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0236 EBENEZER ROAD - Health
236 Ebenezer Road Osterville A= 146 - 034 ° e R i ° ti:. t. • t No �� t. Fee ®o • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migpont *pgtem Congtruttion permit Application for a Permit to Construct( . )Repair(/)Upgrade( )Abandon( ) 0 Complete System El Individual Components Location Address or Lot No. QX Owner's Name,Address and Tel.No. �1 r7_V Q �B��t<zER R,O. ' R1L,4y Assessor's Map/Parcel V V`l1p lam- © .9% v a Installer's Name,Address,and Tel.No. w_0" !� Designer's Name,Address and Tel.No. QRI�Nf a?�E• Col , O 6N, IVOOS J ® 7&6TOJO &A, MAgotwinva's Type of Building: Dwelling No.of Bedrooms 3 _ Lot Size�sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date 75 Number of sheets Revision Date Title Size of Septic Tank /604 Type.of S.A.S. r�66W�S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envi ntal and not to place the system in operation until a Certifi- cate of Compliance has been issued b s Board o e. Signe Date "Q3293Z Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued -----.---------._—_,...,..........._..._.. —_------------ -- --- -- l QO ^y THE COMMONWEALTH OF MASSAUSES - Entered in computer: C� Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Rpprica,tion for Digozaf *p5tem Conotruction Permit Application for a Permit to Construct( )Repair� )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. /�/rZ V O �C8�'�iFz� Ro. "�#aao RILECf Assessor's Map/Parcel )�p *` Installer's Name,Address,and Tel.No. W°~q5y1 Designer's Name,Address and Tel.No. t �RIANf�Y©r�E- Co�tlsr-� 0 7&ZT010 6114, MA4,001VSTIU5Id G/EST adzlaEw IgAG-14146 Type of Building: Dwelling No. of Bedrooms_ Lot Size '�� ,'S sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) t Other Fixtures K. Design Flow _7.0 gallons per day. Calculated daily flow gallons. Plan Date 7�/ 5 Number of sheets Revision Date Title Size of Septic T nk 1600 Type of S.A.S. Description of Soil 't � r Nature of Repairs orA'lterations(Answer when applicable) Date last inspected: Agreement: The undersignedfagrees 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 Environ��ental o viand not to place the system in operation until a Certifi- cate of Compliance has been issued b �is Board o geaklh. Signed Date C9-.2 _05 Application Approved by( _ Date / Application Disapproved for the following reasons Permit No.r,_y—n i Date Issued X� c'- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif irate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (t/')Upgraded( ) Abandoned( )by 141,4 AY6776 at D 3K F 6%zZ6g IRD, has been constructeclin accordance with the pro isions of Title 5 and the for Disposal System Construction Permit No.,)C)o 5 y/5 uc dated O � Installer 89W/ 19yon(_ Designer The issuance of this permit shall of be construed as a guarantee that the system 11 on as d sigma Date 4 - t3Q ' � Inspector No. �� � "`7 r_� ----------------------Fee t� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migozaf *pg;tem Construction Permit Permission is hereby granted to Construct( )Repair(v)Upgrade( )Abandon( ) System located at 0-? �/ JyEZE2 A+0- �TE61�/l�tG and as described in the above Applcation for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the d this pe, it. Date:- �� Approved Town of Barnstable Regulatory Services $ l Thomas F. Geller, Director ,tee Public Health Division 0SThomas McKean, Director _ 200 Main street,Hyannis,NIA 02601 Offic:: 308-8624644 - Fax: 508-790-b3(D4 Installer de Desiert�er CertificationForm lO 3c� Date: Sewage Permits# Assessor'91l[aplk'arceD Designer: .. Installer _ cjite Add,,riss: .1.2 W` C;(2?S S 1-`-r �C;f OAAddress: '7-0 P C,lt-- � ( ZU k4 ( mils tth.s (\W U �kA Cj 26 y On__.. date) (installer) was issued a permit to install a ( septic system.at e based on a design drawn b (address) S y __. e �— dated (designer,,: _( I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes :such as lateral relocation of the distribution box and,7r septic tank. i 1 ceri.ify that the septic system referenced above wasinstalled with major changes (i.e. greater than 10' 1 ateral re;ication -if the SAS or any vertical relocation of any component of the septic system) but it, acco dince_with State& Local. Regulations. Plan revision or certified as-built_lly designer to follow. 4 prT� Mc f ER r c (Installe S' iatuR .� c1���f£ M �0 9�No,35109 —PLJ--1,kL— (Designer's Signature) (Affix Designer's Stamp Here) PLEASE I TLMTQ its cTAB —PUBLIC HEAL1h nrXINiO�CK 'IM1CeT:» OF �Or19FLlAtV�)& WILL �40I � I�.4C�ED iJIvTI oTeTills EURM ,aND cA AAA CEtyED BY TH BAWEEAI$- -I'L'B :Il HEAI 1'3i IDiVdcl®N T w. ' YC� 1 Q-HealtwSeptic[Desipar Certification Form 3-26-04.doc 911003 Notice: This Form Is To.Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION,FORM 1 w Me rdl. ee ,hereby certifg that the engineered plan sign'by nw dated'- ,concerning the property located at- I o 23 6-&L f'7 e,a meets all of the following criteria: o This fatted system is connected to a residential dwelling only. There aree no comnumial or —_ business uses associated with the dwelling. ® The.soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or tray conduct deep test holes and percolation tests at the:site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. ® The bottom of the proposed leaching facility will-be located no less than five feet above the n=imum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 60 4 ( z B) G.W.Elevation z?j +adjustment for high G.W. — DIFFERENCE BETWEEN A and B �✓ 31 SIGNED : DATE: `� f NOTICE Eased upon the above information, a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. q:1Sq06prc"wM.doe TOWN OF BARNSTABLE LOCATION 236 6 /626A W, SEWAGE # VILLAGE I'n� Jar ASSESSOR'S MAP & LOT -O INSTALLER'S NAME&PHONE NO. LVI#A( ll Ynrlie= SC1-kim SEPTIC TANK CAPACITY LEACHING FACIL=: (type) a2 S0® C/ (size) 62`i25'YCJ, NO.OF BEDROOMS BUILDER OR OWNER Mf'iz& PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or 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 �. D>� TOWN OF B E LOCATION �� SEW GE # VILLAGE JAe�L Q ASSESSOR'S MAP,& LOT �- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l D o 6 LEACHING FACILITY: (ty l (size) NO. OF BEDROOMS BUILDER OR OWNER �i PERMIT DATE: COMPLIANCE DATE: Y fl 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 G A4 ►4 �c 1 �t` V TOWN OF BARNSTABLE LOCATION Z.3 SEWAGE # N=IT.LAGE T- �+�"- � ASSESSOR'S MAP& LOT OS�' INSTALLER'S NAME&PHONE NO. a-rLri CK !N• a CD/�/!eL L r,Ne�� SEPTIC TANK CAPACITY 1600 QxLLon LEACHING FACILITY: (type) (size �5 NO..OF.BEDROOMS OWNER -2- WNER a.S©n PERMIT DATE:_ Qe �%,� COMPLIANCE jp/-av D 3 ,�&- V err 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 Page to of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:236 Ebenezer Road,Osterville Owner. Jason O'Rielly Dotte of Inspection:June 15,2005 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. Ebeeezer Road Driveway #236 Gee 29 al 20 35 LOCATION �( � SEWAGE PERMIT NO. VILLAGE ale I N S T A LLER'S NAME i , ADDRESS e U I L D E R OR OWNER Q�.(rua. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � a �-� J cq LOC&.TION : 5EWO,C4E PERMIT MO. ZIA IW57 LER 5 U ADDRESS BUILDER 5 Q &M, F- DDRIE SS DATE PERMIT ISSUED DATE COMPLI &KiCE ISSUED : b .�� , 77 Page 10 of 11 f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 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. Ebenezer Road Driveway #236 Garage 29 41 20 35 Title i 1—y—tinn Fnrm ui rimnnn 10 TOWN OF BARNSTABLE LOCATION -2U C&,AIL4� go, SEWAGE a i VILLAGE /tile IryIJ ASSESSOR'S MAP& LOT- "O INSTALLER'S NAME&PHONE NO. IJK��IIf l�YDy7 -?d" Sg ` SEPTIC TANK CAPACITY /OX LEACHING FACILITY: (type) a—SOO (size) NO.OF BEDROOMS 3 BUILDER OR OWNER MEEZei 6AM2 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet f 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 } r �l �W q i I l Cominonwealth of Massachusetts ' • -• ew - Subsurface Sewage Disposal System Form -Not fbAVoluntary Assessments • , p�ruparty Address � � �tn e, -x va,et Oyvnt:r`i Nam �O V1 h �' 1 t S ifs, �t e.j"Q `►re Y sae t;Ftyf'icrrr'c Mate&ZIp Code 0 Cute crf h ectkin Inspection results must be submitted on this form. inspection forms may not be,altered in any way. A. General Information nformatio A. rre*tS u�f1 EhH xnpt;t�r_Ykap�� - Ay,'he tab Rey r frlC?Yf`bQIN �. = Nar�ts of 1rt' trot• >' ,firs FEtUrFt . �7 mm , (04TI n MOL Matra f edet3haare Numt)er LIS F i tt tie ftlS7]tNMt f ..IL�� } �:.,. Y.'. G '� { .<„, $ i�t. k .-!.t.,�...ui Yl� iM1.3 ,.f'i ab II -(.4 3�4i 'f,k'-. �. ;:... 4i � .Fix} 1� .f�i.� l� pkt rye, ..5.^"M;a x 4•r':f F �.tiXa�fi �'��X.�iL�nJ h1�� �c4'�� -:t� � u r rr t p 7>'�rY �,rr Yf .�5. ;.I�''F!<..,�`. '1,.�i�f7.. a..,a� 4 wt z !*.�r• Z rc _.� {h 4.7;',ti r..� �z..,' sr -, v,��:,h�����.a�• Yt?}:`,:Y z.,�+�.,. °-:r s. `� `� °J f :;i T �f 9 t ;x� 5+��' -,tt ':�a,,s xn� zac �',-v.Y � k .r`�' � .,ate} R'b;:��r t���. �1 i•'1�..t� (1 ..�{yt w.,y'>",jsII �e .:� 2. - t s Y.�•� oR� � ,.J b� 'i 5. z: �}. �' 6. .•r9y>• 3°" -,L£�'�^'� S :r S,k�''a^k' ci. ,'y,. �i ..r;a %�a ,�'�.yy.�a t..�s✓'S1� ;.�`.,. C�Py w� ''��!;�. t''�''f' �£�h at�a�;.,^r°y 'jii � y��n �:•;t. s yc 'i.:�, a,. a � �+ S� t� �ta 'Y><€� a+4 tm- i."� �xf � .5 '!`itx'f'.:„*4-�L�bc t1.g�4' �y ",�F+�3 x5.t � k.� h�', •k •6� �+a ¢g y� .h .n': t wf 4.:anl a' ':Y� FaC^e y �, �, a _ � t. .M:1• ✓- + ! cOrly that 1 have personally inspected the sewage disposedsystem information reported below is trU6, accurate and s rem at this eddre'ss a d that the was a caf'tha tune cat tts in.: . The`! spec tK,n !lzerfprmQd based on my training and exoerence in the Woper func�trc n:Arad rrteut nce of on site sewage disposal systems, t em a DEP approved systern inspector pursuant.to Section 15.340 of 'Title 5(310 CMR 15.000). The s vtam: Passes ( Gonditlonalty Passes Fails r ') Needs Furt.tief- Evaluation by the Local Appfoving Authority In3peutt�r's Signature 16- r�aaa The system inspector sii submit a copy of this inspection re of i��:aitta or t�Ef�) within 3Q days of Completing this ins part tra the Approving Authcar!t.y i'l�uhrn has a design ftow of 10,000 in30 y p g inspection, ►f the syst€�rn is a shared systern or gpd or greeter, the inspector and the systerrt owner shall submit the report to the appropriate regional Office of the DER The original should be sent to the system own(,, dnd co:Ptes seat to the buyer, it a rliGable, is report only describes corrdtt�Gw Of f'and Mder'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. z P A Commonwealth of Mai chu fts r ill Subsurface Sewage i Foff" -Not-4W VdUhtary ftsessments 3 Property Address tdf -(I fl hda 18 rde`t Gct{1 t� - edrer u y�<a c, c:eryrrorm state Zip Code Date at't B. Certification (cont) Inspection Summary_ Check A,13,C,D or E t always complete All Of Section f� A) System Passes: i have (ro#found any inform ation v4ch iridr tes 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, 8) System Conditionally 'asses: one or more system components as described in the "Conditional PaSs""section nod to tatt replaced or repaired. The system, upon completion of the replacement ear repair, as the Board of Me th, inr�ll, p approved try Answer yes, no or not deterrn % 1'Y,N, N# )i,, he forthe following sWtements- If"rrrat d,'"'pleaXr1, LI They septic tank is metal and over 20 years old*,Or t'he septic tank(whe,thter matef or not) is structurally unsound, exhibits substantial infiltration or e xfittration car tank failure System:wig pass in ar#ure is i�rrralner�t ' 'hU.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 Certifrc ale Of Compliance indicating that the tank is less than 20 years old is available. ND Explain: Observation of or or"k-IMA-M ho static water teVel in the distribution box aue to broken or obstructed pi s)Of due to a brie, settled or uneven distribution box. Systerrr witi ppMv broken pipe(s) are replaced LJ obstruction is removed Commonwealth of Massachusetts � �• ,: raw. ; , . Tiffifle WWI Subsurface Sewage Disposal,sy rrt Form f Net-fop.volvnter)t As fits - f a-36 PrOPe¢ty. ddress r i24fcK l ? v F air i,a� tcma state Zip Code ba(e of friOpOc6ri B. Certi icafion (cont.) B) System Concditionally- ( )x ` distribbtlon box is ieveled'or replaced ND ExpialrV 0 The sysf m r aired p g €t r^ t to Drys# pt"tbstructod pipe(s). Trye SYS;terp will Pau inspoetion.if-WWOPPMR1 of ft>St of Health): L1 broken pipe($)are replaced U obstruction is removed ND E xplalrV ' C) Further Evaluation is Required by the Board of Health. Lj Conditions exist which require turhor the system is failing to prat®ct pubheTthety r the"envtron in orr to determine :t , t i ttrrt s rrt f d `31a CMR 15.3030)(b) that the system is not functioning in a manner which �riH prefect public health, safety and the environment: Cesspool or privy is`W thin'50 f" of_$Sure Via: C Cesspool or Pr+" Is whin 5tl�t o( 'prdrrrag ve € ated wetland, or,a salt marsh 2. -System wi)f"If U6100. thi��i�ar�ii. � #� , � x;;#a�a �' bile Water Supplier, if any) determines that the system is fttrtctpnin S of ohvilrtirtttt t t .> s ( �,tteat protects the pulaiie health, " 10 #�. �t YMM (SAS)and the SAS is within (?O.feet of su W"M .-' i *ater supply. The system has septic tank srtd S SAS is within a Zone 1 of a public water , The system has a septio.ten,� supply well. .SAI'ar�ri�'je aA is within 50 feet of a private water - _ Commonwealth of Massachusetts Tftle 5 00, -aWN ""n' Subsurfaco _ PfoperV-Address fifomlatloo is tof v' 4o Vefy-page, GuytTavm State Zip Code Date of Irwp n B. Certificatlon (cunt.) C) Further Evaluation to Required by the ( The system has a septic tank and §AS and eh#.. §i*tqq*, ;_W 100.fe t but 50 fiat or Morey from a privates water supply Wo Method used to determine distance: ,. 'Thrs system passes if they well water analysis, performed at a DEP certified lal orsatoty, for wlitorttl t� :.�1 , � is equal to tar' less than 5 ppm. me t no attached to this form. S ftiggsMd•'A CVY Ott 'analysis must tie 3 Other: D) Systvm Failure e a'A� bl . - .. __:...=per, You ye No . Lj Backup of Sew t 'WP,=,PQ t ,i duel to overloaded of L Disclttare�or '�na� ,.. , .� ' c�#,. t grcd or surfaces waters • ear cppol ( Static lls)u t ! to an overloaded lCF1 ess tf�rn. r.. tole volurf}e is less than Ya day flour • tieced, t ag or AnY` a¢ f sir privy ft b,sl w high ground water elevation. [ [ y eaf . � 4R WWn Mf t of a surface water supply of tributary to a surface wafter supply. . .w�e vdrr�i -F}t4Et 5 i�ftena!Incam.-nsn t:ro.•, c,.a,e.,,a.,..c......_.... ..,.......,�_,_.., ..,..._ .... f Commonwealth of Massachusetts l y Subsurface Sewage Disposal Sy stern Foram �Niat for�t�icittt�ry-As Plopert ress th�rt�r'� ants - tor u»11.Sr CX tT y page. ctc rT vr, State Zip code Date of inspection B. Certification (cant.) U) , Syatent Failure Criteria Appttcalbte to Att Systems(cont,); Yes No Any popftn of`a .spool or privy i$wlthin a Zone 1 of a public wall, U { AnYfwrtlen of a oesspooj 6r privy is ikhinm50 feet of a private water supply well. U. M Any portico of'a teg fi ' 44 id than 100 feet taut greater than 50 feet tdtzie..wator quality.analysis. [This sy�tent p the uvoiC r)n d at a DEP certified abaeftt and the presence of amf�ia:tfo� e+�ta��•..-. t to�{eaa than pro�sided tt+at no o €or falure ppm, �terta are triggered. ,A copy of the analysls and.a„fa n; O dy<.,�umt;ba efted$o Qijorm,j The systrh Gl, faey)ity with design flow of;�QG'i}gpd 1 Q,ifl0gpd. ( The$ystram I ! ve r that one or more of the above failure criteria exist asdesc+^hisd in mO CIVAR 15.303, therefore the system fails. The system owner should ? t.01 then. of,flQ0HeaM to determine what will be -net' s to evt#fie e E) Large systerns: To be conside 6 )at�® aystern the ay$tem must serve>�facility design flown of 1 , .qpd,to 16, y with a ` For large • . . . systems, you ,must indicate either"yes.."or"no" to each questions it) Section D. of the fcillawing, in additiontu tttr Yes No Li the:systetrt is within400 fit Of a surface drinking water supply • the system is wlhFn. UQ feet. f 4'ttufy to a surface drinking water supply the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— CWPA)or a mapped Zone tf of a public water supply well It you have answered "yes" to any question in Section t- the system is considered a. significant threat, or answered Oyes* 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 V regional office of the Department. aava Corm onweatth of Massachusetts Title � � , ,., 6 ProveNad.Address «"nay,,,rt quired iCJr Q,ff" . cry page. t i4y uwrt state zip code Erato of Inspovdan C. Checklist Check it the following Cleve cforae Yt `': tca of t4 a following. Yes Na A Pumping infarma9t�Qn Was t W -by",O ,ar, occupant,`or Ord of Health LJ Were any,Of,the out in the previoug two Weeks? $ El, Has vie s t m,ro @*pg 40M.0-the pravlokis two p06009 in deed to"the system recently or as part of tamined? If they were fwt tt1/ 1sa &of sewage beck up? 9 El wasthe stwihsocted f&s� E were off s ,ekfatib ".t 'SA a, kc cated on site? }� C w inspected for the C `��' nct the interwr of the tank of ,rmetariei at COn atruction, dimenstorts, de{�th 4f i raid. th an Wa9 theyeittty o�merr( t ;, tit Pi'. ` h�vided with information on the proper maintenance of subsurface sewage dispersal systems The size and Location of the Soil Absorption System(SAS)on the site has been determined baked on: Li e,x2ingf ;n : na t ?:pim at thewBoard of Health. Determined in the field (if(if any of,th#failure criteria related to Part C is at issue . ap�arb dfstiet itt urrf��►4ble)[31 Q CMR 15.302(5)] <h>J6 Jtls two COMMOnw0alth of Massachusetts Title .M Subsurface SOwags DisPosall System'Form Not ftt Voluntary Assents ^'rR})CS[Y 5Spp p� nilduu�}is /n� j+ree For �A r ! 0 Y pays. ti�tyJ'rowM State ,Zip code Date of.Inspection D. SYstem Information Residential Flew Condll iongg Number of bedmoms (design): n J Number of bedtoorr I-a�t sf): x 330 DESIGN flow based on 31© GMR 15.203`(far exempts: 1-1 0 9Pd x"'t; of bedrooms): Number of current residents: Does residence have a garbage grinder? r i_] Yes ( Nu Is laundry on a separate sewage system? [it y09 separate inspection required] Yes No Lauriclry system inspected? (} Yes U Nu Seasonal use? Yeti I Nu Water meter readings., if avagabie (last 2 years Usages (gpd))1 SUlnp Pump? f_..� Yes No Last date of occufaajjC'y: 10-1 n Date Co►nmOrciallindustrial Flom Conditions: Type of F:stablishmeni: Design flow (teased On 310LCMR 15.203): ' G81IOns per day(upd) basis of design flaw(s0atWp ;sons/sq.ft., etc.): Grease trap present? Yes No Industrial waste holding tank present? Yes Na Nun-sanitary waste disc POTged to the Title 5 system?. ' [� Yes Lj IVv Water meter readings,if available: F Last state of occupancy/use; Dale Uhler (describe). _ 1 COrm€nonwea th of Massachuse t p5 Title ° Subsurface ge 0i.9pa f Systal" Form m 0 °ter►ts .:.. _ >t tcrr )f e e r Q Owner,- arne :eyusred for -! -V eery pave. �.ttylt'rn Stag zip Code t�ata of 4pectlon M Information (cant.) General Informer Pumping eo.0da. Source of.inform atis "� a Vitas system pumped as pert of the inspection? Yes No If yes, volume pumped: iti�ns Maw was quantity Wiped det R"son for pumping: Type of Syetemr Septic taf*, d*tribution.box, 1504-ObsoVion system L1 Single cesspool Overflow cesspool U Privy l Q Shared system (yes or no)(if yes: attach previous InSpe�ct(in records, if any) Innovativef/dlternative teottncalca�y f , P,a :tt Gwent operfakic,rsr�<f maintenance contract(to be obtet ned front system owner) 0 Tight tank. Attach a copy of#W ap .(. Ll Other(describe): Approximate age of all components,, ,ingta"W i# )er* f Irifbri ati n. VVere sewage odors detected when arriving at the site? Yes � No Commonwealth of Massachusetts Title Wld7 q. r. ' 5 To _.. m St�k>,sa rfaoe age his ! pet , 0 t-Ntrf,fm Vejuntsry t r is ab �e� e e� r'rtrt dress N. $ er � owlier`s rstf; rliiUur! a f , r payer. C itplrp n State Zip Cade Date a(I'1spect#prt D. System Wormation (corn.) Building Sewer(locate on site plan), t 'o Depth betraw grade: t Material of construction: east iron '" 40 PVC _ El other (explain): Distance frorvi private water supply well or suction libw teat Comments (on cdndition of joints, venting, evidence of leakage, etc,): Septic Tank (locate on site plan).- UePtn Wow grader: 1 reei. Material of construction CGnGC@t@ � (Yafit3l .. } fiberglass LJ polyethylene E} other (explaiff} It lank is rrtetal, list age: years Is-age confirmed by a,Certificate of Compliance? (attach a copy of certM' cete) [� 'Yes I" Nei �J C)itnenstons: Jo 00a.1 l. sludge depth: Y Distance from top of slings:to bot4wn of ouftt ta i or batty O Scum thickness a Distance from top of scum to top of outlet tee or,baffle: Distance from b9 t rn of scum to bo tfn of,outlet tee or ba Me Now were dimensions determined? i u , ,aRc 1 Commonwealth of Massachusetts P Address ntpPriteuca:��� f) r ZN:og' � ovary Ac"]ge. City/1'~ stets ...6 - _. : __ P Da to of tnsn D. System Informatio (cont.) Comments (on pumping recommendations, inlet ar)0_9ut4t tom.� t�et � liquid le is as related to out t insert a 'dance of lee l§�t&.A-W6tural integrity, ®�I e ICE M. _ v Q.c Grease Trap (locate on site plant): De Pth below grade. _ feet Material of construction, LI concrete (,,J metal } ffbergl a Elpoly lene Q oit►ar(explaEeI i Dimensions. Scum thicknea4 Distance from top of scum to top of outlet tear or baffle Distance from bottom of scum to bottom of outlet tee or baffle -.. Date of last pump in Dato Comments (ern pumping recommendations, inlet and outlet tee Or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight of N¢atdlrtg Tattle (tank.most# at ante of lns tlof)pOc8ie On site plan): Depth below grade: Material of construction; U concrete rrtetaffiberglass 0 polyethylene [ lather (eyplairil. Commonwealth of Massachusetts , SubsurfecISVae ; tge Di osal�System m ,,,NDt€or'tft�ttts$tary`> Ss ierit5 - Praprt �Pdadress . rrhr e r tj t�wn�r s anaf "S t!C 4tred`fir n 0 Zip Code Date of tnspecitem D. System lrtforrrtatI_o'_n { 1 Tight or Holding Tank(cant.) , Dimenstons. G;dpaciiy: ` gallons Design Flown: gaRans per day _ Alarm present: (-I Yes No Alarm level: Alarm in workin crtier: 9 1 Yes Lj No Date of Iasi laurrtping; GOITI(nents (condition of alarm and float switches, etc.):, ,Attach.copy of current pumping ?contract(required). is Copy attached' r ` U Yes (f Ncr Distribution Box(if Pre;�gnt must be opened) (locate on site plant' (depth of liquid Ie.vet ve.outlet invert _ .. Comments (note if box is level and distribution to outlets equal,aprry evidence of solids carryon r, atly evidence<9f lE3i ►ti3f� tnt0 r Oltt Of 4 , etc.): r tas ►A Pump Chai tuber(locate`oh site ptar); PLrttrp�S in working loran:r, L IYes. N Alarms in working ordef: El Yes U N6 COMMOnweialth of Maaaachu t <.� 2,r .�, i �� r { : Subsurfac® S.o ptaoei,.gy . i 23 6 E6enec t f -... ...... . Props ®dress Uwnas Own rttC}fR7d(lc:Ht i3 . / loquired for )� r r\S t very page. C:dfylTtxuVft State Zip Code Date of Pr*per oP D. System' Gorrrments (note condition of Pump chamber,conditiOn of ptaVs..jind eppOrWM66608, etc..j Sal! AbsOrPtiOn SYMOM ($AS) (locate on site plan, excavation not required): If SAS not located, explain.why: F ype 0 teaching pits number 0 leaching chambers number: lit#! g ll rtee. num-b rrr; Lj leaching tromhool numW Ieh pft L} leaching fields r, dlstertaln:�s; Overflow repeal number: innovative/alternatiue system Type/name of technology: ' GUrrxnents (note condition of soil, signs of hydraulic faogpp, loyal qt .a Tool; c r<cleta not v et tion, etc.): c 4. vQ f �-j � w Commonwealth of WlssraichussWii l _a Tile 5 Off p I2, Subsurface.Sewage Dispc at Systein.Form tJ t or Votuntacy Asssssmtwnts f-,kx4r�AddresA rY(18t — p ._ ..... - �WitBfS Tl@ quifed for , Our A •ery page. Gity(rt� state Zip Code ,` - Date of iI*PectiETdt.• j D. System Information (coat.) Cesspools(cesspool must biP pumped.as part of inspection)Q te:on site plan),.. Num4er 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` F Depth of solid$ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): =J=11U110 uiSiU - li{Ito ONinal 1 Commonwealth of MassachusettsTitle 5 y' uisur4` Getit 9Itlrf #at tiltC�j�15� Cttrt3 ' ,.•' Proper 9dreess p Owner Owner s ame _ .. . �.._... Enfa manor, rectuiredfor every page, cqlrr wrr state Zip Code Cate ofSyStem InspeGtieu� Information (c nt.} TT Sket♦rht,of Sewage Dispotar"tern :'Prra�tift'a`sk4t6h of ilia sevrag0 tf POSO 1§yitern including ties to at least two permanent reference landmarks or benchmarks. Locate all wrells.within 100 feet, t,ocate where public water supply enters the building. S ' tboo I { o� V OfficialTitle 5 n p c ors Forte Subsurfao0 Sewage Disposal System Form Not for Voluntary Assessmusits lc3 ta,r D. System Information (coot.) site Exam "Y .jartaLeWale( Norl f - x titlaldtod depth-to yrvt.tfla water Pie s ujd1:dt0 all rnettiWs used tO d0tefrmne the f)Odh grcaurtr2 water eFevakiszrr t 00tainod frof" sy3tem design plan}s Cori recor(t If cfroae . d date of di~ tcrt Plan i }lieWf3Cl. 6 o _avo,� ~rate E... Observed site (ab6ttirt ro �P g:ttsrty 0bSfstvatiur) hole wiUltr� 1 5U krset uE SA,-;) e rrdc"-d vvith local Board Of Health extalair, L__) Chucked with is xil excavators installers - (attach docun}entattuft) �ic�4�ssseti t. SGS database explain . You must 00s;;tftre t1QW you esta list ed the high 9(ound water elevdtr s r 9 r COMMONWEALTH OF MASSACHUSETTS a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS,= DEPARTMENT OF ENVIRONMENTAL PROTECTION 21 P'1 2: TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION- Property Address: 236 Ebenezer Road Osterville MA 02655 Owner's Name: Jason O'Rielly Owner's Address: 3305 Cedar Glen Way St Augustine FL 30286 Date of Inspection: June 15,2005 '.. Job#05-178 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: ' 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am Rm approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ��``� A OF• _— Passes • • • 's.9�'y' Conditionally Passes _`o P TR Needs Further Evaluation by the Local Approving Authority M. ••„{ Fails Inspector's Signature: Date: 6/15/05 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. Notes and Comments: 1 Liquid level in leaching pit is currently 8" below inlet pipe.High stains indicate leaching pit has been full to top. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board.of Health): broken pipe(s)are replaced obstruction is removed ND explain: Title G Tncnsartinn Fnnm 4/1,;i,)nnn 2 t Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 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 I of a public water supply. —The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Tiflo G Tncnnnfinn T:nrm 4 1 cmnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection:,June 15,2005 ' 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 _X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool z _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/Z day flow X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - _X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or Of ivy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. rLarge Systems: To be considered a large system the system must serve a,facility with a desi gpd, gn flow of 10,000 gpd to 15,000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is,within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located is a nitrogen sensitive_ area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well r 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. Titles G incnantinn Fnrm�n -i�nnn - 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 Check if the following have been done. You must indicate"yes"or."no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks - _X_ Has the system received normal flows in the previous two week period? _X Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ - Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ _X Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of breakout? _X — Were all system components,excluding the SAS,located on site? _X_ _ 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? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. _X_ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] T41.Q inonnrtinn Fnrm AM S/7!1(Vl 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:'236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate-inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)):t2003-88,000 gal.2004—35,000 gal.=168 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL✓INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc:):- Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records: None GENERAL INFORMATION Source of information: - Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X 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: 1976 Were sewage odors detected when arriving at the site(yes or no): No Title G Tnenonfinn Fnrm AEI siInnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 Ebenezer Road,Oiterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): ' Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on,site plan). - Depth below grade: 1' Material of construction:_X_concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5' long x 5.2'wide—1000 gal. Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle:25" Scum thickness: 4" 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: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Outlet baffle decayed replace when new leaching system is installed Liquid level at bottom of outlet invert GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): F Titlo S Tncnnrtinn Fnrni/./1 S/7(1(1f1 7. s Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day - Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into.or out of box, etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title S Tncnartinn Anrm A/1IgMnnn 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type" _X_leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching pit previously full to top has no effective leaching CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No_ (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.): Title S incnortinn F�r.,,rii ci,)nnn 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly Date of Inspection: June 15,2005 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. Ebenezer Road Driveway' #236 Garage 29 41 20 35 r Titla Q fnanantinn Form Arl si,)nnn 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) o Property Address: 236 Ebenezer Road,Osterville Owner: Jason O'Rielly ' Date of Inspection: June 15,2005 - SITE EXAM Slope None Surface water None Check cellar Dry , Shallow wells None Estimated depth to ground water: Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to repair to determine groundwater elevation. d Titlr+i Tnrnortinn T7nrw,ui ti�nnn 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE y r Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'CERTIFICATION Property Address: 236 EBENEZER RD. OSTERVILLE Name of Owner VIRGINIA BRIDSON Address of Owner: SAME , Date of Inspection: 12/17/99 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: n/a D F C 2 8 1g99 Mailing Address: n/a Telephone Number: n/a TOWN OF BARNSTABLE t HEALTH DEPT. reRTIFIGATION STATEMENT 1 certify that I hava personally inspected the sewage disposal system at this address and that the information reported below is true;accurate ' and complete as 3f 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: X Fasses The inpectlon is based on criteria defined In Title V _ Coiditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Ne-ads Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does Fars not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:12/17/99 The System Inspector she 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 now 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 THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9096 Page 1 of 11 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner: y VIRGINIA BRIDSON v5 v Date of Inspection:12/17/99 INSPECTION SUMMARY: Check A. B, C, or D: A. SYSTEM PASSES: _ 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: s System passes Title V inspection ' B. SYSTEM CONDITIONALLY PASSES: n/a 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. WA 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. Na 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 nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed * 3 - s- revised 9/2198 Page 2 of 11 x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r Property Address: 236 EBENEZER RD.OSTERVILLE r Owner:,>. : VIRGINIA BRIDSON .,Date of Inspection:12/17/99 `'� _ C.. ,FURTHER EVALUATION IS REQUIRED BYTHE BOARD OF HEALTH f Conditions exist which require further,evaluation by the Board of Health in order to determine'if the system is failing to protect the public health,safety s and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water r A -0' Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh., , �. 4, ^r nle, 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: _ s 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less _than 5 ppm,'Method used to determine distance n&-(approximation not valid). 3).: OTHER Aft$ _ q , • �@ :�Y$1 1� a ;, .. —t 4 revised 9/2/98 '° Page 3 of 11. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner: VIRGINIA BRIDSON W Date of Inspection:12/17/99 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 failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X °Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n(a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X -Any portion of a cesspool or privy is within 100 feet of a,surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy Is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert'pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X, the system is within 200 feet of a tributary to a surface drinking water supply, X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 . " <, L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r " PART B " ,. CHECKLIST Property-Address: 236 EBENEZER RD.OSTERVILLE ,' �•_ Owner: VIRGINIA BRIDSON " s j Date of Inspection:12117/99 n Check if the following have.been done:You must Indicate either"Yee or"No"as to each of the following: Yes No• X Pumping information was provided by the owner,occupant;or,Board of Health. , X_ 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. X As built plans have been obtained and examined.Note if they are,not available with NIA, X The facility or dwelling was.inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. , X -,The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. n , X a _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles v:or,tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on:; ° X I Existing information,For example,Plan at B4O,H, X Determined in the field(if any,of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)1 °F X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. U e g revised 9/2/98 r Page 5 of I I' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION " Property Address: 236 EBENEZER RD.OSTERVILLE W Owner:. VIRGINIA BRIDSON t Date of Inspection:12/17/99 FLOW CONDITIONS RFSInFNTIAL: Design flow:-M g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: Number of current residents:) Garbage grinder(yes or no):MQ Laundry(separate system)(yes or no): NO if yes,separate inspection required Laundry system inspected(yes or no).JYD Seasonal use(yes or no): NQ Water meter readings,if available(last two year's usage(gpd): n1d Sump Pump(yes or no): NQ Last date of occupancy: nla COM MERCIALnNDUSTRIAL Type of establishment: n/a . Design flow: a&gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): N12 Non-sandary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n/a Last date of occupancy: n/a OTHER: (Describe) Last date of occupancy: nla GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NQ If yes,volume pumped hI& gallons Reason for pumping: n(a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nla APPROXIMATE AGE of all components,date installed(if known)and source of information: 1976 ' Sewage odors detected when arriving at the site:(yes or no): N12 revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner:. VIRGINIA BRIDSON Date of Inspection:121 17/99 , BUILDING SEWER: (Locate on site plan) Depth below grade: I E Material of construction:_ cast Iron X 40 PVC _ other(explain) z Distance from private water supply well or suction line: TOWN Diameter: nla Comments: (condition of Joints,venting,evidence of leakage,etc.) n/a SEPTIC TANK: X (locate on site plan) a: , Depth below grade: i Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No n& Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 2= Distance from top of sludge to bottom of outlet tee or baffle: 32_ Scum thickness:2 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: HE , How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING EVERY TWO YEARS FOR MAINTENANCE- GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _.Polyethylene_other(explain) n/a Dimensions: n/a Scum thickness: nLd Distance from top of scum to top'of outlet tee or baffle:j3La Distance from bottom of scum to bottom of outlet tee or baffle nla Date of last pumping: n/a 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.) n& revised 9/2/98 Page 7 of t 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner: VIRGINIA BRIDSON Date of Inspection:12/17199 TIGHT OR HOLDING TANK:u NO (Tank must be pumped prior to,or at time of,inspection) - (locate on site plan) Depth below grade: nLa Material of construction:_ concrete . metal_'Fiberglass._Polyethylene_ other(explain) Dimensions: n& Capacity: n& .gallons , P Design flow: n& gallons/day Alarm present: NO Alarm level:jV& Alarm in working order:Yes—No—: NO , Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n(a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: NQ ~ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ �. Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner: VIRGINIA BRIDSON Date of Inspection:12/17/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,If possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n1a Type; leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _nLa leaching galleries,number: 11L8 leaching trenches,number,length: nLd wK leaching fields,number,dimensions: nLa, overflow cesspool,number: nLa ' Alternative system: nta Name of Technology: .ola Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT HAS NOT HAD MORE THAN 4'OF WATER IN IT CESSPOOLS: (locate on site plan) a Number and configuration: nLa Depth-top of liquid to inlet Invert: n1a Depth of solids layer: n1a Depth of scum layer. n1a Dimensions of cesspool n& Materials of construction: nLd Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& . Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition.of vegetation,etc.) . DIA PRIVY: (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: nLa , Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 912198 Page 9 of 11 f Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner:. VIRGINIA BRIDSON Date of Inspection:12117/99 r ` SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a U mc p (� A� 26 qc a, revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 EBENEZER RD.OSTERVILLE Owner: VIRGINIA BRIDSON Date of Inspection:12117/99 NRCS Report name: nta Soil Type: n(a Typical depth to groundwater: n& Z USGS Date website visited: nta Observation Wells checked: NQ Groundwater depth:Shallow Moderate_ Deep _ SITE EXAM _ Slope Surface water _ Check Cellar r Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: . Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data, s Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 Date: t�(Da � TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: CMZ, (bjY7hWCVTL-0A BUSINESS LOCATION: 33(o a- &TL R-0 05Tn>�t�% VV\K 02GZ— MAILING ADDRESS: sf Uw(= Mail To: TELEPHONE NUMBER: SbS- L470-1113 Board of Health CIkftULL(� C51� Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline orcoolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS gt,.E+'wom'^�_. . �J-' .... ' '` '1_ a. "�" .. v ., .tY'`rPlw,...-yip i!.Jr.iFq.'�{ -{,.•4:t.,:„ ,. Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM ask- �•n ��"cam.- ) NAMEOFBUSINESS: Z, BUSINESS LOCATION: 33(o. G-Bu—7�- R D 051Mvk�Lc= v� MAILINGADDRESS: 511� Mail To: Board of Health TELEPHONE NUMBER: 501 070_113 Town of Barnstable CONTACTPERSO P.O. Box'534 a i EMERGENCY CONTACT TELEPHONE,NUMBER: S kMU� Hyannis, MA 02601 f TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the.Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: 'r TELEPHONE: i LIST OF TOXIC AND HAZARDOUS MATERIALS . The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor,oils . Pesticides NEW 'USED.` (insecticides, herbicides, rodenticides)- Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED ` x Photochemicals (Developer) Other petroleum products: grease, ( p ) � lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood.preservatives (creosote) Battery acid (electrolyte) Swimming pool'chlorine - Rustproofers Lye or caustic soda 6 Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons,; NEW USED (inc. carbon tetrachloride) Paint &varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform,formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solventsµ Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r No.... ......... _ . THE COMMONWEALTH OF MASSACHUSETTS �.-- BOAR®.2 F H_, L..T H ti....---.....OF.... j°`1 ''Q 's�� ..... Alip ira#iou for Diipoiittl Works Tomitrurtiolt rantit Application is hereby made for a Permit to ,Construct �or Repair ( ) an Individual Sewage Disposal systems ................................��.---'----- ...............................Jam ...._._... - Lo ion-Address Lot J�o. ' ..fin- . ......_.. -w` ° �' ..... -.. caner Address .. ................... ..... 21`�, a"` •. .................. Installer Address rJrJ /4 Type of Building .+ Size Lot_._...._.I................Sq. feet U Dwelling—No. of Bedrooms.......... -------•--------- -----Expansion Attic Garbage Grinder Other—T e of Building .. No. of persons__...... Showers — Cafeteria a Other fixtures ............ ............................ Design Flow................ --gallons per person per day. Total daily flow..-.'.'. -•• ......................... lens. WSeptic Tank—Liquid capacity/V'�-gallons Length......:........ Width................ Diameter_G��____-.... Dep x Disposal Trench—No. .....�........_.. Width.................... Total Length.................... Total leaching area._ ,6....sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area........... .....sq. ft. z Pe colat>onr1Test-Results Performed bying t� _ A .....c --t-------------_ Date....-- .._ ............. ,aa Test Pit No. 1__...2 ____mmutes per inch Depth of Test Pit---d'�---------- Depth to ground water __ . Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ O v Description of Soil-•--------- . ....... � = '� -- - -- - - - -- ------------------•--------------------------- ^1.2� ---- --- = .v®�1 ----------------------------------------------------------------- --------- -. . U Nature of Repairs or Alterations—Answer when'applicable................................................................................................ -•-------------------------------------------•••-----------•--•----•••-•--•-------•-'-------------------•---•-•-----------------....-------•-----•-•--•---•--•-•------••-•-••------------------•---•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT T p 5 of the State Sanitary Code— The undersigned further a ee not to place the system in operation until a Certificate.of Compliance has been issued b the board of . q {� Signed 774 (C��--��h --------------- --- 2A..-.J!/ Date Application Approved By........... ------------ �---L�---� Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------•--------- ..................-••-------•---•--•----------------•------------•-------•---•--------------------------------••-------•---•-------•-••------------•----------•--•-•---•---•----------•--•----......... Date PermitNo......................................................... Issued....................................................... Date of z6z d No.... ......... FEB...F `.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD . F H E,�LLTH OF / ol •K ' , may , pphration for Biiposai Works Toostrurtion ramit Application is hereby made for a Permit to Construct ( ,�j'or Repair ( ) an Individual Sewage Disposal System at L09ftion-Address ....>__IX.C..... ........+' .ai� '=f7=-AA........................................ .................... ---Owner Address Installer Address ,/j Z- ✓4 Q Type of Building ,, Size Lot..........2. .....�..(✓....Sq. feet Dwelling—No. of Bedrooms......... ''.......................Expansion Attic �VKO Garbage Grinder (>� '_l Other—T e of Building No. of persons-_______6.............. Showers — Cafeteria Otherfixtures-.., ---------------------------------------------------------------------- -------------•--•-••••----•----•-----•--••-----•••----------- W Design Flow.................9$- gallons per person per day. Total daily flow____ ,t .................... ns. WSeptic Tank—Liquid capacity, .gallons Length................ Width................ Diameter_/d.� _.... Dep_� li. _..._._ x Disposal Trench—No. ..... ........... Width.................... Total Length.................... Total leaching area_ A..... ft. Seepage Pit No.................,... Diameter.................... Depth below inlet.................... Total leaching area..........r_....sq. ft. Z Other Distribution box (� Dosing tank/( ) - a Percolation Test Results Performed by........"_....... `? . ....._:�.:�-................... Date...._, ....... `l- ----- a Test Pit No. 1.. _. -r.----mmutes per inch Depth of Test Pit----:.?_......._.. Depth to ground water ....... (T., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ry „ �^ . Description of Soil.............. - ------------- --------•--••------------------------------------ .. ' ------------------------------------------------------------------------------------------ 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 I:Li: p 5 of the State Sanitary Code— The undersigned further ague not to place the system in operation until a Certificate of Compliance has been issued by the board of healthh. �0 b l w2,8sr ,,, �• . Application Approved By.......... ""== ... -----------------------------•- -------------------Date----•--•----------- 3 Application Disapproved for the following reasons:..............................................-------------------------------------•-•••=..................... --•-•••••......---•--•-••---•....._..•---•••-•--••-•-•--•---•-•----•-•-••--•-••-•-•-••-•--•--••--------...---•-•--•-----•--••-•••-••-------•---••--•----•-•-•----•---•--------••--••----••--•-----......_ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ,.. .�,, BOARD -O'F HEALTH (grrtif irat of Tompliana THIS IS TO CfRTIFY,•T at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) C) 0 by........ ._ ..............................................................------------------------..... ----------------------------------------------- •------ --........... �� f,/Installers-a at---•--------------------------•----------•----- ? ......................................................................................................................... has been installed in accordance with the provisions of �Y--z �1The State Sanitary Code as described in the application for Disposal Works Construction Permit N ............................. da.ted___.............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1 .................................................. DATE . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH,, .......................................... l s�........................................................ ,.3 a FFiz........................ �i��ro o •k� � trorttion �ermit Permission i5 hereby granted__..._` ••_ -------------•-••-•••-------•--••--••---••------•--•--.........................•••-••................ to Construc e�r -epair"( Individual Se�, gg Dispos S,ys J yua atNo. ...........................•-•--•••-•......••••••. -•••-• ..... -- Street as shown on the-application,for Disposal Works Constructio rnut No ______ atSA/..................................... ✓'' ....................................................... y of Health DATE.................... ............................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ay � . '4'^^.M,,.�...m _..ter✓. ' s.n`^°a""•.a-vev.,rwr..v..n+-.n,.x,...,.n..+ardr.,i."..r...,M.nrnrY A+ww"^ , s. " Az l ,s,� 5 phi �5� ¢ -2_.a 5 LEGEND EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 , FINISHED SPOT ELEVATION ROBERT L-° r 3 y �=. e�Z�z. 7 04 c FINISHED CONTOUR• 0 P APPROVED , BOARD F t 0 HEALTH ,� No z2isz�o� IN ..�.� DATE AGENT h„ SCALEt " �=4a DATEl S 41,F1 C DREDGE ENG/NEER/NG CO. IN GRc "i liz CLIENT I CERTIFY. THAT THE PROPOSED CIVIL LAND JOB N0 EGISTERE 'REGISTERED . Pi v 7-3 BUILDING SHOWN ON THIS PLAN CONFORMS TO THE ZONING LAWS ENGINEER %SURVEYOR DR.BY= '� ' OF BARNSTABLE IASS 712 MAIN ST. CH: BY: . P:/ • S�,A v HYANNIS, MASS. SHEET..[ OF DATE REG. LAND SURVEYOR ?O FT. M//V. /VOTE %F E/TNER ?'yE.SEPT/C TAN/C OR LEACHI/VG P/T ARE MORE 7-H.9/V /2"BEL0W /O F7: M/N. GRAOE� � 24.p/AM ETER CONCRETE COiiER _ �CONCRCTE MbV. A/TGAi ,4VYASTRO/Y COVER SA LLEUS6,o a . Cr/c V, I0O, G /N OR/✓EWA y P•.CHIN, CONCRZ'�TE A GAVE CC)✓ER CLEAN SANG Q` BACICF/L.L. d- 4"CAST .,z,2 2LAYER ` IRON P/PE OF 0 Alm,.P/TG// GAL. , • . . • • • • • e o PtR>? SEPTIC TANK D/ST, o o�A • • • ° • • • • 6 4 WASHED STYJNE J•'"' BOX v • � B • • • • • � .•0 e, e 1 • •EFFECT/✓E • • • '3 4 - �2• `-.' ;:" a ioo • • DEPTH . i i o c 0 WASNAFP STONE a .0 • • • • • • • • • D °�y PRECA5 T SEEPAGE I/Vl/,eRT E4EYA7'10/V5 f� pq S v ►• • • • • • • • • • ' as o P/T OR EQU/v. . ► O /NYERT AT OU/LD/NG f,7.O FT. G F7- D/AM. INLET SEPTIC TANK �� FT, L _ FT O/A!►'J• �I C SEE TABULATION, OUTLET SEPTIC TANK 9 C, 3 FT. r INLET D/STR/E!/T/ON BOX SC•a FT. SECT/ON OF GROUND It47-ER TABLE Ot/TLETD/STR/Bt/T/ON BOX �/S, 9 FT. SEJ�VAGE O/SPOSA L SYSTEM /NL�it T LEAGN/N6 /?/T S, FT TABULATION LEACH/NG /P/T SCALE %" _ /=o" D/MEN.S/ON A 3 Jar. oACSION CR/TER/A AlVAlBER OF BEOROO/ys D/HENS/ON C�1' •_FT. M,n GARQ dGE DISPOSAL UNIT — SOIL. LOG TOT�At L EST/M.4TEp FLo,.v—•3�3 4 G,41.IAA SO-1 L TEST #/ $O/L TE'ST*2 SOIL TEST /NUMBER OF 4eACN/NG pros 1 — /-FLEy, 4G• a. V••ELEeY PATE GF SOIL TEST _M�' S/G.�LEACH/NG PER P/T / 8' SQ. FT. Ir G_ RESULTS IV/TNESSED BY - &A • 1.1 9o7 T'OM LF,4CN/NG PER P/T 8 s: AT. �Gs� Q, s PERCOLAT/ON RRTE�/ ° s r Mi"l-I NCH TOTAL LEACHIMCP AREA �SQ. FT. PMVC0L/47-/0N RATE A2 " '` M1N.//NCN RESERI�ELEAC'N!/V6AREA �$G SP. FT. ae Aer ROBERT. P -",1 «� + IKI o H Mew nU EL DREDGE ENG/N.�R/IVG CO,/NG. �y '90,�/SG/STEM 6��' NO GROUND YY.4TCR ENC041/V7ERE4P HYANN/J, MASS. sown►. GROUA/o kvAT�.? AT ELEII �_ J06 ND. CA.? SHEET OF Flza/ .:..................... THE COMMONWEALTH OF MASSACHUSETTS OAR D - F HEA T -OF. ... . :.../�/I ..��( �/ 7 (per" 6 r 1 34,e' Applirati u -fur Dhipouttl Works Tomitrurtion Vrruiit a3� �� k� 6 i p tcat><on is ereby made fir a ermi tfS Construct �orRepair ( } an Individual Sewage Disposal Syst a --. ... •Address f or Lot No. t• o e Address a ------•---�..... ...... .. -- -------------------•---- ------------------ . .... .. ........ l --•---•---- � Installer Address U Type of Building Size Lot... f� Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) w Other—Type T Building O YPe of B d g -------_.................... No. of persons---------------------------- Showers ( ) — Cafeterta_(.....)_ dOther fixtures .C72<- ' ''- ....................---•-------••---...----•....................................•-•--- w Design Flow.............770................�..y..gallons pe erson.per day. Total daily flow----------- ..........gallons. WSeptic Tank—Liquid capacitallons Length................ Width.____..----- _._ Diameter...........----- Depth-__._--_-_--- x Disposal Trench—No_____________________ Width ----------------- Tota ngth_.-_--___-__.-_-__Atal le hin rea___--7.e_- =i'. sq. ft. 3 Seepage Pit No... Di ..__.�-.'? De n 1�a lr sq. ft. Z Other Distribution box ( ) • Dosing tank /— 7 w /`�✓L Percolation Test Results Performed bY.......................................................................... Date--------------------------------------- a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...---. -.---.--.--. - f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.--._.-_-.-_-._____--- ------- --•-- • --------------------------- Description of,Soil----- -- L� 1y.d . --------- ..... . furl -_----_-------------------- U ----------------a-------/_=�- -----� - ` -------------------------------------------------------------------- w V Nature of Repairs or Alterations—Answer.when applicable----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------••-•-------------------------------------••-•----------------------------------------.----------------------•------•---__-_-----.------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. It __�7 oApplication Approved BY--------y `- �- Date Application Disapproved for the following reasons: - --------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date M THE COMMONWEALTH OF MASSACHUSETTS Gam.--- 'BOARD OF HEAL-THE .t-....OF.;,...... �/� iI F .... .................. ApplirFation -fur Bigpoiiai Works Tonstrurtivaa Vrrmait Application is hereby made for a Permit to Construct Repair an Individual Sewage Disposal System aty: +' .............................................. ./ ..............•---•------ ---•-•-•---••----•----...--•••-•----••---•-----••••-•-•-•••---•-••------------•---•....._......-- ^ ?>L'ocation-Address / ,/d� or Lot No. Owner / - i Address Installer Address / Q Type of Building v �} Size Lot... feet U Dwelling—No. of Bedrooms-.--_----.v--'.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures - -------------------------------------------•-•-------------------------------------------------------------------------------- W Design Flow........... ..._.._._._..__ ___ aper person per day. Total daily flow..............- _ !_�1_------------gallons. ..�._._.___ __gons lions _ W Septic Tank—Liquid capacity:K2_�.all Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width�--_---_-_--.--_ Total L-ength___-_-_------___- ...Total 1 chin ,rea....:'3., �_sq. ft. 3 Seepage Pit No... 1f���/_ Di j eter'���-- Depth-b�l. �let�__.______l.- 6 i'le'ac7ii,1 � -----------------sq. it. Z Other Distribution box ( ) _ - Dosing tank ( ) /)V / - 7 aPercolation Test Results Performed by-------- -------------------- -------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water-..--.---_---------_.... P4 ------------------------ ---- ------••-- . • ✓._...--------------------- xDescription of I Soil_----------•-�� h._.. ..1 h��?�� .'- � - E:�-------•"--,.�-._�:,�_�E ���`�------------------------- x -------------- ------------------•------.-.------------•--------------------------- -----•---------•----------------------•-•-------.•----.-•-------------------------------._---------•----•--•-------- U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- -------------------------- ---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ign -�� /. Application Approved By-------- - ----E-' L=G/� ��A. ------------- f Date Application Disapproved for the following reasons---------------------------------o-------_----------_-----------------•----•-------------------_------------- --•-•••---•..............••-----_-----•--•------------------•••••--------••-•...........................................................--•--------.--•---------------------•---.--•------------------- Date PermitNo......................................................... Issued...................... ------------------- Date THE COMMONWEALTH OF MASSACHUSETTS _-- BOARD f-OF HEALTH � .........OF./, � s�a7. .......................... Qrrtifiratr of W"Jam haurr � THIS11S'TO ,CERTIFY, That th /Individual Sewage Disposal System constructe&�(.-� )-or Repaired ( ) by..............................'"�' --------------.---• .............................. Installer at; ----------------------------------------------------------------------------------- _-.......................... has been installed in accordance with the provisions of Ar/ VA/tcl XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-OV.-Y-7-6.............. dated..... -Q-- S---__ -�_._.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATEo_.. •, Qs� Inspector-- C� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. o � 1 J��� OF.. ! (' ..... No•.:/•7�- Ci FEE/ ------•---•- i>� ott� Norkii �ua�� `fr�tr#iu$trraatit Permission is hereby`'granted______! ..`" 'G'' t_.____,!'. ----- ____.._ ------•--- ------------------........................... to Construct,,,(�)or Repair (--�) an Individual Sewage Disposal System at No.------ �4=// �'� �' f c//Ja��/ - ------ `'-'�.-,� �?.-•-•- -------•--// = �'r / Street c as shown on the application for Disposal Works Construction Perm o---_-__--.�...__ . Da �J-._.� c__ __ .._.__. i � -' -------------_ r~ � � Board of/ eH alt DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f � - - .. 1 {✓ / is 3 � ,- t e � ✓; r - La �re iP ,1 f Ok -tA Ai- � r DO x .GIOGi�7'/®aR/• GgS9�2 v/c L ,��i,�,.r�,- Gv�` �� ,�, G'F>'.vr� ��v/z"�' ,Oi<S7'2•,�vT.r�o y' ,C�+� �"r �Y q� � 2:.�✓e���y eE�TiF Y 7 s-1A7 S,r1p6V.V Off./ lid/: AG A*A.1 /S L.00R77Et7 O.V ���'�?tJi6✓9 RS .S/dCW.V H���oltJ GiMl� TNolg?T G%C`� S COAJFO�.V1 TO �O -,//AJC��_ v1 � r THE Tt7WA.1 OF �.97��STi9 By'-LAbVS o n ;ram _p. v u~ / � T tqT iGbdJTE 6�4�-Y�.�i►iPOG/Tf-1, M�755.. z�Rr,--- �+-'4� _ -#�d�• 4,4 �++��1� +•/mac/— .(��/ - � � r' Y 1_ ��.� ` w 1 30 LEGEND nala°os W y N c r ^� LOCUS �ep �S,he�fB PROPOSED CONTOUR o 0 a 2J 99 PROPOSED SPOT GRADE s m Rebecco +,. O g WoY -1 0--- EXISTING „CONTOUR N s K cu Nothan EXIST/N ` Pl T 110 EXISTING SPOT GRADE S way s`o TO BE REA40VED TEST PIT 7o Goes' ( Note 11) <r� ® a See, also, ROUTE 28 W---"' EXISTING WATER SERVICE EXISTING SEPTIC TANK o TOP OF TANK EL: 98.85 $ Sol, INV(OUT) EL: 97.52t 0' LOCUS MAP N.T.S. S 17'14'24" E 100.17 !!EWJT x 101. 17 164. 75' d TP EL=101.3 --; GENERAL NOTES: ' e 25 ---� 35 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL `~ 1 BOARD OF HEALTH AND THE DESIGN ENGINEER. s u ! Vut ff `' 1 �''� EX/S77A6 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS j -.. .. GAiRAGE HOUSE(#236) `' �OCAL RULES AND ENVIRONMENTAL RpGIJLATIONS ,� ODE, TITLE V, AND ANY APPLICABLE T.o.F=1o2:2 v r _ : � � A�c.�;J ----�,,,•, f(;1,22 � �.i 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. .. ,!�--- -� j i 4, ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING ��! Cat p �'"" I FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. i r*t 5, ALL ELEVATIONS BASED ON ASSUMED DATUM. RAI VE_D_ r 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF - Ai 71 fz VIA Y .. LOT 39 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. �{J� f i ;� 7 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. IJ �� �.... �._ ._ � APN 146,-O34 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. 1 15,551 fS F. 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED basin � - _ � _�_ � _ �� TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. - 0 - 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE I: THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING I CONSTRUCTION. _ l._.'..._ L=36..86' 11, WHERE REQUIRED, CONTRACTOR SHALL: REMOVE ALL UNSUITABLE SOILS 103. 10 IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE SA.S. S 17"1424" E y` R=239.60 AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). -- - -- - 1 --- ---------- " 9 6.82 e(jqc ° povq ' PROPOSES SEPTIC SYSTEM. UPGRADE EBENEZER ROAD { o PETER T. !� � McENTEE � 236 EBENEZER ROAD, OSTERVILLE, MA v CIVIL No.CIVIL Prepared for: Mitzu ORiiey, 4020 Grande Vista Blvd, St. Augustine, FL 32084 BENCHMARK S1�R�� �� Engineering by: SCALE DRAWN J08. N0. TOP OF CONCRETE BOUND ts' E Engineering Works 1"=20' P.T.M. 175-05 ELEV.=100.00 (ASSUMED) 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. ; Lam (508) 477-5313 7/16/05 P.T.M. 1 Of 2 6 ' NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION ly F.G. EL: 101..3t1 FINISH GRADE SHALL NOT BE < EL:96.5 (EXISTING) ' (EXISTING) EVENT FOR A DISTANCE OF 15' AROUND THE F.G. EL: 101.Ot F.G. EL: 100.45t F.G. EL: 101.2t PERIMETER OF THE S.A.S. ' (EXISTING) (EXISTING) ,.(EXISTING) MAINTAIN 2% MIN SLOPE OVER S.A.S. mom Immmomm ,I INSTALL RISER OVER D-BOX TO 500 GALLON LEACHING CHAMBERS INSTALL RISER OVER CHAMBER/S INSTALL RISERS OVER INLET & OUTLET SHOWN ON PLAN AND SET COVER/S TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL +IDES WITHIN 6" OF FINISH GRADE m L =12' L =5' 4" SCH 40 PVC 4" SCH 40 PVC 2" LAYER OF 1/8" TO 1/2" A' ,o EXISTING 14� ® S= 1% (MIN.) s ® S= 1% (MIN.) ®Tmetal a DOUBLE WASHED STONE ®aa®®a6 EXISTING 1000 GALLON 2' EFF. DEPTH ®aaaaBa 3/4"-1 1/2" e••"• : INV. ELEV.=97.30 D-BOX SEPTIC TANK INV. ELEV.=97.13 3.5' 5.2' 3.5 DOUBLE WASHED INV. ELEV.=97.52t W/ RISER a EFFECTIVE WIDTH = 12.2' STONE (EXISTING) INSTALL INLET & OUTLET TEES INV. ELEV.=97.00 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY I TOP CONC. ELEV,=97.8 ---BREAKOUT ELEV.=97.5 TUF-TITE, ZABEL, OR EQUAL INV. ELEV.=97.00 ®aaa ®ease a®aaaalaa a D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE Ba®®®aa®® BOTTOM ELEV=95 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED . .00 4' 2 x 8.5' = 17.0' 4' STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2), S' MIN. ABOVE BOTTOM OF FEFFECTIVE LENGTH = 25.0' T.P. EXCAVATION-OR G.W. fir �qs SEPTIC SYSTEM P R O Fi LE BOTTOM OF TP EL.=89.8 ACHING SYSTEM SECTION �10 Jq�yG PETER T. N.T.S. McENTEE v CIVIL No. 35109 (3) 5" DIA.OUTLETS ° RFG/SZE��� 16" _I I_2" DESIGN CRITERIA NUMBER OF BEDROOMS: 3 BEDROOMS �Lb�1 15. s s" 6" e" SOIL LOG SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 2 MIN./IN. ' 2" �--- 25' ---�►{ DAILY FLOW: 330 G.P.D. H-10 LOADING DATE: JUNE 30,2005 f- ^ " — — — DESIGN FLOW: 330 G.P.D ®-BOX N SOIL EVALUATOR: PETER T. MCENTEE PE, CSE GARBAGE GRINDER: NO N,L6 N i PROF. S.A.S. i 36's' WITNESS NOT REQ'D (CLASS 1 SOILS) _ _ _ 35.2' LEACHING AREA REQUIRED: (330) = 445.9 S.F. oZ — TP- 1 .74 ,Sal . Q IElev. Depth CE /`� �' 101.3 p° EXISTING SEPTIC TANK: 1000 GALLON (ESTIMA1fED) Em ®EaEaEa 3000 33' 8ASANDY LOAMINVERT5I®®a®®®® 3� •y`� O tOYR 3/324" ®®®®®®®® p 14oD•s a 5 USE 2-500 GALLON LEACHING CHAMBERS IN SERIES W I SANDY LOAM 102" 98.3 10YR 5/8 3&" SIDEWALL AREA: 2(12.2' + 25.0') X 2 = 148.8 S.F. C BOTTOM AREA: 12.2' x 25.0' = 305.0 S.F. 4' KNOCKOUT 'a TOTAL AREA: 453.8 S.F. 20"OIA. COVER 4" KNOCKOUT o�4' KNOCKOUT 62" DESIGN FLOW PROVIDED: 0.74(453.8) = 335.$ G.P.D. MEDIUM SAND PROPOSED SEPTIC SYSTEM UPGRADE 4' KNOCKOUT 2.5Y 7/6 236 EBENEZER ROAD, OSTERVILLE, MA C81 , Prepared for: Mitzu ORiley, 4020 Grande Vista Blvd, St, Augustine, FL 32084 500 GALLON CAPACITY, H-10 LOADING S.A.S. LAYOUT 89.8 138" Engineering by: SCALE DRAWN JOB. N0. CHAMBERS "Ts f NO G.W. ENCOUNTERED Engineering Works NTS P.T.M. 175-05 PERC RATE: <2 MIN/IN. ("C" HORIZON) 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. �" (508) 477-5313 7/16/05 P.T.M. 2 Of 2