HomeMy WebLinkAbout0137 EAST BAY ROAD - Health 137;EAST BAY.•ROAD, OSTERVILLE
A= 140 160
r
it
o
�y
Q
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M a 137 East Bay Road
Property Address 1.0
4
Mary Ryan Trust 01
Owner Owner's Name
_.
information is
required for every Osterville "V MA 02655 10/25/2017
page. Cityrrown State Zip Code Date of Inspection
l.n
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 filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Ford Septic Services, LLC
„y Company Name,
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
Needs Further E al ation by the Local Approving Authority
11/9/2017
Inspectr Signature Date
The s t m inspecto shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
1�GF� rS .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town 'State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
Commonwealth of Massachusetts
v Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name -
information is Osterville MA 02655 10/25/2017
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑.Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
'supply
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:,
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded.or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 Y2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within.100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The.
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to.each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
i
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
137 East Bay Road
M
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osteryille MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of-Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osteryille MA 02655 10/25/201.7
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: pumped in July 2017
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system u
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a,copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
system installed -unknown
Were sewage odors detected when arriving at the site? ❑ Yes,® No
Building Sewer(locate on site plan):
Depth below grade: 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: 12„feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal.
Sludge depth: 1
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 14
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. no sign,of leakage.
Grease Trap(locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass' . ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I
i
Commonwealth of Massachusetts
v Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655- . 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): -
The D-box was normal
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osteryille MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2 - 1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The pits were dry and clean. No sign of failure. A camera was used to inspect.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration,
Depth—top of liquid to inlet invert °
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
N/a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
• Commonwealth of Massachusetts
• r Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M a 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A
a
o
3 12 a l ys`
O 3 ;,S` Sob
y o
s' sa
s
,Sins•1111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA , 02655 10/25/2017
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 4
28'
Estimated depth to high ground water: , feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
is Topo and water contours map
❑ Checked with local excavators, installers-(attach documentation)
4
❑ Accessed USGS database -explain:
You must describe how you,established the high ground water-elevation:
see above
j
t
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
• Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 137 East Bay Road
Property Address
Mary Ryan Trust
Owner Owner's Name
information is required for every Osterville MA 02655 10/25/2017
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
I
I
E
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Search by +r ' p g • ,.,,.. *"+;s` .. <rn +q.,,.• ; w^..,.T :.
r ACdress .: Permss.r Prated Review ars ed ons C 0 0 5 noff GIS +Personnel Reports'VJeb Schedule' Y" Y'
,;+
i R/P kfl orowro ect Review i.red-.Tri_.�OU
5"vast: Pouset W
FF, Reviewstatus:COMPlete R2wrtlssuan,
• s 1. i37 1. t:
d .._.......__. » - ....Health
- j 9uliding-Remo i Consxrv.0on Inspector
q Ct oeat5.1 ®I,Conran w 1 (0.
'.'win-'cu+.:rric�r:,.�,wea.*wrroypw..raM++d ,
Pemlks a -tI a11J Ra w3(s}.Fwrd {
+� A
� w
i
i _.. P'2014-05056
,..... 0 2014-04587.y - - j
.-.. TE-2014-04507 .— .—
Reviewing Department: f +
-..- B-z6a7 o5has ` Health-Inspector Dept. Review For:8.2014-04587 v, ie:FLIT—El 2ola 0 save Review
� Review Status:
i -- G-2007-03081 .DprarcC i� _ {' Requved f Requested C' Honel ®'--
0 Prated Revle arsy ®EmalApplicent
'....-�'+�. G-2DD7A2346 - '
:-.. P-2007-02347 - Pr n•.
`: Slnft Asa'ignmen( holed Maosgomen+ Shaw Project Renew History �; IVOSry Revie,e s of P an¢R suhm p,mi
--..�B-2007-00874
6 2007.006E1 Last Reviewed By:PAR-..� .:
tL ege_n>d Project Comments&Requirements in.e>'raum�naTax - 1�,y.P irel Com•,r-nt P
Permit select------ F yDe -
Add
T• your comet nt here c seleo from the Es:
Itla Show All Types
.-.::t- _ - - '
Community Dev .i. f _ .. _ .. . _ ..:::_ .,..
�,Baddwg + July HLTHJPAR 201404587 85-310.4SR MAX
{
All Licenses - + 15 y
201a i
DPW
K
Health _ .st7�,, , +:
Fire,. +.
l -
i
25
185.64
o
o , L
M 01 A-3
N �
> 1.46
_ •0
q
�N CO KC a-00
c �-- SHED
me-4 v Hp. 13�
o �
N
. to
W -
r
BUILDING LINE
20: 94.40
87.79
EpsI BAY ROAD '
NO DETERMINATION :IS .:MADE AS TO..VALIDITY OF OR. EXISTENCE
OF EASEMENTS. FOR DRIVEWAY PURPOSES.,
MORTGAGE LOAN INSPECTION ML1967
SAGAMORE SURVEY ASSOCIATES SCALE: -1 IN.= 60 FT. tµOf"'
P,O. BOX 28 DATE: SEPTEMBER 59 1997 *� gss4�
MA. 02562 : THOMAS sG
(508M888 8667H� =� do�C/J �° c m
o PONTBRtAND y
- CERTIFY TO J.:SCHULZ, ESQ. ec:JOHN G. & MARY L RYAN No.343i4 a
THAT THE LOCATION OF;THE :B,UILDING:'SHOWN HEREON CONFORMS 'OgoF x .NPR
TO THE ZONING; OF THE: TOWNS OF BARNSTABLE (OSTERVILLE) c� Essio P
CERTIFY THAT LOCUS 'DOtS NOT LIE' WITHIN THE FLOOD HAZARD "OsuFlv�'�°
.ors` , . A
ZONE AS DELINIATED ON MAP •_0016C COMMUNITY' NO. . 250001 h r
PLAN REFERENCE BARNSTA13L . EGISTRY OF DEEDS REGISTRY OWNER: .
'BOOK/PAGE:- LC :NO 15967 I k
LOT NO.:. 24
w s
PLAN BY:: BAXTER : BUYERAND NYE, IJ�. 1 fr
DATED: : OCTOBER. 479
7 f�
THIS b MADE-;-FROM "A IN MN UV A 0
FOR. FENCES, H>=DGES OR TO ESTABLISH LOT LINES.. FOR USE OF BANK ONL,Yr =USEq
F
V
CERTIFIED. SEPTIC SYSTEM REPORT
DECEIVE®
LOCATION
APR ? 4 1996
HEALTH DEPT.
137 EAST BAY RD . TM OFWNSTABLE
OSTERVILLE, MA
MAP 140 PARCEL 160 001 LOT 24
PREPARED FOR
SELLER
MR. & MRS MICHAEL T . SULLIVAN
170 E . 87TH ST .
NEW YORK, NY 10128
BUYER
MR. & MRS . JOHN H . WELLINGTON
75 ARCHER DRIVE
BRONXVILLE, NY 1.0708
PREPARED BY
HILLIARD HILLER
P .O . BOX 250
CENTERVILLE, MA •02632
508-778-1472
c
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of i
Environmental Protection
WNNw F WNd. Tnrdy,cos.
cia.n,or S-NA-Y.
Argao Paul_C�liuee! David B.Struhs-
u.oa.ma
commsione�
SUBSURFACE.SEWAGE,DISPOSAL SYSTEM:INSPECTION FORK[
PART.A.
CERTIFICATION
Property Address:. /37 Y X 7'E' ewew"E Address of owner. fr/tir �1•�.�fiPEL 7-- 64i61-1eO/
Date as'Iagreetioa:. ' `�.Z3�J�. (Ifdifferent)
Name of Inspector• IIIZZIf/�2o
Company-Name,Address and Telephone Number.-.. FY &oN. o752>` /vEW Yo.PK' /Y y /oia
GL.t/lt%IU/AGE' .ter/9 0?�31 .
CERTIFICATION STATEMENT
I certify that L 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 inspection- The-inspection was:performed based on my training and experience'•in.the-proper-functiomand-
mainteawn of'on-sits sewage disposal systems.- The system:.
LPasses
_ Conditionally-Passes:
Needs Further Evaluation By the Local:Approving?Authority
Fails.
Laspeateew Slgoatm- :: Dater'.
Tba 87Wm Iaspeetor shall submit a copy of this inspection.report to.the Approving;Authority within.thirty,(30)days.of completing-thin _...
inspection:-If thrsyetem.is:a=shared system or has a,design_f(ow-of 101000,gpd."or greater„the inspeetorand..the system:owner shalI:atbmit the
to,tbs rapmt appr.prrata-regtanal offm,ofthe:Department.of-Eavi:vnmentRI-Piotection_
T1*ar*nslshmld ba sent.to the system:ownerand-copier sent to the buyer,.,if applicable!and.the.approving authority:.
INSPECTION:SUI MARY:
A]:S,Y887=LPASSE9.:. _
y I bars.wt found.any information,which:indicates that the system,violates:any of the failure criteria-as=defined:in.310 CM&15:303:
Azy t>ihue:criteria:not evaluated:are-indicated.below:.
Bl SYSTMECONDMONALLYPASSE3:----....._..._.. .._w.. F ....___ _
,
Oatormoir system oomponents:need to:be replaced.orrepaired- The`system,upon completion.of the replaosmentor repair,psmew-
Iadieats yes;.ao;.ar rase dotarmined.(Y;.N,.or ND).. Desrnbr basin of detarmination.is all.instances: If'not determined:,saplaia..wby=)
The arptie.tank is metal:.cracke&structurally unsound;shows.substantial infiltration:or ezSkration or tank failumis.
nnznn ants The.system.will pass:inspeetioa if the•existing septic tank is=replaced.with a Fonforming-septic:tank as:approved
by-tha:Board afFlialth-
(revisadf ivas/gs) L
OrwYAnterStreet- w Soatorr,.Massachusetts02108 FAX(617)556-104t w> Te1ophone,(617).2024M:
PnntedroRReeyekd Pacer
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(continued)
Pro.pertyAddresc /3 7 LF" Sr: /3AY 4 O O's TE/IvIGL E
Owner !�r/�?" A114,-fqxL Z. Sit c lvs�,v
Date of:Iaspeohonr y/a�l3G
B)SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The,system.will parr inspection if(with approval of the Board of.
broken pipe(s)are replaced.
obstruction-is:removed'
distribution box is levelled or replaced:
This system.required pumping more than four times a-year-due•to.broken or obstructed pipe(s)_ The system:will:pass.
inspection.if'(with.approval of the Board of Health):
h. broken pipe(s)'are replaced •,
obstruction.,ir removed:.
C) FURTHER EVALUATION:IS REQUIRED BY'THE BOARD OF`HEALTik
,Conditions.exist which.require further evaluation.by the-Board:of Health in order to determine if the system.is failing to protect the
public health,.safety and the,environment:
1) SYSTEM_WILL.PASS UNLESS'BOARD OF HEALTH DETERMINES.THAT'THE SYSTEMAS NOT FUNCTIONING IN A.
MANNER WHICH WILL:PROTECT THE PUBLIC:HEALTR AND SAFETY AND THE:ENVIRONMENT::
_ C =pooL 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..
a
Z) SYSTEIKwML FAIL.UNLESS",THE.BOARD.'OF-HEALTR,'(AND PUBLIC WATEKSUPPLIER,IF:APPROPRIATE);
Dom-THAT:THE SYSTEM:IS FUNCTIONING IN-A MANNER THAT.PROTECT'TIM PUBLIC'HEALTH:AND
SAFMAND-THE:ENVIRONMENT.:. ry
„ ,.. .
The,system:has a septic tank and soil absorption.system:and is:within.100 feet to a.surface water:supply or tributary to a.
aorfar�swatersnpply:
The,system has-a:septic tank and:soill absorption.system.and_is.withia.a,Zone I of:a public-water-supply"well:
_ The,system.haa a septic tankan&soil"absorption system:and is within.50 feet.of.a.private-water_supply well_
The system has.a mptie tank and.soil absorption system and is,less;than 100 feet:but 50 fast or-more-from.a private water
supply welt,.unless.a well.water:analysis=:for coliform bacteria-and volatile,organic.compounds indicatesi that the:welLit,free.
from ponatioa from-that facility and,the.- praence�of.:ammonia:nitmgea and nitrate nitrogen.ia:equal,to.or less:than.5 ppm.
(revised 11/ 3/95:)
t,
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
..PART A
CERTIFICATION'(continued)
Property Addres 137 /igal r1Ay iQp !'ST1/Ii//GGF
Owner.
Date of Inspection:
D] SYSTEM.FAILB:
I have determined that the system.violates one or more of the following failure criteria as defined in 310 CMR 15.303: The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct:the
failure.
Backup of sewage into facility or system component due to an 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 1FY: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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a.cesspool or privy is within 100 feet of:a surface water supply or tributary to a surface'water supply:
Any portion of a cesspool or privy is.within a Zone I.of a public well.
Any portion.of a.cesspool or,privy-jai within 50 feet-of'a private water�supply well
Any,portion.of.* cesspool or privy is leas:thin.100 feet but:greater-than 50 feet from a Private;.water supply well`with..no
acceptable water-quality analysis. If the,well has:been analyzed to be acceptable,attach copy of well water,analysis,for.
coldorm bacteria,volatile organic-compounds ammonia nitrogen and nitrate nitrogen
El.LARGE SYSTEM.FAILS:
The-following criteria apply to large systems'in addition to the,criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is:a%significant thteat:to public
health and safety and the environment because one or more,of'the following conditions.exist:
the system is withinA00 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.ofa public
wall supply-well)
The:ownsuoz operator of-any such system shall.bring_the,system and facility into full.compliance with the groundwater treatment.prog am,
�quirsm nu.of 314•CBM.5.00 ancL e.00.. Please consult-the local.regional.office of the Department for.further.-information...
veviaed:11/03/95), 3.
' . is
f
i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-, PART B.
CHECKLIST
Pn%)erty Addm=
Owner.. `�.y
Dante d'Inspeotiun;.
'Cbeck if the following have been done:.
/!Pumping information was requested,of the owner, occupant, and.Board_of.Health..
f1None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
/during.that period.. Large volumes.of water-have not-been.introduced_into.the system recently or as part of this.inspection.
v A,built plans have been.obtained.and:examined. Note•if they are not available with.N/A.,_
The facility or dwelling;was inspected.for signs,of sewage-back-up.,
the system does not receive.non-sanitary or industrial.waste flow _
The site,was inspected for signs of breakout.
All system components,acluding the Soil Absorption.System, have been located on the'site.
.{,'The septic.tank manholes were uncovered,opened, arid.the interior of the septic:tank:was inspected-for condition of'baffles or.
teen;.material of construction,.dimensions,,depth of liquid;depth.of sludge,.,depth.of.scum.,
vThr size and.location of the Soil.Absorption.System.o&the site has been,determined based on:existing::information.or
appra�mated by non-intrusive methods K :
' The facility'owner(and occupants,if different.from owner)were:provided,with,information on'the propermaintenance-of.'Sub-
Surface Disposal.System.
.. x?' is'.•�•��SS :1....... a .n 1 '4 „' !V. _ a.
(revised.,11/03/95) 4.,
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddresx qp asr,�'/1vxL.f
Owner-
Date of Inspection:
FLOW CONDITIONS
RBBIDENTIAI:
Design flow:�llons
Number•of ms:bedroo
Number of enreeat resideats:Q
Garbage grinder(yes or no):�5
ha airy amsneeted to system(yes or no): YGS -
se..onal.
Water meter readings, if available: /993
Tfr.�/1z is fI t.��•r/ E�•Pi,rrrG.��P
East date of ooaipa ay:_ -1-EA,,,142t - p
COMMERCIALIINDUSTRIAL
Type of establishment:
Design"flow:: gallons/day"
Grease:trap,present:.(yes or no)_- _
Industrial.-Waste.Holding Tank..present: (yes.or-no)__ _.. •» w
Non-sauitary waste discharged.to the Title.5,system:.(yes.or.no)_. -
Water,meter aeadingejf available:
Last:date of occupancy:
OTHER::(Dsscibe)
Lest.date of occupancy:
GENERAL INFORMATION
, .,.
PUMPING RECORDS and.source ofanformation:: -
A/0 /16co1i!O
System-Pumped.as part of inspection: (yes or ao)
- :Ryes;vohtme`pumped: - Qallons
for PAP
TYPILOF'SYSTEM—.
Septic taak/distnbuttioa baa/soil absorption.system. - -.
Sittslis cesspool
Overflow cesspool
Privy.
Sheted.system(yes or no) (if yes,attach Previous inspection.records, if any)
Odw(aplain)
APPROWIATE'AGE of all components,date ias<alled,(if;lmown)and sou se:cf information: pC�i�r Dig y/3�� j
Swap odors detected when arriving;at:the:site:.(yea.or.no)Li/D
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION+FORM
PART,C
SYSTEM INFORMATION (oontinued)
PropertyAddrees:. /37 E9sr /5�RY RO osT�Qv�GL,F '
Owner. .Gi/G��sl,E L T. SvGGivA,v
..
Date of Inspection:: VI.1 j/9c
SEPTIC TANX-
(bate on site plan)
Depth.below rude:
Material of"ommbvction:ZMacrete._metal_FRP—other(explain)
6�6AL "a
Dimrnsioms: 49// 101,+;1C14
Distance hom top of"sludge to bottom of outlet tee or-baffle: gal
scum thidmesa: ' " ? y
Distam l,f#om-top of scum to top of"outlet tee or baffle: �Y
Distance from bottom of'scum.to bottom of outlet tee or baffle:_
Comments: »
(reammeadation for pumping,condition of inlet and outlet tees.or baffles;depth of liquid level in relation to outlet invert,'structural.integrity;.
evWence.of leakage, etc.) TEES of vo ;Pzd ,w GcrokZo A�, ,[iIy .1/G.y
�'�co�c,ylva Pd sroi��i zy4, Y
GREASE.TRAP::
(locate.on:aite,plan) _
Depth-below,Fude:
MatwiaLof'acrostruetion:_concrete-_metal:_FRP_other(ezplain)
Dimensions:
Beam thiA—_
Dndanoeff3rom:top
of.manAo top otoutlet:tee or-baffle:
Dlstama43eom:bottom.of scum to bottom of.-outlet tee or-baffle.Commentw
t
(zw meadation,for'pumping;condition-of inlet and outlet tees or baffles, depth-,of liquid.level-in relation.to outlet invert-.structural,integrity,
evidence:of leakage;etc.)
..»�+r..�m•...."w.ti,•,+•n«.. ,..w w«..r ..:•--. _..... �.�..,... .r..� ..... _.,r.".....-i-.n.-,d..-. _ �......... .=..v "..a,N-... ,..._.... +.... .-
- .i^ - » � �. `-�,.;b�+a., .:t" .- ....� •a..'o"` �. `"y' _ _ ,."',' ... ,caw:. w ...,t... L'. `',s ...
(rev�eed:11/03L95)cr
s.,. �.
+ a 3
t,
f
t
}
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION(oontinued)'
Peopbrtr Addresv:� l37 -',41sr X67.
Owner. I7/� �l�Gff6tEL T. svGG✓�/s/.t/ *.,;u£; _
Dale of Inepeotion:.
TIGHT OR HOLDING TANK_..
(locate on site plan)
Depth b�W7vvde:__.
Material of constizroctioa.y_conc:etz._metal—FRP_other(e:plain)
Dimensions
Capacity: gallons ... ....
Design flow: _gallons/day _ -
ALrm.level
Comments: ,
(condition-of inlet tee;condition-of alarm and.float switches,etc.)
DISTRIBUTION BOX
(locate on sits.plan)
Depth,of liquid:lvvel above outlet invert:
Comments:,
(note if level.sad distribution-is.egval,.evidence of solids-carrymr,evidence:of`leakage int,�or out:of"box-..etcJ' /�X
ftL���%/o..5/G.d"��...„��G�4G,�._.._Gc�/J •6�iP.c'ltTld� .l�:�Tw/.�.L:y /yL�T/t.� _ .
O�FG,dat,¢,rr6E i/i
o� t
• nrs.++�....w'rr.r .s.. � r ...-. ,o. v«.. _..-+ +•vv +s-.. .v.x+... ....�.rr H ...-_.. r .._ �-I� ..n+ r.... r _......+r.. .u...
PUMPCHAMBEW_ w+-.wx. r+_w..r......,+. r ......w........w_.......,«.r-+..u,... _ ..n .�.n..Mr.. .. • ry
Pump&in working mder:(yea or no) _. .
Qmuaats:
(mown condition of pump chamber,condition.of pumps:and appurtenances,etc.)
(revised:11Y03-/95): T
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
•
SYSTEM INFORMATIONh(continued)
Property'Addreew /3? 2.9sr d�Y •Qo osTe/1v�LG£
Owner. Iz/.ri .�f/Gy��� T,
Date of Inspection: y/a3/9G
SOIL ABSORPTION SYSTEM(SAS):!
(locate.an,ske PV4 if posable;excavation not required,but may be apProximated by non-intrusive methods)
If not determined to be present,axplain..
Type;
-leaching Pita,number,?
leaching ehambea,:number:_ _
Isse Galleries,number:
leechiirg:trenches,.number;length.
Wching:fields,number;dimensions: W<
overllaw•cesspool;.number. _
Comments:'(note condition of*oil,signs of hydraulic failure, level of ponding,conditiom of vegetation etc.)
P�i�U2� Top D/� DiTs Dery 3 ' T.��y ei££/lt .l.�> �x�✓11C0 -
cvyeai
(locate on
ppOm�e:plea).�.�.,._...r�_.._._.-�.. _,___ A,.._.__.. . �� . . .� .., - •y _ ,. �...._..
Number and_eoa8guration:
Depth-top•of liquid to inlet invert
Depth:of solids,layer
Depth-of,,arm l
Yatari+daot, trnete timL.-
Indiation.
-iaflo�►(ee!spool muse.be pumped:.as`part'of_"inspectionJY
_.
------------
Comment+:(note condition,of.'scil„signs.of hydraulic:failure, level of-.pondtng;condition of vegetation,etc:)-
PRIVY:.
(locate'am-site.plan) -
MataiaL:afcomrt:vtzron - _ _ Dimensions
+.(facts eomd:tron:of ior1,agtis of hydraulic failure; level_. condr .TM
._ . ,_ ofPonding,. tics of vegetation,.etc:)
•H
* SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION:(continued).
?mpoety Addeem, /37. SST �is?Y R D
"Wner.
Dote of bugmctiour.. h��a3/r1G
3HSTCH OF SEWAGE DISPOSAL.SYSTEM.-
hwjuds.t»e to st kast two permanent references landmarkii or benchmark..i
locate an.wells.within 100'
-------------
i
lRo�
4 Pit
DEP.TH;TO GROUNDWATER~
Depthtaaoimdwater- ,3 feet.
mat>sod.of:dataminetiom.or apprasimation /3/5'.Qu9Tf►�L� �+/S S/1cXdS TNT !�
8 T/1�' �i9.�tGsTjA6�E �BSF.eyID L�//VTliL' Th'.11.E dvvC f •`ice geN?F s T/>E 4�rGiC
7 eff4Z ?U !dG 9L406✓ A-' - °,r 1s Z' yA'cO A,riO rsr.E lf-,A �O
THE USES G®�ie�G?'/o•v /S � 7'
tmised;11/03/9sr s...
TOWN OF BARNSTABLE Vol
LOCATION 137 Aesr & Y de SEWAGE #
PILLAGE ASSESSOR'S MAP& L A:
INSTALLER'S NAME&PHONE NO. AL/Wf-D /S�4G 7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS y
BtMVER-OR OWNER W/eh` ,Zz
PERMITDATE: y�3,/�S� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching faci ''ty) Feet
Furnished by
i
t of
y
O
i Q
i
T�
. l�
LOCATION SEWAGE PERMIT NO.
VILLAGE r
.;�INSTA LI. 'S N ME i ADDRESS
'``B,UILDE R OR OWNER
DATE ,gP.ERMIT ISSUED
DAT E C0MPH4NCE ISSUED ._ )
I
I.
i
i
LOCATION SEWAGE 1/PERMIT N0.
e,4fi o9/ /?d7
VILLAGE
INSTALLER'S NAME & ADDRESS
Zan
B UIID R OR :OWNER
e
DATE PERMIT ISSUED
DAT E CO.MPLIANCE ISSUED
i
f � t
� r
a
r
S � �.
� �
c-
��
�w
� �
� � � :r
� ��
- �
� � ..
9
n
a ,1
p�
C
R
d
i�
��
76)
No.......... _ F� ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
(C'YI.5T"[�1�..................................
App iration for Uiipniia1 1Vvrkg Towitrurtivia ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( !--'an Individual Sewage Disposal
system at
L°' ..o.............•----_... ----....-----•......--•••-.......... ...........................................................
oeation ddres or Lot No.
Owner Address
_ � r
7t3). P
Installer Address
QType of Building " ' Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( )
4,,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter.:........__.._. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--_---------------- Diameter-------------------- Depth below inlet.................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No.. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' - =----.....--•-----------------•--•-----......--•-----------------•-.........................................................
ODescription of Soil.......... �:f Cok_A............................................................................-----•-----------•-•------------•
U -•----------
-------------------------
•-------------------------------
•---------------------------------------------------------------------------------------
.--------------------------
------•---------
W ---------------------------------------------------------------------------------------•------------------------------------------•-- ----•---
UNature of Repairs or Alterations—Answer when applicable.__.. Q.. /-(lam'-ja f;....�. ' dL��(�_��� �1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i IT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be. s ed by the ar health.
Signed - 1....-- r
-••-•- •-----------------------------•----•--•- Date
ApplicationApproved By-------------------------------------------------------------------------------------------------- -•---------------------------.......---
Date
Application Disapproved for the following reasons:.................................................................... .........................................
-
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
:... �` Fms
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Alipf ration for Disposal Works Tnns#rnrtiaan Vrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( "an Individual Sewage Disposal
Sy t atche
.
ocation�'Addres or Lot No.
Owner K Address
t �!__ ..... . f.l �.....................................................
Installer Address
d Type of Building ,' 1;` , Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other Type of Building ____________________________ No. of persons.-=........................... Showers ( ) — Cafeteria ( )
Otherfixtures' __....--•=--••---••---•-----•--•-•----•••------••-•--•---•-•••--•-•-••---•-••-•-------------•--•-••••-••-•--••--------••---••._....__.._......._._.._
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
#.a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground, water_______________________.
(W Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---'- -----•................. .•••• --_._.. _...._..........••••-•_..._.
-�
O Description of Soil......... } -
W $;*
►� ------ - } ey
U k Nature of Repairs or Alterations—Answer when applicable.__._ _ :._!' "_
= --
_____________________________________________......................................................................._.............................................._�w____.__._ ,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal.;System in accordance with
the provisions of TITL. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until aCertificate-of Compliance has been s' ed by.tlie_•b ard of health.
. � d,Signed r --- =y�` "� r.. .--• ------ rr .........................
/'> Date
ApplicationApproved By.................................................................................................. ......................................
Date
Application Disapproved for the following reasons:_...---•----------------------------•-------------------------------------------------------•••••••--••-••••-•-
-t; = •••- ................... --------------------------------•---•-
y
------•--------•-------------•-••••--•--•-'--•---------• ;
4
a.. Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
A.
BOARD OF HEALTH
P.
� .tJ .......o '�'? �-I- ) .......... E .. ._.......
Trrtifirat a of'Tamplianre
THIS IS TO CERTIFY, That the Individual Se"w;igey�Diis�p^oosal System constructed ( ) or Repaired (1,4
y........... c? Ir1s Iler ------------------•-•-•--------._...----------•
511
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as des,-ibed in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAXTISFACTORY.
DATE................................................................................ Inspector....... ----------............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................4 ' ......OF.... (AM a }, ...............................
No......................... FEE,h!.. .........
Disposal Works 6nstruxtion Vrrmit �
Permission is hereby granted `_ .''- ---.-'--•-! ...................................
to Construct
) or Repair (l.V)an Individual 'S m,age Disposal System
'Street
as shown on the application for Disposal Works Construction a �it o_________ _........ Dated..........................................
____ ..:. .! !r - ---�_______________________________
DATE...... d ................... Board of A h
FO�RM� 1255 HOBBS`&-WARREN. INC., PUBLISHERS ,
qr ,
No. -f`3---`3- F:ms.../ .'_0. ........
(
00 l THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
......... .........................---....O F.............................................----------•---...............................
Appliration for Disposal Works Tunstrnrtinn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
E
ti8n d.ess or Lot No.
� -�1: ..... _ ............................... ............................................. -------
--..
w t. � Addre ;
'{.•..r4..[,_.!._ 't 4F� ...............................
w� .
Installer Address A
Type of Building Size Lot....�....................Sq. feet
U Dwelling �/ .__..Expansion Attic ( ) Garbage Grinder ( )
•�No. of Bedrooms. T
Other—T e of Building No. of persons.........................: Showers — Cafeteria
04 d Other fixtures -------•---•-----------------------•-------•----•--------------------------------------- ..........................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.--•--•--•-__----.-- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
1
aTest Pit No. 1................minutes per inch Depth of Test Pit___-_-._--__---__-• Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Descriptionof Soil....... - > -------------•---------------------------------------------------------------------------
V ..•-•-•--'----•--•-._.....•-•-------------•--•------•---•---•-•------------------••--•----•••••-•----'-----•-•......----...... .......•-•---....-----...........-•--
W ------ -----------------------------------------------------------------------•-•--------------------`,� =- " --
UNature of Repai �.o,�Alt rations—Ans er w n applicab _.__1___' _ :.. __ ...............
I �® . ---------------------•-••--•-. ----------------
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 b the board f ealth.
Signed_: .. / --------------------•----- I ........... ..._
/�� te
Application Approved B ` l� Da
Date
Application Disapproved for the following reasons---------------•-----------------.....--•---------------------------------------•----------...•--._._............
:•....-•----=•---•---•----•--•••-•-------•-------------------------------------------------------------•••-••-'•--••...•-------•-•---••-••---•-••-----•-•--•---------••-----•-----•-----•••.....---•-
Date
PermitNo................................................... .... Issued...........................••---•---•----•---•----•-----
Date
6
15*j
No.------ ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF-................ ..........................................................
Appliration for Disposal Works Toutitrurtion "pamit
Application is hereby made for a Permit-to Construct or Repair an Individiilif,;.'Sewage Disposal
System ae:"
.......... ....................la......... ........I...................................... .........................................................
ress or Lot No.
-------------.. ....................................... "
- ---------------------------------------- -----------------------------------------
-----------
Adi&
......... .....
.............
.4r Installer Address
Size Lot........0.000
Type of Building y- ...............Sq. feet
U Garbage Grinder
Dwelling4e No. of Bedrooms.__ Expansion Attic
.tl...................................
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
P4Other fixtures ........................................................................................................I..............................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width_____.___.____._ Diameter._._..__.______. Depth___________.....
Disposal Trench—No_.................... Width_____._.__..______._ Total Length.___________.___.___ Total leaching area....................sq. ft.
>
Seepage Pit No_____________________
Diameter._._.__.._..._______ Depth below inlet._____.__........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
4 Percolation Test Results Performed by......................................................................... Date........................................
a
Test Pit No. I................minutesperinch Depth of Test Pit__.__.____________._ Depth to ground water_.___.___._.___________.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.____.__:._._______. Depth to ground water......................
P4 .......... ............................... ........................................................................ .-----------"-------
0 Description of Soil____..__ ---------------*--------------------------------------*--------**--------------.................................
W
U .........................................................................................................................................................................................................
W ............................................................................................................... .......................4
pair 41fa tons ns er. plicjje .................
Al
U Nature of Re t* A er w ap
Aeemen -W.- -4-----------------------------------------------------------------------------------------------
gr
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 p�fhealth.
Signeu_�2. ... .....�.Od .....in........................... 3
..........................
Date
Application Approved By.......1----------*V............... ------- ........................................
--------*-------------------------"-------I,/ I Date
Application Disapproved for the following reasons:.................................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo.......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 'r li,
BOARD OF HEALTH
......... vL 6e..................OF....... .............................................
Entifiratr of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by._... .........../7.(- .......... ............................................................................................... .............,..........
Install er
at.............ZIL":". ............... ...... ( /.4.Lc.............................. ..........................................
--------------*------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Wo' r*'ks Construction Permit,No------ ....................... dated_-_:._____---- ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------`-... a ............5................................... Inspector........---- ................01--.4swi .....
..................
'THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF "HEALTH
...................I......./0 pft zc_... ............OF....................................................................................
No........................... FEE....................
lY
Permissionis hereby granted. ...........1.....................................................................................................................
to Construct or Repair (X') an Individual Sewage Disposal System
at No.......A 2_1�....Z5!±.t..........JV.!L11.................r................
Street elf.
as shown on the application fdr'Disposal Works Construction Permit No___.................. Dated............ .....................
......... ............................................. Y2rd of Health------7- ---------------------------
DATE =
................................
.............
FORM* 1255"A. M. SULKIN, INC.. BOSTON
q�,
2"
f
C GSO, o
o
L
c� n
'1 . 1
�r
o f, -
rb
C � v ?
C �
i
i1
PC-3c.Jx
CN
f
w v.
Il
♦+ 1
. Gr C
rN
-
77
Lgl
e
-1 V
»
,M1
4 ,gip/ �• � ""'>.
_ a
e >
1
a -
r
a ,
r .
46'
n
r---------------------=
I �.�i•. •��`:�'!�'• '•/ �'• .i; '•.•a�.. •r. :>. �.•a• � :i i•:' ::fi'.• •.f^' i•:' •v.:' :;• iY.;.J y1:.',.,
- ---------------------------------------------------
I O z
L_�
I
G) D
I
I I
rn
-TI
Q I "'
rn O
I
I r_�
14� L-_________________________________________________ ——
'i'� _ .L. �?�� 'i,.::�� :{'• 'L�:�i, �. ..�.h. ^f)`.�,•s; •ri..i:.r,.:;.{.^.-:v.r. ..f i'i..� I
L-----------------------------------------------------------------
"24'-54
O 3,,
z 10-44
0
O
z
IA
Z �° Ig o
71
I Owl,
:1.
Z N °' N
-0 X
U)
m �� N •
6> a
U �
ti
0
O O
n
0
ti
P`
aN
X O
� rn
t �
4
c �; �y e N N
�, c • cn o
p 4 0 w a X .., X .
V � p c � om
S 1 La
A
O n PROJECT:
rn Garage
o -rn LOCATION: 137 East Bay Road in o H . P. Custom Builders Inc.
II
20 W Z ARC"ITECT: 981A Main Street
O = c CONTRACTOR:
b = MP Ryan Builders
CUSTOMER: OSterviIle j MA 02655
O rn W
m TITLEMain:508-280-7288 Fax:508-419-7708
FND & FRAMING PLAN
1
48'
16'-22" 16'-22" 6'-511
G� N
D
rn
r
O
rn
70
rn i
rn
r74
- 10'-411
n '
D
rn
S
C Vf
h � N
' common '
O ti m : c:0
"�— — - C1 is,!S n
_ --- - - =I - —
.�
A
D e
rn
�w�1- BEitt�•l�tJTa - FitAr1� psei ay�J .�JkA pe, 1� f•
rn
r
rn
rn
r
O 00
rn
. I
t
i
o O n PROJECT: Garage
03 ~ D A � H . P. Custom Builders Inc.
m o °`rn LOCATION: 137 East Ba Road •
m Z. ARCHITECT:.
98A o Main Street
o _ _ c CONTRACTOR: H.P. Custom Builders
brn
D CUSTOMER: M Ran Osterville, MA 02655
N m r- TITLE: Main:508-280-7288 Fax:508-419-7708
FLOOR PLANS