �j _q yy t � r � � DAVID c' Cf, 4 BOTTOM AREA: Z� 1 Z► �C Ui - Z37, �' ( Q MASON rl O ' 0 p No.1066GQ Gyp l 9 0 9 TA , I ;ram 00 SEPTIC SYSTEM SECT I ON ,�o L L L . R_ 1 w+q A=27.0 R=206.89' / 28.29' .�.��YLLi A 63 13' _---- Hw o GAL � dE�RFIELp EI ROAD SEPTIC TAN '' a l v _ �� - ` t, , i SITE AND SEWAGE PLAN , LOCATION : v { PREPARED FOR : �wr rj, Lf O' �q i SCALE: W DAV I D B . MASON ?6 DATE: a1Z 201� z . DBC ENVIRONMENTAL DESIGNS s EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833— 2 177 i