Loading...
HomeMy WebLinkAbout0206 EBENEZER ROAD - Health FA20 6 EBENEZER ROOSTERVILLE = -146 077 rf � V tw' a i �, a c Commonwealth of Massachusetts w Title 5 Official Inspection Form A r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address r . '•° Jerry Curcione _ Owner Owner's Name rgy information is required for every Osterville e MA 02655 5-15-19 page. City/Town . State Zip Code Date of Inspection p, Ui Inspection results must be submitted on this form. lnspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Sl .•(3��y Shawn Mcelroy Name of Inspector ` Upper Cape Septic services Company Name ' P.O. Box 73 , Company Address E. Falmouth MA Y-• - 02536 City/Town State Zip Code '1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in.full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and r the inspection was performed'based on,my trainirig and experience in the proper function and ' "maintenance of on-site sewage'disposal systems.After conducting this inspection I have determined that the system: s 1. ® Passes' 2. ❑- Conditionally_Passes E 3., ❑ Needs Further Evaluation by-the Local Approving Authority 4. ❑ Fails 5-15-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. a 7 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 r� Title 5 Official Inspection Form wa • cl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione r Owner Owner's Name information is required for every Osterville 4 MA 02655 5-15-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. %1); System.Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: - ❑ One or more system components as described in the "ConditionalPass" 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 exfrltration 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 ON ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione _. Owner Owner's Name information is required for every Osterville� �,,, + MA 02655 5-15-19 page. City/Town 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 °i pumps/alarms are repaired. 7 ❑ 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): ' t r ❑ broken pipe(s)'are replaced ❑'Y ❑N ❑T ND (Explain below): . ❑ - obstruction'is'removed l Y '`EIN ' ❑ ND (Explain below): ' El— 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): 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, a safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 1 Commonwealth of Massachusetts a Title 5 Official Inspection Form (-f' 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd J Property Address Jerry Curcione Owner Owner's Name information is required for every Osterville MA 02655 5-15-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) f ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that 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: 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.7/26/2018 w Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 r Commonwealth of Massachusetts - ,w Title 5 Official Inspection Form - i0.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd , Property Address Jerry Curcione Owner Owner's Name information is required for every Osterville f ,. MA 02655 5-15-19 page. City/Town , a State Zip Code Date of Inspection C. Inspection Summary (cont.) - .{• .A ,.. •4)..System Failure Criteria Applicable.to All Systems: (cont.) 4 Yes, ,,No r t Static liquid level in the.distribution"boz above outlet'invert`due to an overloaded ❑ ® or clogged SAS'or cesspoolF Liquid depth in❑" cesspool is less than 6" below invert or available volume is less® than 1/2 day`flow. . ❑• ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: r ❑ ;•W ® ••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 " ❑ ® L' tributary'to a'surface water supply. t Any portion of a cesspool or privyis.within a Zone 1 of a public water supply ® s well. - El ® Any portion of'a cesspool or privy is within 50 feet of a private water supply well. ` a❑ ' ® 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 v 1'w 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- - ' The system fails.1 have determined that one or more of the above failure ` El ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The . • * , p-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 10,600 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. f x 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 11 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 1 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form ►r :%r. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name information is required for every Osterville MA 02655 5-15-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) r 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 aff 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? ® l ❑ Wasthe 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 f Commonwealth of Massachusetts t� r Title 5 official Inspection Form , hM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address r Jerry Curcione Owner Owner's Name r • , information is required for every Osterville 4 = MA 02655 5-15-.19 t . page. City/Town State Zip Code Date of Inspection D. System Information . 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: ,,, , 0 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 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: Sump pump? r .f ❑ Yes ® No Last date of occupancy: 2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts , 3 Title 5 Official Inspection Form r-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name information is required for every Osterville MA 02655 5-15-19 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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): 3. Pumping Records: Source of information: Owner---not within last 3 yrs 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 Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 f r Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name information is required for every Osterville MA 02655 5-15-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . .s 4. Type of System: : r ® = Septic tank, distribution box, soil absorption system r; +- ❑ . 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 DER approval.• ❑ F Other(describe): a a Approximate-age of all components, date installed (if known) and source of information: 2005 Were sewage odors detected,when arriving,at the site? r ❑ Yes ® No 5. Building Sewer(locate on site plan): • „ ,• �, Depth below`g 30+''rade: +' feet ' Material of+construction: - ❑ cast iron - l ®40=PVC ' '❑ other(explain): p Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26=18 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form ( PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address . Jerry Curcione Owner Owner's Name information is required for every Osteryille MA 02655 5-15-19 State Zi page. City/Townp Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: _24"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: - 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle* 26+n Scum thickness 0 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 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ` Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i r _.. Commonwealth of Massachusetts it Title 5 official Inspection Form- fir► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name ; information is Osterville MA 02655 5-15-19 required for every . � page. City/Town t, State . Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of.construction: . . k. - •r . ❑ 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:• :; ,, _ 14 ' 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.): ' r' 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 4. 3 Title 5 Official Inspection Form •.wa 0> ,(4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name information is Osterville MA 02655 5-15-19 required for every page. City/Town 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): i 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.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts p l Title 5 Official Inspection Form I"I' i-M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd • Property Address , Jerry Curcione Owner Owner's Name information is OStelVllle , required for every MA 02655 5-15-19 page. City/Town State Zip Code Date of Inspection" D. System Information (cont.) 10. Pump Chamber(locate on site plan): ' Pumps in'working order:" ❑'Yes ❑ No" Alarms in working'order: ❑ Yes El 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. e 11. Soil Absorption System (SAS) (locate on site plan,-excavation not required): If SAS not located, explain why: Type; ❑ leaching pits' ' "'number: ® leaching chambers number: 2-500's ❑' leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Nl> it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name information is required for every Osterville MA 02655 5-15-19 page, City/Town State Zip Code Date of Inspection a 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. 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.): , Z t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form ! i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W 206 Ebenezer Rd Property Address Jerry Curcione �. Owner Owner's Name information is Osteryille , MA 02655 5-15-19 t required for every t • ' page. City/Town 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.): 4 • t — .. t5insp.doc-rev.7l M018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 l c Commonwealth of Massachusetts . j Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione Owner Owner's Name information is Os required for every terville MA 02655 5-15-19 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 is I i 1 l - �- 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 l I. Commonwealth of Massachusetts t ,. Title 5 Official Inspection Form %i Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd Property Address Jerry Curcione , Owner Owner's Name information is Osterville MA 02655 5-15-19 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.)} r q • ; j 15. Site Exam: • r. ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water:.. 12' '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: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 01 8. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts y Title 5, Official Inspection Form , ! i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Rd J Property Address Jerry Curcione Owner Owner's Name information is Osterville MA 02655 5-15-19 required for every 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 checked ® C. Inspection Summary: rY: 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 May 09 2016 21:50 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts 0� - Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick& Sadie Meehan Owner Owner's Name information 1s �7 required for every Osterville ✓ MA 02655 5-9-16 page. City/Town State Zip Code Date of Inspection f•+ Inapeotion reautto moat be aubmitted on this form. lnapection forma 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 // /t/n `�tttttulttltgpsii� on the computer, Sl i I/i,r / \```�`,%�jH OF.M4 •,"�9�'��'4 use only the tab C �y 1. Ins actor. , �.. •,y , key to move your p =C5 N cursor-do not ,lames D.Sea"rs t 'V• JAMES use the return Name of Inspector E3 key. Capewide Enterprises, LLC s�• �� ��o•'�� Company Name .1 IleF.R it,VIC] ,.•G `� 153 Commercial Street n,;;sp ��`���� Company Address Mashpee MA 02649 Citylrown y State Zip Code 508-477-8877 S1623 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-9-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable; and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 rTitle 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 1 of 17 May 09 2016 21:51 Jim The Inspector Man 5085349919 page- 20 Commonwealth of Massachusetts Title 5 Official . Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Road Property Address , ` Patrick&Sadie Meehan . Owner Owner's Name information is ' every required for ev Osterville MA 02655 5-916 paQe, Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: The system is a 1000 Gal. Tank D Box and two 500 Gal. Chambers. 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 orexfiltration 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): • j 15ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Olsposal System•Page 2 of 17 May 09 2016 21:52 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts . Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebenezer Road _r Property Address Y Patrick&Sadie Meehan, ` A Owner Owners Name Information is llle required for every OStery MA 02655 5-9-16 . 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 pipo(e) aro rcplacod ❑t Y. ❑ N ❑ ND(Explain below)- obstruction is removed ❑ -Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ 'Y ❑ N .❑ ND (Explain below): El 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-3113 TRIe 5 0friicial Inspeclion Form:Subsurface Sewage Disposal System-Pape 3 of 17 May 09 2016 21:52 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts . - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for voluntary Assessments 206 Ebenezer Road Property Address, Patrick&Sadie Meehan Owner owner's Name information is x required for every Osterville MA 02655 5-9-16 page. City/Town i C 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 ofa 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: 4 , **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 eyuat 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. , t 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 is less than 6" below.invert or available volume is less than X2 day flow 84 elll,y c t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 May 09 2016 21:53 Jim The Inspector 'Man 5085349919 page 23 Commonwealth of Massachusetts . Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick& Sadie Meehan owner Owner's Name information is required for every Osterville MA 02655 5-9-16 page. Cityrrown 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 colifonn 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.], ❑ R The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The eyetom faiie_ I Novo dotorminod that one or moro of tho.obovo failuro 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 El 0 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•3113 - Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•PaGs 5 of 17 May 09 2016 21:54 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick& Sadie Meehan Owner Owner's Name information is required Po every r ery Osterville MA 02655 5-9-16 . - page. Citylrown 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? Z ❑ 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) Z _ ❑ 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 liquidi 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): $ Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins'3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 May 09 2016 21:55 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 206 Ebenezer Road Property Address Patrick&Sadie Meehan Owner Owner's Name information is sterville MA 02655 5-9-16 required for every O , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and two 500 Gal. chambers Number of current residents: ' 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014-78,000Gals g ( y 9 (9P �)' 2015-84,000Gal's Detail: Sump pumps ❑ Yes ® No Last date of occupancy: Present Date Commemialllndustrial 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 Nnn_sani4ary%tuacfm r icchoroor! to tho Titlo 5 cyctom7 ❑ Yoo ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r May 09 2016 21:55 Jim The Inspector. Man 5085349919 page 26 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebenezer Road Property Address r _ Patrick & Sadie Meehan Owner Owner's Name information is required for every Osterville MA 02555 5-9-16 . page. CityfTown cState Zip Code Date of Inspection M System Information (cunt.) ` Last date of occupancy/use: Date Other(describe below): a General Information Pumping Records: Source of information:. f. NA. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: aauons 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 es attach Previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and 4` maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a'copy of the DEP approval. ❑ Other(describe): l5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 May 09 2016 21:56 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments sY .b 206 Ebenezer Road ' - Prnnerty Ar1ri racst* 3 Patrick& Sadie Meehan ref Owner's Name information is Osterville MA 02655 5-9-16 required for every page. R CitylTown State Zip Code Date of"Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank NA Leaching 2005 permit H 2O05 -252. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): • , Depth below grade: 38"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.): Pipeing is 4" PVC SCH.40. r Septic Tank (locate on site plan): Depth below grade: 28" 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: . 1000 Gal. Precast H-10 ,. . Sludge depth: t5ins•3113 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System-Page 9 of 17 May 09 2016 21:57 Jim The Inspector. Man 5085349919 page 28 . Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick &Sadie Meehan Owner Owner's Name information is required for every Cisterville MA 02655 5-9-16 - page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2911 Scum thickness 12„ Distance from top of scum to`top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape- Plan Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 28" below grade. W/inlet& center cover-at. 9". Inlet tee,outlet baffle. No sign of leakage or over loading. Grease Trap (locate,on,site plan): " Depth below grade: '' feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: " Scum thickness Distance from top of scum to top of outlet tee or baffle !. ^ Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 May 09 2016 21:57 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 . Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i a 206 Ebenezer Road Property Address PatrickA Sadie Meehan Owner Owner's Name information is required for every Osteiville MA 02655 5-9-16. ' page. CityrFown 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 .ex lain ( P ) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No - Alarm level: Alarm in working order: El 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•3115 - - _ Title 5 OtTclal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 May '09 2016 21:58 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Road- Property Address Patrick& Sadie Meehan Owner Owner's Name information is required for every Osterville MA 02655 5-9-16 , - page. Cityrfown - 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 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.): D Box is 16"x 16"42" below grade wlcover at 1'. Box is clean and solid w/two lines out. No sign of over loading or solid carry over. 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: I5ins•3113 - - 'Tide 5 Official Inspection Form:Subsurface Sewage Disposal Systarr•Paige 12 of 17 May 09 2016 21:59 Jim The Inspector Man .5085349919 page 31 . } Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick &Sadie Meehan Owner Owner's Name information is Osterville MA 02655 5-9-16.required forevory , page. City/Town State Zip Code Date of Inspection D. System' Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches. number, length: ❑ , leaching.fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system . Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,"etc.): Leaching is two 500 Gal. dry well chamber(13'x25'x2'). Chambers are 49" below grade w/cover at 10". Wet bottom, wall's clean like new. No sign of over loading or solid carry over. 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 . r Indication of groundwater inflow. ❑ Yes ❑ No t5ins-3113 _ _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 May 09 2016 21:59 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title S Official Inspection .Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick&Sadie Meehan Owner Owner's Name information is required for every Osterville MA . ' 02655 5-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cost) 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 i Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•3113 -Title 501Rcial Inspection Form:Subsurface Sewage Disposal Systerr•Page 14 of 17 May 09 2016 22:00 Jim The .Inspector Man 5085349919. page 33 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 206 Ebenezer Road Property Address Patrick& Sadie Meehan Owner Owner's Name information is required for every Osterville MA �02655 page. Cityfrown 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 wham ptihlir.watpr CuPPly enters the building. Chock one of the boxoc bolow: ® hand-sketch in the area below ❑ drawing attached separ'ately £ CfC i Sao Cl< P 6 n IT 40 L f T6z , t5ins•3113 Tille 5 Ottldal Inspection Form:Subsurface Sewage Disposal System-Page 15 o117 May .09 2016 22:00 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 206 Ebenezer Road Property Address - Patrick&Sadie Meehan Owner. Owner's Name information is required for every Osterville • MA+; 02655 5-9-16 page. Cityrrown State Zip.Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope El Surface water t ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water: 11.5'+ Net Please indicate all methods used to determine the high ground water elevation; ® Obtained from system design plans on record If checked, date of design plan reviewed: 4-28-05 Date Observed site (abutting propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ` Lot high from street., ❑ Checked with local excavators, installers-(attach documentation) ❑ 'Accessed USGS database -explain: You must describe how you established the high ground water elevation: T.H.on Design plan 4-28-05 no G.W.at 11-5'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5Official Inspeollon Form:Stbsurteoe Sewage Disposal System-Page 1e of 17 May 09 2016 22:01 Jim The Inspector 'Man 5085349919 page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 206 Ebenezer Road - Property Address Patrick& Sadie Meehan " Owner Owner's Name information is required for every Osterville MA 02655 5-9-16 page. Cityrrown 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 t5ins•3113 - Title 5 Official inspection Form:Subsurface Sewage Disposal System•pegs 17 of 17 a , , Tow. N OF B RNSTABLE. — - a orr C�� 6 e�e_z Loc xm VILLA s. AS .SSolt�s A►SSTP�L1.BIt`S 1+tA111��P�IDIdE PIO: C.TANK-CAMCITY I CSC S L1�ACIUNG 1PACE�LI't`Y:{ty+p$) _ IDUILDER.IaR;D�?VN 1R PBRMIT32A.TBi Gt]I YC.IA TCE 1D/4'i' :..w __ St p lbo: Ivt xiunum Adjust tl Grauncfww tic 'abie Ca th6 Bduatn 6f 1.40 ►WS Fru;�li y. t Priv e'4 pt��r Suppiy V1cU sued i eue4iag i ac ry of many►s ft BxSst att ONA.ne�Ittun?AO'feat a 1 Shia fxcs ty) Eli a of�►1c. ai►d and Lo►c, 09.t aD ty.�k u�ny wetter emsc Feet withI4 300 feet p L ing:�'adlatty) 3 T Loi 0 I a ,,a- 5 ?1 bd- 4vg, P TOWN OF BARNSTABLE LOCATION 4� . .L�'��sT z,r- SEWAGE # AV P�, ?S'.Z VII.LAGE �c4 i`le ASSESSOR'S MAP & LOT_ft "V INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACTI'Y /,Cl cxv GG LEACHING FACILrrY: (type) !acj G'gL C "l 6) (size) 1*02 T°A:&` NO.OF BEDROOMS BUILDER OR WNER d r✓Pe� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Zigi:g ¢ ��� _ _ \ �,. r - P' � .._ _ LJ � s� '/ G` \ ��` �O I I TOWN OF BARNSTABLE L°'OCATION CZC-4— SEWAGE # VILLAGE (26 ASSESSOR'S MAP& LOT 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c1 Or LEACHING FACILITY: (type) _P i� (size) kCQQ!21 Or NO.OF BEDROOMS BUILDER OR OWNER 6Ac11 tNo PEie*IfDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) I Feet Furnished by eC14AD `olC�tp L i all r X1 z aj' � A 3- 3k b3 3Si �y . 3-)` Commonwealth of Massachusetts a Title 5 Official Inspection ForIN Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road ,. Property Address HSBC Bank Owner Owners Name requir required is Osterville MA 02655 k 5/12/09. required for' _ „ every page. City/TownI State Zip Code Date of Inspection Inspection results.must be submitted on this form. Inspection forms may not be altered in any way. A.. Important: A. General:Information When filling out m y forms on the — I I computer,use P 1. Inspector: . ,- .� I ,-_ only the tab key m v r to o e your Michael Kellett - cursor-do not I Name of Inspector' use the return key. Aardvark Environmental Inspection --a Company Name P.O. Box 896 m Company Address East Dennis MA A61, 41 11 Cityfrown '' State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification F ._ 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes W ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority 05/14/09 Inspector's Signature Date The system:inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments b , ' 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is required for Osterville MA 02655 5/12/09 _ every page. Citylrown 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: d ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is Osterville MA 02655 5/12/09 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification.(cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation_is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. . ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer`Road Property Address HSBC Bank Owner Owner's Name information is required for Osterville MA 02655 5/12/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): []'The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 El ® 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 t due to an overloaded or clogged SAS or cesspool �j ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is Osterville MA 02655 5/12%09 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® ' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [E 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- 10,000gpd. ❑ ® The system fails.] 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. Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner -Owners Name , information is required for Osteryille MA 02655 5/12/09 every page. Cityrrown 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 El Z 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy< 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is required for Osterville MA 02655 5/12/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms actual 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate„inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,If available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No 01/09 Last date of occupancy: Date Date Commerciallindustrial 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: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is required for Osterville MA 02655 5/12/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: -Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 06/06/05 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s °t 206 Ebeneezer Road Property Address -HSBC Bank Owner Owner's Name information is required for Osterville MA 02655 5/12/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information-(cont.) Building Sewer(locate on site plan): Depth below grade: 3.0 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: 2.0 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: 1000 gal 2" Sludge depth: Distance from top.of sludge to bottom of outlettee or baffle 2911 2" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle.. Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Measured Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is required for Osteryille MA 02655 ' 5/12/09 every page. Citylrown 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.): The tank was sound and tight with liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: F 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.): 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): Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is Osterville MA 4 02655 5/12/09 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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 box was level and tight with no sign of carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 official Inspection Form 'Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.•`'t 206 Ebeneezer Road . Property Address HSBC Bank Owner Owner's Name information is required for Osterville MA. 02655 5/12/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 why: Type: ❑ leaching pits number: � leaching ch ambers rs 7 number: 2 ❑ leaching galleries number:,. Fj eaching 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 ot vegetation, etc.): The system has two five hundred gallon drywells in a25'x13'stone field. There was no sign of ponding or failure in th a stones. Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is required for Osteryille MA 02655 5/12/09 every page. CitylTown State. Zip Code: Date of Inspection D. System Information (cont.) 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.): Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner Owner's Name information is Osterville MA 02655 5/12/09 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information.(cont.) 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. 4CA, 61 s Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 206 Ebeneezer Road Property Address HSBC Bank Owner . Owner's Name information is required for Osterville. MA 02655 5/12/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high.ground water. 20.0 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: ❑ Checked with local excavators, installers-(attach documentation) Z Accessed USGS database-explain: " You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. r god Fee 6 ®� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Digpogal bpotem Construction 3permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System [Kdividual Compone Location Address or Lot No. 70.6 ,rIge#e z el^ Owner's Name,Address and Tel.No. Assessor's pffla 1 �ry��flville Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No. 6rAp/oi' i��j`" Type of Building: Dwelling No.of Bedrooms Lot Size�] sq.ft. Garbage Grinder( i� Other Type of Building^ f , 61C.e_No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ©k 3 _ ✓7 gallons per day. Calculated daily flow . 317 gallons. Plan Date Number of sheets�� Revision Date Title / ,_5 5 & 4 046 Ed ewez z°,-^ Size of Septic Tank /®eB Type of S.A.S. � r Description of Soil /vX 7_5_Ar 7- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by *s Boar f alth. Signed Date Application Approved by Date �- d Application Disapproved for the following reasons Permit No. Date Issued U �R �,t•y �, O� �M� a- _j, _ No. ` � _ .t ,,.,. Fee / t �;THE,COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes - PUBLIC HEALTH,,.DIVISION -TOWN OF BARNSTABLEI-MASSACHUSETTS tltlYicati0t� for Mtopaal *patent Cow5truction Pennit Application for a:Permit to Construct( . )Repair(P Upgrade( )Abandon( ) El Complete System L'J Individual Components__`___. Location Address or Lot No. 20/ r, �eNe z ell �� Owner's Name,Address and Tel.No. x! /�1D/'I4rI J�r zcr�UICGis Assessoys,�I�p/Pafcel, Installer's ame,Address,and Tel. Designer's Name,Address and Tel.No. Type of Building: //�� Dwelling No.of Bedrooms 3 Lot Size Z 7X6 sq.ft. Garbage Grinder( �� Other Type of Building e5lWC'�ICeNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //OX 3 : 3342 gallons per day. Calculated daily flow ✓ . Z gallons. Plan Date Number of sheets / Revision Date _ Title 10)wJ`P 5 2°� /'�' _� '�5/�� a>'' Z06 Size of Septic Tank �DO�1 Q/ �� �`%�'> Type of S.A.S. Description of Soil /3.k Z Nature of Repairs or Alterations'(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system,00r,"' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued b hisBoar0of H.alth. µ Signed Date Application Approved by Date Application Disapproved for the following reasons _ Permit No. S Date Issued U THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comphance THIS IS TO CERT•FY, that the/On- i e.Sewje Disposal System Constructed( )Repaired (,Al)Upgraded( ) Abandoned ,/�)by ©r�`ol� �/, (__ 1✓;/_l at Z f� �14�' e'K l'C� • -** � has been constructed�'nn ccordance with the provision- Title 5 an the. or Disposal System Construction Permit No. 5�-a 0'-- dated (07" 15 Installer Designer The issuance of this�je tt shall not be construed as a guarantee that the system wil f : cti n as_desig ed. Date / �5 Inspector . — - —=---'---=== ----------------- ——— . No. C��` Fee 0_'"`-('�THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi.5po$a1 *p$tent Congtructton J)erntit Permission is hereby granted t- Const uc y( )Re air ")Upgrade( )Abandon System located at �� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construefion ust be completed within three years of th` ate/d of th s pe, 't Date:__ Appro`vedb_y -- —"� 07-01-2005 10:21AM FROM SWEETSER ENGINEERING TO 15oe42eg399 P.03 Town of Barnstable Regulatory Services Thomas F.Geiler,Director . Public Health Division � • Thomas McKean,Director [Ply 200 Main Street,Hyannis,MA 02601 U x t- .. Office: 508-862-4649 Fax. 508-790-6304 Installer &Designer Certification Fgr m Date: Designer: �'rL_c� . S h� Installer: Address. d 4l Address: �����-G► Senn i,�,�'!'1R �b�o ����®��s.� %/s.�� �z6L1� On 6/ �� 1d � Co�sT. was issued a permit to install a (date) (installer) septic system at �a6 E�oV e25 "/' ` `z based on a design drawn by (address) dated d OQS (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system); but in accordance with State & Local,Regulations. Plan.revision or certified as-built by designer to follow. • f �A 0,F �"•.fir`�- �qsr ` (Installes Signature) _'" ORAIG ` y SHORT s . ^ No.. 274 s'l4$3 (Desi er's Signature) ( :`b R Here) NAL PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH t" N. CERMCATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q;Keal�lScp��De�i�o�r C�r�flcatioa Form ,: - TnT01 D M-Z j' .. P 03&CT DESCRIPTION: 'AS=BUILT BENCHMARK TOP OF FOUNDATION ASSUMED ELEVATION 100.00 / • 101.7 PIPE INVERT AT SEPTIC TANK OUT ELEV 9.6.08 / PIPE INVERT AT DIST BOX IN ELEV 05.73 PIPE INVERT AT DIST BOX OUT ELEV 95.56 11a21 01.6 PIPE INVERT AT S.A.S. ELEV 95.26 BOTTOM OF S.A.S. ELFV 93.26 DISTANCE ABOVE BOTTOM OF TEST HOLE 5.46' / 101.4 uvc- 1 . 99.7 i — - ?0'1¢ . s M i 1�3 �awc-t arc,e', s, 12.2' . 102.2 � ����' � rpwr 98. SEP77C TANK 8.9 99.4 100.0 E D C S.A.S.: 2 500 GAL K .DRY ` owh,ar W/STOMES �� \ B DECK 101. I DIST BOX EXISANG °AK O DWELLING / Qh 99.2 �cr a � 99.2 / 101. C / ass 98.5 / 99.2 �.I c! /BIT—DRIVE C 7'-4" BC 10'-8� ' 9 0l i - -(s8 _ 9. AD 10 -3" BD 12,-9,� . _ �• � AE 13 -6 XE 29 -&� 30�-8„ XF 35;-80 I I h ■ 96f7 �95.4/ • 38'-4n XG 36,3� 9 97.6 , / 45 -5 XEI 45 -4 s .2 x 96.s 51'-3" XI 47'-0" 28.4, / LOTS 24 & 57A 21,7154 f S.F. .1 Member ASCE MARION & DAVID JUZAPAVICUS CRKG R. SHORT,- P.E. j F P.O. BOX 1044 ss9 Locus.• 906 EBENEZER ROAD SOUTH DENNM$ MA 02660 0RAIG It S R llmwy BARNSTABLE, MASS Professional CM Engineer • S611 Evaluator Licensed Construction Supervisor • Septic Inspector, '` CIVIL Septic • Site • Piers • Structures • House Designs, 'i o.•274 3 c DATE JUNE 30 2005 FILE 1-1030 try Office: (508) 398-8311 Fax: (508) 398-3063� 'fpNA E SCALE 1"=20' 1 4,0JECT DESCRIPTION: `AS--BUILT BENCHMARK .TOP OF FOUNDATION ASSUMED ELEVATION 100.00 / x 101.7 PIPE INVERT AT SEPTIC TANK OUT ELEV 90.08 PIPE INVERT AT DIST BOX IN ELEV 95.73 / PIPE INVERT AT DIST BOX OUT ELEV 95.56 11a21 01.6 PIPE INVERT AT. S.A.S. ELEV 95.26 BOTTOM- OF S.A.S. ELEV 93.26 -DISTANCE ABOVE BOTTOM OF TEST HOLE 5.46' / 101.4 f _ 99.7 99.1 12.2' 102.2PAW PAW 98.7 \ �?OAKA SEPAC TANK 8.9 K 99.4 100.0 E, D ^C BH.' ow�w' ORYW£LLS500 GAL ��CX \ i W/STONE / f / DECK 101. H DIST BOX B EX/SANG O DKWNG © PA AO 906 I 99.2 ax ar 9.2 / 101. 98.5 / 99.2 B/T-DRIVE C 7D-4." BC 10'-8 ' 9 0, _(sa _ 99. AD 10—3 BD 12 -9� �� AE 13 —6" XE 29'—iM '—iM 30'-8" XF 35'-8o r h 96 7 �95.4/ 38'-4" XG 36'—k s?9" 97.6„ // ! / 45'-5" XH 45'-4" 9 .2 51'-3" XI 47'-0" 28.4' ,� (96)- - / LOTS 24 do 57A F 21,764 f S.F. / 1 Member ASCE u �R MARION & DAVID JUZAPAVICUS CRAIG R. SHORT, P.E. OF Lr P.O. BOX 1044 ;� Jq Locus06 EBENEZER ROAD SOUTH D£NN/� MA 02660 013"If' SSG (r' BARNSTABLE MASS Professional Cia1 Engineer • Soi1 Evaluator <<� CIVIL � � ' Licensed Construction Supervisor • Septic Inspector j No. 2't; Septic • Site • Plers • Structures • House Designs1-1030 DAB JUNE 30 2005 Office: (508) 398-8311 Fax: (508) 398-3063 + SCALE 1 =20 1 R . 07-01-2005 10:21AM FROM SWEETSER ENGINEERING TO 150842e9399 P.03 Town of Barnstable Regulatory Services Thomas F.Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 0",ce: 508-862-4644 r Fax: 508-790-6304 Installer &Designer Certification F9rm Date: tr ; Designer: r �. �. S hbrl- Installer- �7�1D Address: P� d • �Qyx Address: , �l5y ✓ /�� on '� ( �P/ Gl �Sr -was issued a permit to install a (date) (installer) septic system at ?,00 based on a design drawn by (address) r .Shaft- dated Df.1 olK ol 005 (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. t I certify that the septic system referenced above was installed with maJ'or changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system.1but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ttr (Installes Signature) C3HAIG C1 Z9 'Uil. � . No 27463 (Deli er's Signature) Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH 1V ION. CERT_I_FICATE OFCOMPLIANCE WILL NOT BE ISSUW UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED THE BARNSTABLE PUBLIC HEALTH DMSION. THANK YOU. Q:Keal�USep��D�i���r C�r�flcatioo Form , . TnTOI P M-Z CRAIG R. SHORT, P. E. P.O. Box 1044 235 Great Western Road Telephone(508)398-8311 South Dennis,MA 02660 Fax(508)398-3063 PROFESSIONAL CIVIL ENGINEER-SOIL EVALUATOR SEPTIC SYSTEM DESIGN—HOUSE DESIGN PLANS—WATERFRONT DESIGN&.PERMITTING July 8,2005 Barnstable Health Department 200 Main Street Hyannis, MA 02601 RE: 206 Ebenezer Road,Oster0le,MA Marion&David Juzapavicus CRS File#1-1030, Enclosed please find the Septic.Installation Certification form as well as my Septic As-Built plan for the referenced site. A copy has been sent to the homeowner and the installer. If you have any questions,please give me a call. Sincerely, Craig R. Short,P.E. Enc. cc: Marion&David Juzapavicus—Owner Bortolotti Construction-Installer CO'_\IMO\%VEALTH OF NL•%SSACHUSETTS E�tECL TI�-E OFFICE OF EN-VIRONAIE\TAL, RS PRO - OF Eh�tONMENTAL TIO , n = DEPARTMENT ONE V%INTER S':R- BOSTO\ \LA 0210S l611! 292 t9 �' Of9ARNSIABIF TRL;DY COX-. v �p►ZIlOFp�• eecretar. ARGEO PAUL CELLUCCI r. s DAVID'?STP.�HS Governor. v'` \ 1 Commissicner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' r1n11 � _14G PARTA ' \f�+1n1� CERTIFICATION - n Property Address: ^� �; � _ �'�' `�`� Name of Owner \ -ress of Owner: •rQ(1�'y�C tv 'L�-`��-C� Date of Inspection: \i \ \ / // U��j �}i _ •t" f�. C Name of Inspector:(Please Prirtt) •L�2 c%e �t�EckU I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: At1 -�� Mailing Address: le r "� �f_+ ��Sy �= f7'� U2 4,-c1 Telephone Number: T-SG —"�` 31 Lo CERTIFICATION STATEMENT - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my.training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation7tj[ Approving Authority Fails Date:Inspector's Signature• The System Inspector shall submit a copy of this inspection report to the Approving.Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to The system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS o- r Nzi- f A� C�/V19 Fat ro"OF 1999 �- A t P' revised 9/2/98 v Pigelortl `� Panted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION (continued) 'roperty Add�ess.1, Jwne.r: Date of Inspection: INS PECTION'SLIMMARY: Check A, B, C, or D: A. SYSTEM PASSES: f~► I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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 pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if Iwith approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 14 revised 9/2/98 Page2of11 s . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: - Date of Inspection: ' f 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 ailing to protect the public health, safety and the environment: 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.300 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND TYIE ENVJRON'MENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has�a septic tank and soil absorption system (SAS)and a SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the AS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and thh SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and ytie SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for co.form bacteria and volatile organic compounds indicates that thf well is free from pollution from that facility and the prese a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER , fi.. revised 9/2/98 Page 3or11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 fa6ure. i Yes No Backup of sewage into facility or system component due to an overloaded or /rclogged S or cesspool. Discharge or ponding of effluent to the surface of the ground or surface water overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is lesday flow. Required pumping more than 4 times in the last year NO/ee ogged r obstructed pipels). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or w he high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of ater supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of al.Any portion of a cesspool or privy is within 50 feet of a ter supply well. Any portion of a cesspool or privy is less-than 100 feet than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has bee O�analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammof is nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No to each of the following• The following criteria apply to large systems in additici` to the criteria above: The system serves a facility with a design flow o 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because ne or more of the following conditions exist: Yes No the system is within 400 feetpf a surface drinking water supply the system is within 200 feeett of a tributary to a surface drinking water supply the system is located ir(a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 t - I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i'ropenyAddress:3ti� Owner: Date of Inspections Check if the following have been done: You must indicate either "Yes" on"No" as to each of the following: r Y Yes No y s' Pumping information was provided by the owner, occupant, or Board of Health.' — None 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.., As 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, excluding the Soil Absorption System, have been located on the site. — The septic tank-manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth-of liquid, depth of sludge. depth of scum. The size and location of the Soil Absorptioh.System on 11 the'site nas tree:, determined based on: Existing information. For example, Plan at.B.O.H. - Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] The facility owner (and occupants,if different from owner) were provided with information on the proper maintenancrr of SubSurfa6e Disposal Systems. i rL :-: . • n r . 3' ya .. , III , e r , revised 9/2/98 Pzgc5of11 .L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 'roperty Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: :::;:,'Og.p.d.!bedroom. Number of bedrooms (design):; Number of bedrooms (actual): 0?j Total DESIGN flow .^ ;o Number of current residents: Q3 Garbage grinder (yes or no): IJ Laundry(separate system) 1 es or(Q:_; If yes, separate inspection required Laundry system inspected(ye or no) Seasonal use (yes or no):�� Water meter readings, if availabie (last two year's usage (gpd). (� Sump Pump (yes or no): _ Last date of occupancy: TL g2,,v l i `l-u COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd I Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ t '� If yes, volume pumped: gallons 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)_ revised 9/2/96 Page 6ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'rop."Address: Owner: s Date of Inspection: BUILDING SEWER t (Locate on site plan) r. Depth below grade: 'n t Material of construction:_ cast iron A'40_PVC _•other (explain) Distance from private water supply well or.suction line \ Diameter=1 Comments: (condition of joints, venting,"eviddenc�e oflea 7c kage,-etc.) �w: � uF C V2'r.i\ N� SEPTIC TANK:�r; (locate on site plan) Depth below grade:l0 Material of construction: concrete_metal _Fiberglass _Polyethylene+_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth:� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: \ Distance from top of scum to top of outlet tee or baffle:'- Distance from bottom of scum to bottom of outlet t e or baffle How dimensions were determined: :omments: ^ (recommendation for pumping, conditic f of,�nlet^and outlet tees or baffles, depth of liquid level in relation to outlet in art/stru'tural'integrity, �`i' r evidence of igak qe,etc.) `• �� ��!!�P r t GREASE TRAP: l� _ r (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: -� Date of last pumping: Comments: (recommendation 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.) } revised 9/2/98 Page 7ofII 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'rope.rty Address:, V Owner: Date of Inspection: TIGHT OR HOLDING TANK:__L/`,,�(Tank must be pumped prior to, or at time of, inspection) I (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass_Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: tj (locate on site plan) ^� Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal evidence of solids car ryov evide of leakage into or out of box, etc.) ,. � y �• � •1 HV � U PUMP CHAMBER:— (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corned) row 'roperty Address. Owner: Date of Inspection: P SOIL ABSORPTION SYSTEM (SAS):��" I ` (locate on site possible; excavation not required, location may be approximated by non-intrusive methods); e lan, If not located, explain: Type:e: leaching pits, number:��x,p " -'x' leaching chambers, number._ " leaching galleries. number._ ' ` leaching trenches, number, length: leaching fields, number, dimensions: ". overflow cesspool number._ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of-ponding, dam sojl, con io vegetation, etc l N CESSPOOLS: lu (locate on site •Ian) J Number and configuration:. Depth-top of liquid to inlet invert: Depth of solids layer. )epth of scum layer. Dimensions of cesspool Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Co mments: Incite condition of soil, signs of hydraulic failure, level of ponding,-condition of vegetation, etc.) PRIVY: ,T.� (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.) I revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address:1,10 v � Jwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: I include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Li 01 c� a ; �2Z-2�� ` 52 -3o) Q 2r Jt r b3- 3�I 'A1�,( ` 37' revised 9/2/98 Pagc10ofI] f , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) :opefty Address: � �. �locnN Owner: Date of Inspection: NRCS Report name ) i - -- — Soil Type_ -- Typical depth to groundwater _. __ USGS Date website visited Observation Wells checked j Groundwater depth: Shallow' Moderate Deep SITE EXAM Slope C Surface water Check Cellar Shallow wells1-4A-j t Estimated Depth to Groundwater Feet, ` Please indicate all the methods used to determine High Groundwater Elevation; ` Obtained from Design Plans on record Observed Site (Abutting pr'operty, observation hole, basement sump etc.) • Determined from local conditions m Checked with local Board of health -Checked FEMA Maps Checked pumping records Checked local excavators, installers z Used USGS Data , Describe how you established the High Groundwater Elevation. (Must be completed) r • �� iC� S6��% � C/�Q10.(GS) C �"�S I cc} J��u-JI 14, a revised 9/2/98 Page 11ofit i.t�� ��nt nr,t C r-I Stu rL 1.4}Jb Coowr 1�1.1�'�: F=t_.aw = E 1� � �. = '��o G•r`'•�. �,�''" Li uE 495 urn'_• tc�o;-� s��,r~. ��,�.�` uSe (c>c)o f . k,iQ,t_1_ Av-t^.t. tSn �.�•t;.....®,_.a.,... / r �"7 G.P.L. . ,/ r �l a I ic�G#.. ToTA L 425 Ako TN. Tb't-A t_ t 4,1 I_:,f 1=t r>�� - 330 C•P7t N= /C}-" �� Qa.a7a 4 �3 I�GTZ-C-D ,L\`t"1Ct,,l CZI�TL- � lU �M l u OTZ LBs", ���-� r s�Q t�,+,: •a TGt �sJ•h t IOA.O ..» e ''�M�F� �000 It•h! 's p -SOY 4�.a Sc= Ic +Q y rNv. ( TA►teC S�?xlU !A✓� LcN 9G•o RG•i� �a 1� FIT % I ' WAS►•dED STow� �.t4' _ L:C»,cep Qca 5GAl — SG./,Lte;, I 'I (�© No Ted t C_E.tt"t thy( T�-�,i>,T' TtL� t'dtJ ��A'riOs..l StZGu11.? P-4.._.13,Q lzG E:-W-ia V.1GC-- c-�� 1�'E.t`.t.! Gc��d�>?E_�S �U I't•t� "t"l l Slnc�,�t►�E LOT 24 o v 1► �: B A R-QIST A,6 L-t C..t.z t!UT tt c>-'rr r''V%�t_t r2�E{ t...E !'��tom.,!��' U I,Mt dE� t_r� C i_I l li=_ i - ___ aPt✓ ev THE COMMONWEALTH OF MASSACHUSETTS BOA RD QF F-1 EA T .-...-.OF...... .. ----• --------•--•_-_--------- �'� Applirativit for Disposal Murks Tonstrurtiun Vamit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal �. Syst a- ...---- .� . . - ...----- ... .. --- ....._ a .cation- d s or Lot No., . . !.. _._. % .. ...................... .... .................... ...... ..................... �` e- Owner p ,e Address a •--•-••••-•-••-•!(�_. 4-----•-- . .. ........... ................. ......•...................... ....--- -••- ...................................... Installer Address U Type of=Building, - Size Lot.��,� �..�Sq. feet s a Dwelling—No. of Bedrooms___________________________________________Expansion Attic-( ) Garbage Grinder ( ) aOthear=Type of Building ____________________________ No. of persons___..____._______-__-7`_ Showers ( ) — Cafeteria ( ) Otherfixtures ......................................... .............................................................. w Design Flow........j�F.___0.........................gallons per person per day. Total daily-,,..flow................ ..............gallons. WSeptic Tank—Liquid capacity_1_' Mns ' Length................ p Width.._ :'.. Diameter................ Depth x Disposal Trench—No. .................... W' ._. tal Length............ ___.__ al leaching area--------------------sq. ft. Seepage Pit No______ _ _______ _r ..__..._ h�ow ' otal leaching area__ i _ .sq. ft. Z Other Distribution box ( ) Dosing t nk ) �,6, �e I- /A` ~" Percolation Test Results Performed by-_.. _ __ -P:__.' .�._ �4:._.__ Date---g�-l,c=_?_7------------- ,.•a Test Pit No. 1 _._.1-.._._minutes per inch Depth of Test Prt____________________ Depth to ground water---------_.............. (4 Test Pit No. 2......._........minutes per inch Depth of Test Pit____________________ Depth to ground water____________, :n--- �- '. Description S il_.. .__l�_'_. x p P i r .z.-----. �--------.. ------- -•---------------mod --- --:....._..-------- U .............7-i• ......1-X............- -----------------------........................................................................................... w VNature of Repairs or Alterations—Answer when applicable............................................................................................... -•------------------------------•-----------------------------------------------------------.._.....----••--------------._..----------------------------------...-•---------------------.._.._......•--- Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLi: 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 bard of health. igned-- • • ••--•- ------- B.Pe`--- - • -----.._..-- ..... Da .. .. Application Approved By•••-- +�- -••-•- --� .'l-- . ____-- -••j -- ... Date Date Application Disapproved for the following reasons:....................................---...----.................................................................. -------------------------------------------•--------------------•--•----•-------•--••-•---•------..._..---•-•-•-•--•-••-•----•--•-----•----•----•••. .................................................. _ ­21 Date PermitNo......................................................... 1 Issued,--. '\• Date TIT 7 , WANo..... ... .. THE COMMbE,ALTPF M TS s BC E H EA fi � ,+� a .... ....................... Application is hereby made for a=��Pcrmt to,C'.onsfruct-( ) or Repair ( ) an Individual Sewage Disposal Syst a ,r alvllen� .................. ,+_.. ocahoness ''S '- - or Lot No* .........i.__ ....... .. - &- Af ... ...................••___oe _.... _ ..I.__ ........................ .. .__. .. Ownerr Address r. �.. Installer Address Type of Building Size Lot_ /, _ __' Sq. feet 4. U Dwelling_No. of Bedrooms_._.__ ______________________________Expansion Attic ( ) -Garbage Grinder ( ) aOther—Type of Building ............................. No. of persons......................... Showers ( ) Cafeteria ( ) R er Design Flow.Othf�ures ___ �" ""gallons 1 on' s p person per day. Total daily flow..............._ __ ______.......gallons. WSeptic Tank"—Liquid capacity 4 _ - ons Length....:`=_._.______ Width___. . Diameter _____..___.... Depth................ ' x Disposal Trench No W otal Length al leaching area.................... q. ft. Seepage Pit No:__-- - ow • -___-._-••__ tallrleaching area.. _ ,sq. ft. Z Other""Distribution box ( ) Dosing nk ) , �� '-' Percolation Test Results Performed.by-._ -' -- ...l.._. �'-._. Date__. �-/y�.*: _1............. i , R..: 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 P r Description alt _... r1 - x 'z_ e_••--� --- �., " •. - 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 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 bard of health. Date Application Approved .By-- : <" !i .: ._. ....... ... .... Date Application Disapproved for the following reasons: ------=------........................ •-------------••-----•--•-------•---••--•--•---••-••-----••---••-•-•---- -=----••-------------------------------•------------•----------------------------•--..._..-------------------•------..-----------------------•----------------------------------------------........_ 7 `7 Date ......... Issued------=- ------- Permit No........................•---..._._-------•---•- ----------_--------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS :;'t, BOARD Q HEALT 9M 4 r'+t ....OF. � r u� THIS TO CERTIFY, a�'the vidual Sewage Disposal System constructed ( ) or Repaired ( ) V- -- f by .�ifl . ....:..: = n all at--- ' - -- --- has been installed in accordance with e provisions of ofhe State Sanitary Code as described >n the application for Disposal Works Construction Per Nd 'rJ ' s►.� dated.. - •. .-2 7_7 ••--••-•_.: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �� DATE._....../- ). .........................................................- Inspector........r_..__ _- THE COMMONWEALTH OF MASSACHUSETTS } BOARD ® HEALT, , r., .. ..OF.. .a� .�... ��t _... ................. , FEE ` Permission is, e y granted °" .-- --- •-••- ----. -- .................. ................ to Construc..( or Re air an Individual Se t eisposal st Street as shown on the application for Disposal Works Construction P r" it N ___ ___. ..::. Dated_._ '_ . .........................' __ ---- .........................- 12 �- 7 oard o h DATE � --------•------(((---------------••--•--------••...... •-•....._._..-•----. . � r FORM 1255 HOBBS &-WARREN, INC., PUBLISHERS r L SOIL TE T .a I $ _ TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR DATE OF SOIL TEST 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE SOIL TEST DONE BY ELEV 10 FT. MINIMUM r--CLEAN SAND WITNESSED BY _� �-s •s._ �o wA (ASSUMED) CONCRETE ,Tv�i I�•9 Yr COVES LOAM AND SEED OBSERVATION HOLE 1 ELEV.- 4" SCHEDULE 40 PVC PIPE PERCOLATION RATE MIN./INCH AT . G8 INCHES - -- r" MIN. PITCH 1/8' PER FT, C 2" LAYER OF 1/8 " TO 1/2" DEPTH H0RI2 TEXTURE COLOR MOTE. OTHER WASHED STONE y 1 Qy� it.lc. 4' CAST IRON PIPE , " MAX. 4/2- 9 M•*+ 2 r � (OR EQUAL) MINIMUM /�' .S'�n d• PITCH 1/4 PER FT, y a aQs.�•2, 2 ZABEL FILTER-), i { � I nn,rtni - ` � 0 _ rr FLOW LINE i 9G. S I I 33 3�C E 9c.ss ELEV. = q6 G? 10. . 7_0 C.3E3ooC3 ❑ ❑ noo _ f �IMIN. LEV. _ �.�. LZEVEL ❑ ❑ ❑ ❑ C7 ❑❑ ❑ I 7 ❑ 4 ° I° C Ca�✓s / '1R l r _ ____ 6' SUMP ELEV. 9s'47 ° I ELEV. - �• S BAFFLE SELEV, - - ° ° 000000001 -? 0 2' ° i DISTRIBUTION LEv. ` ° ° ° oomo ❑o ❑ oo ❑ , p LIQUID OUTLET _- BOX Y,f:..ro o° ° ° ° ELEV. _L •sC' rr I 4 FEET 14 INCHES DE21H TEE TO BE WATER TESTED T /`,v Za r 113 8 1000 GALLON IF MORE THAN ONE OUTLET: 0- 500 GALLON DRYWELL S W17H Sro E f. 70 /Va WATER ENCOUNTERED AT _�� 'ELEV. _ &7 8 I 5 FEET 19 INCHES , /,, 6 FEET 24 INCHES IN AN /3�' ZJ +s TRENCH FORM,, I Z WE - ! 7h FEET 29 INCHES EXISTING (TO BE PLACED ON FIRM BASE) ZONE L8 FEET 34 INCHES SEPTIC TANK 3/4' TO 1 1/2" CLEAN SOIL ABSORPTION u) INDEX~ I DOUBLE WASHED STONE ADJUST. DESIGN CALCULATIONS FREE OF SAS SYSTEM NUMBER OF BEDROOMS I _�-- GARBAGE DISPOSAL UNIT USGS PROBABLE WATER TABLE ELEV = TOTAL ESTIMATED FLOW SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ) ELEV. = _ (10 GAIWINYX .7 W) -:734 GAL/DAY I NOT TO SCALE BOTTOM OF TEST HOLE ELEV _ RE4U/RE0 SEPTIC TANK CAPACITY /4000 f■+IL.. �X%fir i ACTUAL SEPTIC TANK CAPACITY � GAL. I M1N./INCH SOIL CLASS! CA DES/GIN PERCOLATION RATE i EFFLUENT LOADING RA 7F GAL./VA YAF. 7���2+�'-�r�_-7- . I LEACHING AREA (/3 ><?S (� SQ FT LEACHING CAPACITY 4>'7 h • '7`gr 21f2 GAL./DAY I RESERVE LEACHING CAPACITY ''P AL./DAY �r l r O 1 L'i�.7: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF ■ 101.7 SEWAGE. 2 ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE. 01.6 ,, .3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEM" ARE UNDER OR WITHIN 10 FT. OF ` DRIVES OR PARKING AREAS, H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. i 10 9 101.4 -- 4. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED 1 �` ► 99.7 ( IN PLACE. 1 ?pr} 99.1 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO OBTAIN SUCH I I hti " 4 j DETERMINATION FROM APPROPRIATE AUTHORITY. 5 L'T?Ec, c nyyll "PE ArpRo y'I`AaTF !-)h0_Y FxCAVATION CONTRACTOR IS TO I 102.2 ? ,;' i� . S�C.`Z + 12.2' 93.8.. CALL "DIG-SAFE" AT 1-888-344--7233 AT LEAST 72 HOURS PRIOR TO _ ► (,D 96. COMMENCING WORK ON SITE. 7CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE 98'7 y 97.1 CONDITIONS PRIOR TO COMMENCING WORK ON SITE, ANY VARIATION IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY. 8.9 8. PARCEL IS IN FLOOD ZONE -_C-_-• SEPT I p S y ,; ��� •f 4 T�N^�" 9. LOT IS SHOWN ON ASSESSORS MAP ¢� AS PARCEL 93.5 92.3 10. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER, AND FOR A 0 s BN. MINIMUM OF 5 FEET FROM AROUND THE SOIL ABSORPTION SYSTEM. AND BE t I 2.8 ", fl8 �, ` ,ahn -- � --' -�^ - -' REPLACED WITH SAND AS SPECIFIED IN 310 CMR 15.255: (3) (i.E. TITLE 5) IF + y . l �, l ENCOUNTERED BELOW S.A.S. PIPE INVERT. 3 fx�fl,,;r,�` Z / l 11. EXISTING LEACH PIT TO BE PUMPED AND FILLED NTH SAND OR REMOVED. d DECK ' 1 ' !I 4 I ' 12 A ZABEL A1800 FILTER IS TO BE INSTALLED.rop4� IJ CONTRACTOR TO PROVIDE SHORING A. NEEDED TO PROTECT BUILDING AND 97.0 /� 1' s PROPERTY LINE. � t L 14, CONTRACTOR TO CONFIRM SEPTIC TANK STRUCTUAL SOUNDNESS AND OUTLET r �. 9 3.7 / 92.0 ELEVATION BEFORE INSTALLING NEW SEPTIC SYSTEM. S' �r' War�� 'v�t _ r SHOR CI}1Lt, APPROVED. BOARD OF HEALTH 99.2 3.3 91.8 __-- � ar�f' >��' �//�' 1)' t,,�r '`'" �;,� v � ��" w�-� • -�r ,� J# DATE AGEN T 9.2 � �� SEPTIC DESIGN I LEGMD: � 9 PROPOSED TOWN WATER-* -w -w - Ol _ WATER SHUT-OFF. . • \,j 98.5 ` ,`� D ]�� FOR T��r WATER VALVUE 1 i 1 ,tip t -�'° `` J BIT-DRlieE 38,7 J'Ill1`3IirIOi J UZ4PA i�l l.r US GAS LINE--ens--cns- GAS �- GAS METER. . ® r GAS VALVE LOC. 2QIS �, �� Z ROAD ELECTRIC LINE E --E ELECTRIC METER © V� \ OSTERljILLE; MA y ELECTRIC BOX. ® . . . . . z 96,,7 ~'.95.4 B I�,ST E ELECTRIC MANHOLE . • V 0102.2 ?9' 97.6 \ LOCU CATCH BASIN- . . . P. CESSPOOL. . . . . . 9$.2 96.6 G; ,, CRAIG R. S OR T, LEACH PIT Q 28.4' o 91.2 - - 235 GREAT WESTERN ROAD LOTS 24 & 57A '� P. 0. .BOX 1044 CLEANOUT -FYC.O. , EXISTING SPOT ELEVATION- •x 0.0 r 21,784 t SF. /9� 1 5px39d8311 SOUTH DENN/S MASS. 02660 50a394t"i 96 7 EXISTING CONTOUR-(0-0) [� FINAL. SPOT ELEVATION ® �O FINAL CONTOUR 94.0 �O' 91.0 Za DATE APR.bR. 28, 2 [_�$QALE 1 "� • FLAGPOLE r. . , . . . . HYDRANT. . .• . • . . . . . . .. . . . • .ad1.Lf.._1 LA S R i UGHTPOST. .. . , �0 Q 10 20 MANHOLE . . • • .. .... . . Q 1-1l3Q ! 085. WELL SCALE 1 INCH 20 FEETIL SEWER LINE---`s SEWER MANHOLE �LO/�A �jf�J,,T AIAP REV. j SHEET 1 0E� SOIL TEST LOCATION ( V1`i lVt� t I TELEPHONE BOX C3 01-10JO Juza UTILtTY POLE, povrcus_Rf.dwq C2005 CRAIG R. SHORT, P.E. � �, � _--.