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HomeMy WebLinkAbout0060 DEERFIELD ROAD - Health >r 60 Deerfield Road PF ,A= 166 070 Osterville I I i -S M BALD® No.2-153LGM UPC 12134 smead.com a Made in USA 9MD�� p U CY I M� !y t� � F i .+B-• 1�5 �� vA� k.,�� � `t�-,�",#�.� 3,�j6 �'� �. :i 5 X L.�„�•p � ti.. $.�'*} it .%IP�p'��*QI. E't, .+• _ yr,.cW'9 c`f. tgs"i.'ts�'�`� �� s'�a.�'"� �.• a "-m�+° '� --r:r �, xd-r '- at-a m t 4 �'2"Z"s z a�x' `. .,r. y r �,(„j +'}v�Iyttp•�'' r�' ; aa s3 a,� r cs y _' ¢ � �Z-f�� i."� g to S t •fi z° �w "erwiA".+w ,g� ? �- �" . •+ 7' �-� f syE n �� .x, T *a`t'�:` 4" �wd;' r•ra ° �`� F'.i �Yr.'A^ t ? -=• _, MITI '�* 1(T a r � ,'�s' ,il Al •a:,.K ,pi lf ,-¢ .t a' . A T ,s : t`•t r r+ F .k ' J �PS '� new., •2 �'�,,. rf.yAW 0�g �•^'-r' �` £ � •rv,,. �, a... Ca .1�(.,t Vx a L^�.,(r" r�"�"�`+•�s, }F'��' � �� c.f ° �G�s s�.d'� a a` PS-pe��'1.��«'�} 'l lye. r�T�'�4/ �O. 'e e, r;w ,; ��4�oil�_M. .11 r r Oj .y, 3 aaa4 ';� `" ,iq awl AQ '*t t.�' _ „1 Fr. ._ a ski'"ti*w• ,«�Fs ,Y. 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No. Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpfication for Viso 16pstem Construction Vermit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No." O is Name Address,and Tel.No. Assessor's Map/ParcelUlmj Ins ller's Name,,Address,and Te. o. �l^ � esign er's• ,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.req fired) �� gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank pe of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _F>fl tl� WZZ Date 4st 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 not lace the system in operation until a Certificate of Compliance has been issued by this HNtufAalth. Si e Date AA r Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued a m No. � Fee Q " THE COMMONWEALTH OF MASSACHUSETTS Entered in c puler: soel PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y JtlYitAtiDYY fOrIStJDB Y opstPrn Construction-Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System. El Individual Components Location Address or Lot No. � Pes r's Name,Address,and Tel.No. t Assessor's Map/Parcel Installer's Name,Address,and Tel. o. ner's,Name,Ad ress,and el. o. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.req fired) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank pe of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7 L �� ! Date ast 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 not to Rlace the system in operation until a Certificate of Compliance has been issued by this B rd.o, alth. Sig Date v Application Approved by Date Application Disapproved by Date for the following reasons Permit No1"fi/,Q '�! Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS 0, (� Certificate of Compliance "i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(y Upgraded( ) Abandoned( )by 1 Jl%7()j A at as been constructed in accordance -with the provisions of Title 5 and the for Disp sal System Constructi n Permit Nob>22 r-�_ , ated lJ Installer L� KA QI-lDesigner_kliA #bedrooms Approved design flow gpd The issuance of t ermit shall not be construed as a guarantee that the system wily functio designe his Date 01 Inspector (� -No. _ Fee THE COMMONWEALTH OF MASSACHUSETTS 0� / 0 PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MisposaY *pstrm C nstrurtion Permit Permission is hereby granted to Construct( ) Repair(Upgrade( ) Abandon( ) System located at .? d. TAD" 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 must a competed within three years of the date of this pe it. - Date ja Approved by / ---•—a----- s► ,�, Town of Barnstable Inspectional Services HARNI3TABLL, 9. ,�� Public Health Division rf0" p 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730.000.1 4988 0961 R October 15, 2019 LOONEY, PAUL A & CAROL ANN 9 PHEASANT LANE LEXINGTON, MA 02421 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 60 Deerfield Road;Osterville, MA was inspected on 10/02/2019 by Chad Hathaway, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines'of 1995 TITLE V (310 CMR 15.00) due to the following: e The distribution box is rotted. You are ordered to replace the distribution box within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH I Thomas McKean, R.S., C Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\60 Deerfield Road Osterville.doc Town of Barnstable Barnstable KAS& Board of Health "` '�``a��" 039. 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 FAX: 508-790-6304 October 9,2012 Revised November 20,2013 Public and Environmental Health Program Policies,Procedures, and Guidelines H-10 Components Discovered Beneath Parking Areas-and Driveways During Septic System Inspections Conducted Under 310 CMR 15.301,State Environmental Code,Title 5 No.2012-005 When a DEP certified inspector discovers an H-10 septic system component located.beneath a parking area or driveway during a septic system inspection, conducted under 310 CMR 15.301 State Environmental Code Title 5, the system shall be deemed as a "conditional pass." The system owner will then be ordered, by the Board of Health, to'correct this problem within two(2) years and will be provided several options to rectify the issue, including by: a.) replacing the septic system component with a new component relocated into another area of land which is not beneath any parking area or driveway, and properly abandoning the discovered H-10 component; or by b.) replacing the septic system component with an H-20 component beneath the parking area or driveway, and properly abandoning the discovered H-10 component, (or in the case of leaching pit, replacing the top of the leaching pit with an H-20 slab top); or by c.) relocating the parking area or driveway in such away that no vehicle will have access or the ability to drive over the existing H-10 septic system component. f If it is unknown whether or not a particular system component which is located beneath a parking area or driveway, is H-10 or H-20 (for example: a leaching pit is located beneath a paved driveway without an accessible steel cover to grade and there are no records on file indicating whether the system component is H-10 or H-20),the system shall.also be deemed as a "conditional pass". In this case,the seller must make the potential buyer(s)aware of the "conditional pass" status,the unknown construction of the septic system component(s), and it's safety concerns. Wayne Miller,M.D. Paul Canniff, D.M.D. Junichi Sawayanagi Q:\POLICIES\H I OComponents Beneath Driveways&ParkingAreasRevised20l3.doc P�oF 1�rohti • Town of Barnstable + + BARNSfAHLE. A 6 4 Inspectional Services Department rfD MA'S A Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing li id level at or above the invert pipe (per Town Code §360-20 h) OTHER j�}'I So in c��r�� ]� ��w Repair deadline: j, p c,r Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc of t"e ram, Town of Barnstable Barnstable 6 S. Board of Health i e1CeC prF0599 A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 October 9,2012 Revised November 20,2013 Public and Environmental Health Program Policies,Procedures,and Guidelines H-10 Components Discovered Beneath Parking Areas and Driveways During Septic System Inspections Conducted Under 310 CMR 15.301,State Environmental Code,Title 5 No.2012-005' When a DEP certified inspector discovers an H710 septic system component located beneath a parking area or driveway during a septic system inspection, conducted under 310 CMR 15.301 State Environmental Code Title 5,the system shall be deemed as a "conditional pass." The system owner will then be ordered, by the Board of Health,to correct this problem within two(2) years and will be provided several options to rectify the issue, including by: a.) replacing the septic system component with a new component relocated into another area of land which is not beneath any parking area or driveway, and properly abandoning the discovered H-10 component; or by b.) replacing the septic system component with an H-20 component beneath the parking area: or driveway, and properly abandoning the discovered H-10 component, (or in the case of leaching pit, replacing the top of the leaching pit with an H-20 slab top); or by c.) relocating the parking area or driveway in such a way that no vehicle will have access or the ability to drive over the existing H-10 septic system component. If it is unknown whether or not a particular system'component which is located beneath a parking area or driveway, is H-10 or H-20 (for example: a leaching pit is located beneath a paved driveway without an accessible steel cover to grade and there are no records on file indicating whether the system component is H-10 or H-20), the system shall also be deemed as a "conditional pass". In this case,the seller must make the potential buyer(s)aware of the "conditional pass" status,the unknown construction of the septic system component(s), and it's safety concerns. Wayne Miller,M.D. Paul Canniff,D.M.D.. Junichi Sawayanagi Q:\POLICIES\H I OComponents Beneath Driveways&ParkingAreasRevised2013.doe PS Commonwealth of Massachusetts 07 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 60 Deerfield Rd t.- Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. City/Town J State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information i 1 filling out forms p �•�- q f on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not HPS use the return Company Name 5 key. P.O.Box 151 reb Company Address ` Forestdale Ma 02644 City/Town State Zip Code xenon 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported.below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2.. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10/2/19 Inspector ignature Date The system inspector sh submit py of this inspection report to the Approving Authority (Board of Health or DEP)with1 0 of completing this inspection. if the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ` Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal,System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,¢n 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma- 10/2/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ 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 hot evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass ov 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): , t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 60 Deerfield Rd _ Property Address , Looney Owner Owner's Name information is required for every Osteryllle Ma 10/2/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): Distribution box is located in stone driveway area. Dbox has major rott and needs replacement ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced . ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ® Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) I 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. c. Other: , system is located in stone driveway and is of H10 rating. back edge of tank is located in driveway. Dbox is in driveway and has major rott. Leach pit is located in driveway all are h10 4) 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 t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Deerfield Rd Property Address , Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than .100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owners Name information is required for every osterville Ma 10/2/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ - ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal'System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name - information is required for every osterville Ma 10/2/19 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: " Number of bedrooms (design): no design Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): min. 440 Description: typical 6'x6' pit with 2'stone gpd 549 gal ! Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑•Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection [I*Yes ® No information in this report.) Laundry system inspected? ti '❑"Yes ® No Seasonaluse? ❑ Yes ® No , - Water meter readings, if available(last 2 years usage(gpd)): ' Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current !' Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts 1, ,IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.), 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes. ❑ No- Non-sanitary waste discharged to the Title 5 system? ❑ 'Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): " r 3. Pumping Records: Source of information: unknown ' Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: . t5insp.doc•rev.7/26/2018 Title 5 Official Inspectioro Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma, 10/2/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: 1980s Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 1 feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of poor venting or leaks light root growth around inlet pipe to tank reccomending digging up tank and sealing pipe with cement t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ` Commonwealth of Massachusetts In ,ip Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney ' Owner Owner's Name information is required for every osterville Ma 10/2/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.75 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 Gal h10 tank light root growth from small maple tree next to tank roots appear to be growing into tank around where pipes go in and out of tank. recommend sealing around pipes. no risers present. back end of tank is at edge of driveway. see as built. recommend pumping tank for maintenance If tank is metal, list age: years d Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6„x5, 12" Sludge depth: Distance from top of sludge to bottom of outlet the or baffle 22 , K Scum thickness 411 Distance from top of scum to top of outlet tee or baffle 41 Distance from bottom of scum to bottom of outlet tee or baffle 1611 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): baffles in place no heavy decay visable no signs of leaks or cracks t5insp.doc•rev.7/26/2018 Title 5 Official.Inspection.Form-Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): fi 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑;metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons . Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System,-Page,11 of 18. Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): Dbox is H10 and has heavy decay located in stone driveway area E t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface.Sewage Disposal.System•Page.12 of 1.8- Commonwealth of Massachusetts ,i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Deerfield Rd ' Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 10. Pump Chamber(locate on site plan): Pumps in working order: 6❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* l Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): F * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Y. a Type: ® leaching pits number: ❑ leaching chambers number: ` ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ' k ❑ overflow cesspool number: ❑ innovative/alternative system r ' Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsuiface.Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -� 60 Deerfield Rd Property Address Looney I Owner Owner's Name information is required for every osterville Ma 10/2/19 page. City/Town State Zip Code Date of Inspection D. System Information. (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I pit dug up Pit is h10 and located in stone driveway. see as built. Pit has 18"of water in bottom with no staining over current level pit is 3' below grade with no riser in place 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5.Official Inspection Form:Subsurface Sewage Disposal,System.-Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name „ information is osterville Ma 10/2/19 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): T 1 { • f e { t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18, Commonwealth of Massachusetts • �� ip Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is osterville Ma 10/2/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system;including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: , ® hand-sketch in the area below ❑ drawing attached separately 8 �� 3s• �3 3Ca , w 9 3 2 . 3 s U a� Q o j, U oG y J o '[� S cc� \A�c CCU t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f I c Commonwealth of Massachusetts ,ip Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is osterville Ma 10/2/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: s ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) z Accessed USGS database-explain- - town GIS mapping lot el. 52' You must describe how you established the high ground water elevation: low in area el. 8' coleman and North ponds. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Deerfield Rd Property Address Looney Owner Owner's Name information is required for every osterville Ma 10/2/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: . 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed , ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 '\ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments 01 —®<76 Subsurface Sewage Disposal System Form, Inspection results must be submitted on this form or on the official Title S.Inspection Form dated 6/1512000 Inspection forms may not be altered In anyway. --- A. Certification Important:,IWhenmpo rang out 1. Prope_ Inf on: 1 Copy forms on the computer.use .only the tab key to move your l)TS A rJ CL l)i LA o / ®C7 PV e-, cursor-do not Owners a use the return key. 1P_+=-�-/a'^� L y 9, j Owner Address ,J /o s� a �oZ Cily/Town -i' - State ZAP Code t'/J� to t3 Date of Inspection: Date • _ 2. Ins r. 1 No �P,dc GoffLUny Citylrown state Zip Cow Telephone Number 4 y F Certification Statement: I certify that I have personally inspected the sewage disposal system at thls addresses Ynd that the Information reported below Is true,accurate and complete as of the time of the in on.The inspection 3 was performed based on my training and experience in the proper function and malfiW nance rff, n sit sewage disposal systems.J am a DEP approved system Inspector pursuant to on 15--140 of Title 5(31 0 R 15.000).The system: asses .❑ Conditionally Passes ❑ Falls L N ds kaLn the'LocalApproving A rityl inspectors Signature Date The system Inspector 11 submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the. report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that'time.This Inspection does not address hover the system will perform in the future under the same or different conditions of use. t5insp.doc•11/2004 TWO 5 Oftfciai Inspection Form:Subsurface Sewage Disposal System- Page 1 of 16 llb8) Commonwealth of Massachusetts Title 5 Official Inspection Form UVNot for Voluntary Assessments Subsurface Sewage Disposal System Form A. C(/e//j.J,-j`Mifin (cone) P\, T e.-11 Ere- . . P {2���1z.� /� ob ZIP coft O%nees Name Dati of Wispection 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) Syste Conditionally Passes: ❑ One or system components as described in the'Conditional Pass"section need to be replaced or aired.The system,upon completion.of the replacement or repair,as approved by the Board of He ,will pass. Answer yes, no or not date nod (Y,N,ND)in the❑for the following statements.If not determined,"please explain. ❑ The septic tank is metal and over 2 ars old*or the be tank whether metal or not Is P ) structurally unsound,exhibits substantia ' Itration or exfiltration or tank failure is imminent System will pass inspection If the existing to replaced with a complying septic tank as approved by the Board of Health. . *A metal septic tank will pass inspection If it is structural nd,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years is available. ND Explain: 15-msp.doc•1 W004 Title 5 Offtw inspection Form:Subsurface Sewage Disposal System Page 2 of16 ' Commonwealth of Massachusetts Title 5 official Inspection. Form Not for Voluntary Assessments Subsurface Sewage.Disposal System Form A. Ce 'fica (wont) - IP t� Owner's Name Date B) tern Conditionally.passes(copt.): , bsmation of sewage backup or break out or high static water level in the distribution box due broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box System will p inspection If(with approval of Board of H-ealth): ❑ ' bro ipe(s)are replaced ❑ obstruction removed ❑ distribution box is leveled or replaced ND Explain: ❑ The syste uired mping more than 4 times a year due to broken or obstructed pipe(s).The system will pa on if(%*Ath approval of the Board of Health): ❑ broken pi s)are replaced. ❑ obstruction is re ND Explain: C Further Evaluation is Required by the Board of Health:c ❑ Conditions exist which u' evaluation by the Board of Health in order to determine If the system is failing to pro 'c health,safety or the environment. 1. System will pass unless d of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is functioning in a manner which will protect public health, safety and the environment~ ❑ Cesspool or privy is within 50 feet surface water ❑ ,Cesspool or privy Is within 50,feet of a bordering vegetated wetland or a salt marsh Mnsp.doc-11120N TMG'S OMdal Inspecdon Form:subsurface Sewage Disposal system Page 3 of 16 Commonwealth of Massachusetts Title 5 Offic ial. inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Ce 'fic n (cont.) � . Cityrr state �-- Zlp Code '00-4 / � Ovkiee3 Name Date of Insobcdon C) Further Evaluation is Required by the Board of Health(cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determi that the system is functioning in a manner that protects the public health, safety an environment: ❑ ZOfe tem has a septic tank and soil absorption system(SAS)and the SAS is within of a surface water supply or tributary to a surface water supply. ❑ The system s a septic tank and SAS and the SAS is within a Zone 1 of a public water. suPP►Y• . s4 ❑ The system has a se pfi and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and Sand the SAS Is less than 100 feet but 50 feet or more from a private water supply wel 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 6*ogen 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. vnsp.doc•11/2004 'Tore 5 Official inspection Forth Subsudace Sewage Disposal System- ' Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection .Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Ce 'fic ' n (cone) / P�. C uy Owners Name Date of 1 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 dogged SAS or cesspool ❑ Disdiarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static flquid level in the distribution box above outlet invert due to an overloaded or dogged 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 dogged or G 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 withiril 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 ppmr provided that no other failure criterla are triggered.A copy of the analysis must be attached to this form Yes No - ❑ The system falls.I have determined that one or.more of the above facture 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. 15insp.doc.11/2004 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal system Page 5 of 16 Commonwealth of Massachusetts :Title 5 Official Inspection ..Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Ce 'fica ' (cont.) !7e T- -,f2-4 L)I', City/T. state Zip code owners Name Date o(InspAction E) Large Systems: To be considered a large system the system must serve a facility with a design of 10,000 gpd to 15,000 gpd. For large s ems,you must indicate either"yes"or'no"to each of the following,in addition to the questions in ction D. YES NO ❑ ❑ the system is within 400 feet of surface drinking water supply ❑ ❑ the em is within 200 feet of a tributary to a surface drinking water supply ❑ the s is located in a nitrogen sensitive area (Interim Wellhead Protection 13 Area— )or a mapped.Zone it of a public water supply well If you have answered`yes'to any qu on 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 Departrnent. Winsp.doc-11/2004 Tile 5 Offxcal inspection Form.Subsurface Swap Disposal System Page 6 Of 16 Commonwealth of Massachusetts - Title 5 Official Inspection[ Form Not for Voluntary Assessments t Subsurface Sewage Disposal System Form B. ChecklistP rem I J ress t_ �rS 6J f c stale n �.� Zip Code �� �! a Ovmmers Name Date of n Check if the following have been done.You must Indicate°yes'or"no'as to each of the following: YES NO' A ❑ 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? p ❑ Has the system received normal flows In the previous two week period? ❑ Have large volumes of water been Introduced to the system recently or part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they wen3 not available note as NIA) - ❑ Was the facility or dwelling Inspected for signs of sewage bade up? ❑ Was the site inspected for signs of break out?,. ❑' Were all system components;excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank / inspected for the condition of the baffles or tees material of construction, _ dimensions,depth of liquid,depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the'Soil Absorption System'(SAS)on the site has been determined based on: ❑ Existing:information:'For.example,a plan at the.Board of Health. ❑ Determined in the field(if any.of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3xb)] L-4nv.doc•11/2004 •Title 5 Ott ins pection Form:Subsurface Sewage Dispose(System Page 7 of 16 commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal'System Formlug C. Sys em ormati P /ems v e`� / � S �� de 4 co �v ,�� v-�' owners Name Residential Flow Conditions: Number of bedrooms(design): - Number of bedrooms(actual) DESIGN flow based on 310 CMR 15203(for example. I10 gpd x#of bedrooms): Number of current.residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?'[if yea separate inspection required] ❑ Yes ( No Laundry system inspected? ( Yes ❑ No Seasonal use? Cl Yes [ No Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Yes 0� No "1 C-&L�r Last date of occupancy. Commerctalfindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): day(Wd) Basis of design flow(seatslpersons/sq.fL,etc.); Grease trap present? ^/� ❑- Yes [I No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? Yes ❑ No Water meter readings,If available: Last date of occupancy/use: pate Other(describe): tmnsp.doc•11/2004 We 5 Official Inspection Form:Subsurface Sewage Disposal system- Page 8 of 16 Commonwealth of Massachusetts .Title 5 Official Inspection Form Not for Voluntary Assessments. Subsurface Sewage Disposal System Form. C. Sys em lnf anon cons cnyrr Stal code owners Name Nis otimpecom General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gaUm8 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/Aftemative 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. El Other(describe): Approximate age of all components,date installed ff known)and source of information: 4 rt Qb2 Were sewage odors detected when arriving at the site? ❑ Yes No t5iw.doc•1112004 TWO 5 Ora"Inspection Form:Subsurface Sewage Disposal System Page 9 of.16 Commonwealth of Massachusetts . Title 5 Official. Inspection- Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Syst m In. atio_ city state . Zip code owners Name Dade or l Building Sewer(locate on site plan): Depth below grade: A) A 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.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: (�oncrete ❑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 es❑ No Dimensions: Z5_-0Q Sludge depth: / Distance from top of sludge to bottom of outlet tee or baffle �l Scum thickness Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5hsp.doc-1112W4 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern Page 10 of 16 Commonwealth of.Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. syslem 1 rmati (co t. n� / state cityvq r- owners NameDate of ral in Comments(on pumping r mmendations,inlet and outlet tee or baffle condition,structu ilquid levels as related to outlet invert,evidence of leakage,etc. Grease Trap(locate on site plan): Depth below grade:. fee 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 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity P g ilquid levels as related to outlet invert,evidence of leakage,etc.): q Tight or Holding Tank(tank must be pum 'me of inspection)(locate on site plan): Depth bekwv grade: Material of construction: lass ❑polyethylene ❑other.(explain): ❑concrete ❑metal ❑fiberglass Title 5 oww inspection Form:Subsurface Sewage Dist o System t5h-Mp.doc-1112004 Page 11 of 1e commonwean of Mapachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form c. Sys im 1 rmatio (cont P d�.5. do26SJ coneSIMS . Date of. Ownefs Name Tight or Holding Tank(cone) Dimensions: Capacity. gaM°ns Design Flow: ferns per day Alarm present: . El.Yes ❑ No Alarm in working order: ❑ Yes❑. No Alarm level: Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Distribution Box(if present must be opened)(locate on s' plan) Depth of liquid level above 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.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No • Tttfe 5 of6ciw Inspection Form:Subsurface SeWaW D System pap 12 of la tstnsp.doc 112ooa Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form u C. Sy tem 1 m rat (co t. I v Pro Addre55 -- City n Stat Zip Code iJ✓ e1/ a Q Owner's Name Date o n ection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain wh Type: leaching pits number. /❑ leaching chambers number. ❑ leashing galleries number. ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. D 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.): e)Aj t5insp.doc•11/2004 •rule 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 r . Commonwealth of Massachusetts . Title 5 official Inspection Form Not for Voluntary Assessments , - Subsurface Sewage Disposal System Form ' C. Sys>xem Infonpanon nt.) P ddrss City/'r State /' P code r �L , 0 Ownels Nam_ Data of I 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 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.): t5irts clot•11/2004 Title 5 official Inspection Form:Subsurface Sewage Disposal SYsiem p. Page 14 of 16 Commonwealth of Massachusetts w Title 5 Official Inspection Form ormn Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Informati (cons P ip Code Owners Name Zowf �ecffo� 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, Ae- d� i t5nsp.doc•i 7/2004 Title 5 Official Inspection Form:subsurface sewage Disposal System Page 15'of 16. Commonwealth of Massachusetts Title 5 Official Inspection Fornn Not for Voluntary Assessments Subsurface Sewage Disposal System Form, C. Sys e ormati (cont.) 29 Prop ddre - - ., �� � C<S S�. Stat X Zip Code Cl w �a Date of In ection C! Owner's Name Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record ' of design Ian reviewed:. If checked, date g . p Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-,q;�Wain: Checked th local excavators,installers-(attach documentation) . Accessed USGS database -explain: You must describe how you established the high ground water elevation: v 10A e,4t t5insp.doc•1112004 Title 5 official Inspection Form:Subsurface Sewage Disposal system• Page 16 of 16 ! Engineering Dept.(3rd floor) Map `�, Parcel FAl Permit# rim House#— (1110 Date Issued _ / Z2 Board of Health(3rd floor)(8:15-9:30/1:00-4:30) g_ ���Fee 3 7 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) SSEP 9 Planning Dept.(1st floor/School Admin.Bldg.) wT,I,C�SYS�EflI�Iifi E � .. ,,/ ALLED IN CO Definitive Plan Approved by Planning Board. O ENVIRONMENTAL "�� TOWN OF BARNSTA RE�U Building Permit Application Project Street Address , 60 Deerfield Road (Tt�, 6 k \ Village Osterville Owner Mr. Paul Looney Address 60 Deerfield Road, Ostervi lle Telephone 428-7981 i Permit Request 1) Enclose existing deck (To become a screened—in porch) 25 x 14 2) Construct a new 16 x 16 deck to side. First Floor square feet Second Floor square feet Construction Type Wood residential Estimated Project Cost $ 12,000.00 Zoning District RC Flood Plain No Water Protection Lot Size 23,000 Sq.ft. Grandfathered ❑Yes M No Dwelling Type: Single Family ® Two Family ❑ Multi-Family(#units) Age of Existing Structure 16 yrs- Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) NO Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths):Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces:Existing New Existing wood/coal stove ❑Yes ❑No 1 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ®No If yes,site plan review# Current Use Residential Proposed Use Builder Information Name E. J. Jaxtimer Telephone Number 778-4911 Address 48.Rosary Lane License# 003251 Hyannis, MA Home Improvement Contractor# 110609 Worker's Compensation# WC97=695028 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO omber's Dumpster SIGNATURE DATE BUILDING PERM ED FOR THE FOLLOWING REASON(S) -In fA -1. LOCATION SEWAGE PERMIT 930• v VILLAGE A � Oho INSTA LLED'S {SAME `� ADDRESS U UILDER 0R NER L L 6' c- DA T E PERMIT ISSUED DATE COMPLIANCE ISSUED � ��� l �i QcK.s'T -FRo?o'i �7 A OqA G t rRo 23� 3� 3 .ems 1 i<,C- e � N __-- Fss........... .............. THE COMMONWEALTH.OF MASSACHUSETTS hs lid BOARD OF HEALTH .........:....OF...../(�� i ----.......----._........._...._...... ,gyp iration for 14spnsa1 iVorkii Tanstrnrtion Prrmit Application is hereby made for a Permit to ConstructA or Repair ( ) an Individual Sewage Disposal System at: _ �� .. .. .- -_____ •............................ ... .... .. ....... - • Location-Addre 74.1 or Lot N canerAddress W a fnstall ....................... •.................•----•--.....................••------......--•-•-•---•••••................_..... Address Type f Building ize Lot.�a �-Q.... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( Garbage Grinder (° `4 Other—T e of Building g ____________________________'No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other-fixtures .. . •------------------.•------------•-•------••......--- -----.....-•--------••-•--••---------••----......_....-•---- �. G4___ allons per person e day. Total da flow__ w Design Flow..... .......... .•-- -----•• g P P P � Y• �Y ----------L-La-------•-•---.---ga)lons. 04 W Septic Tank—Liquid capacity I� lons Length_:_ __ . ....... Width__57.._._... Diameter................ Depth. _ .� _ x Disposal Trench—No. .................... Width.................... Total Length.................,...Total leaching area....................sq. ft. Seepage Pit No.......I............. Diameter.._. ..... Depth below inlet........ Total leaching area_3..c�._5_._sq. ft. z Other Distribution box ( Dosing tan ( ) aPercolation Test Result Performed by.... _°s .- :. .................... Date....V �-�h_.0- ......--•-•- 0 Test Pit No. 1...._________---minutes per inch Depth of Test Pit... ...... Depth to ground water...ovn: .1_Z f74 Test Pit No. 2................minutes per inch Depth of Test Pit---- .._.2._.______. Depth to ground water.._____..ti.............. .. GG O Description of Soil �L�?'Y1�__....15 ...-•---•----------------•--------------------------•---------...--.................................... x c, w U Nature 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 iITIE 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. � k Signe -•---••••--•------•-•-----••-----------------------•---------...------••---•-------- ') Date Application Approved By..... .� "� l—- ----------------- Date Application Disapproved for the following reasons:..................... ---•------•--------•------•-••-•--•.....•-••-•••••-••••--•••----•--••--•••--•--.......... --------------------------------------------------------------------------- - Date Permit No............. ........ .... Date • - FIG..- --,v Fus....3.1J............� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O F ;6W1L✓ i d-- -----.... Allp iratiun for Disposal Works Ton,strnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individdual Sewage Disposal System at• *' t 'f-L - ... --- ... § .... �dI'io - dress ( my w ' ner7— a Address .........•••...... =. . ... ........................................... •......_._....•---•----------_......•-----••----------.....•-•----•-••-...._..............•....... Installer Address U Type of Building Size Lot_..4.�,.t�,±°���---..Sq. feet 4®`Dwelling—No. of Bedrooms....................._............____-__--Expansion Attic ( Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d „ =.........................--------------------------------------------------------------------• ... g / alloo ss per Leng th n�per day. Total th Pdaily.loDianlete 6. w Design Flow------�•-`-'=------�---•- ��'a j-'"' a +�----------------- long. WSeptic Tank—Liquid capacity].. g gt , ......__. Depth�=_-•{,,� x Disposal Trench—No. .................... Width.................... Total Length....... ._ ,_..Total leaching area....................sq. ft. Seepage Pit No......,.......__.__.. Diameter....(......... Depth below inlet....._. °►:....... Total leaching area..$,.._.sq. ft. Z Other Distribution box ( )` Dosing tanl� ( ) a Percolation Test Result Performed by____ .....: f1 °!f. Date_. L � ......- ---- Test Pit No. I................minutes per inch Depth of Test Pit--- A_....... Depth to ground water-_ '+J_�?' 1Z f=, Test Pit No. 2................minutes per inch Depth of Test Pit___ ........ Depth to ground water---------is........... i - ------------- ...... •-------- -----.................................................................................... O Description of Soil------ 1 ' �. &..-�_.... -----` -�t-�--'�='�� ------------------------------------------------------------------------------------------------------ x w UNature 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 L 1 4 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. Signe --•-----•---•-------------------------••-----......-------•-•-....................... ........----------.......... �,,1 Date Application Approved By----= cnf,. /' < l� -��=.. d.._.. Date Application Disapproved for the following reasons:.....:............... ........................•-------•- i ..........................•--•----......-----------•--------------••---•------••-•-----•-----...---------....•--•-----••----•••••--------•-----------..--•--------•---•---•-------•------•------•••------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /.... .l..a/7-i..O F..........4.1 :21................................................ Trrtifiratr of TompliFam T S I 0 TI,FY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by. --- ••--- . .......................................................................................... - / Install ._ 4 2 f'------------------•.-.- -- ---- J---------•--......•... has been installed in accordance with the provisions of T Z_LE 5 of The State Sanitary C.o e as described in the application for Disposal Works Construction Permit N application ............ dated---- _----_.___.._.._.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ 5_41.......................... Inspector..... -C L` -.--.--.-.------••-•--•------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ,OiEALTH C" �" r........ ... ............... No.....................•... �i �1dl ku trudin vanfit Permission is hereby granted............ .... ... ---------------------------•-----------•--------........----._....................----- to Constr/use) or/Repair (� ) and ndivida!Se a e�Disposal�System J/ at No..- /i=.--crt /�.! iE�! ......(...... = %1/. ....t -..y-_. ••-- 1......................................... ,> Street as shown on the application for Disposal Works Construction Per- it No.. 2....... Dated- 1-_...r__= i1 --•----•••----......_. DATE......---•-------••-•---•--- 11.1.......................................... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS �7 , lam• \-S • t f Y t 64 / ANE f.J :' PiT 4G•2 4 �� 94-17 AREA 47 U y hJ I ZZ I f q4 Viz_` .Q • N : Via - Aso vo `. ' r s, F;i StuGe_a` t=AMILY • 3 4► - �.� OA l�_Y �t..Ow a I l0 � ?�-t•�Io''4Fi�.P.>D ..... . ..1, _.. ... . _ ..__. ., ,. _.._ l t SEPn G TAU.►K • ��p X.200 ��i= �� .:_._ : : ! 'I y1$PoSAI. PtT V;E tDOp5TolJ� SoTTOAA AReA ToTa%. 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