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HomeMy WebLinkAbout0058 EEL RIVER ROAD - Health (2) 58 Eel River Road Commonwealth of Massachusetts 1��� 0 Title 5 Official Inspection Fora i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd r4' Property Address Paul Bergin Owner Owner's Name information is required for every Osterville - MA 02655 9-24-20 •;� <'. page_ City/Town r State Zip Code Date of Inspection Inspection results must be submitted on this form. l'nspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information 514 lL+ Shawn Mcelroy Name of Inspector N ` t t• ;*. , .t+ i r f Upper Cape Septic SbNices Company Name P.O. Box 73 Company Address East Falmouth 4 +. ,.' ,•, MA x... �, f .02536 City/Town - State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: - - 1. ® Passes 2. ❑ Conditionally Passes 3.1, ❑ Needs Further Evaluation by,the Local Apkv'ing.Authority > ,w 4. ❑ Fails 9-24-20 I spector's Signature '' I Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ' r f L.1 r # Commonwealth of Massachusetts r� Title 5 Official Inspection Form- w: 5 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is Osteryille required for every MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary i Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System'Passes:k ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System,Conditionally Passes: . - ❑ One or more system components as described,in the "ConditionalPass" section need to be replaced or repaired. The system, upon completion of.the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration.or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is"replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): k. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ht Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 58 Eel River Rd , Property Address Paul Bergin. Owner Owner's Name information is required for every Osterville MA 02655 9-24-20 , page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if t pumps/alarms are repaired: ❑ Observation of sewage backup or break out or high static.water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will -pass inspection if(with approval of Board of Health): ❑ ,broken pipe(sj are replaced' ' ­ ❑ Y ❑N "• ❑" ND (Explain below): • ❑ -obstruction is removed' ' ' -❑ Y :❑N ❑ ND (Explain below): ' ❑ distribution box is leveled or replaced ❑Y ' ❑ N` ❑ ND (Explain below): _ y El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ; ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment., ' a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, ' safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cam` Commonwealth of Massachusetts - �' Title 5 Official Inspection Form wa ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;> 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osterville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ' ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a'surface water supply. ❑The system has a septic tank and SAS and,the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T >" 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is Osterville . MA 02655 9-24-20. required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) v, 4) ,System.Failure Criteria Applicable to All Systems: (cont.) L i r_ . . Yes `No tt , ,. r=. r� k, t *' ®' Static liquid level'in'the distribution box above outlet invert due to an overloaded El or clogged SAS or cesspool ' '' ` ❑ ,® Liquid depth in cesspool is less than 6" below invert or available volume is less - than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑„ , , Any portion of the SAS, cesspool,or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or f -tributary to a surface water supply. '', I ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. - , ' ®' •a...r Any portion'of a cesspool or privy is within 50 feet of a private water supply well. ❑""` ® ' Any portion•of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This Y system passes if,the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis „and chain of custody must be attached to this form.] ❑ ®� The system is a cesspool serving a facility with a design flow of 2000 gpd- J- 10,000 gpd. t The system fails.]'have determined that one or more of the above failure '❑ ® ' criteria exist as described in 310 CMR 15.303,therefore the system fails. The system•owner should contact the Board of Health to determine what will be ry _ necessary,to correct the failure.. , a•1 r 5) Large Systems:To be considered a large system the system must serve a facility with a design 'flow of 10,000 gpd to 15,000 gpd. y For large systems, you.must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA.- , „ Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts y Title 5 Official Inspection Form - wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd •�._Vr_ Property Address Paul Bergin Owner Owner's Name information is Os required for every terville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of•the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ' 0 Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection -Form —I i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osteryille - MA 02655 9-24-20 ' page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ,. _ , , , , ❑ Yes ® No Does residence have a water treatment unit? t r ,, < ., ,, ,` ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) d - > Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: r-., : , f 2020 - : Date A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� .3, Title 5 Official Inspection Form w:1 l'-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osterville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: ' Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner-----pumped 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts - Title 5 Official. Inspection Form C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd Property Address , Paul Bergin Owner Owner's Name information is required for every OstefYille MA 02655 9-24-20. page. City/Town State Zip Code Date of Inspection D. System Information (cone.) 4. Type of System: ® '-Septic tank, distribution box, soil absorption system , ❑ Single cesspool ❑, r Overflow cesspool, ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ r -Tight tank.Attach a copy of the,DEP approval. ❑ Other(describe): Approximate age of all components,.date installed (if,known).and source of,information: 1980's Were sewage odors detected when arriving at the site? t ... ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below 30""grade: , feet • r, Material'of construction: r ' ❑ cast iron ®'40PVC' ','❑'other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w., i>�i Subsurface Sewage Disposal System Form :Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Cisterville MA 02655 9-24-20 e. City/Town State Zip Code Date of Inspection page. p D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle .15" • How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts 11�� ' Title 5 Official Inspection Form FF Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osterville - MA 02655 9-24 20 page. City/Town r, State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): , Depth below grade: ,- feet 't ` 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:,. t,. t . . :., Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,Mevidence of leakage,'ete.): - • -4 P J kl ,'f ti! a a!^ '.•y+ rj- •� f•f , l., �tM a A , .- a s i - L 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osterville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was video inspected and found to be in good condition with water at working level and no sign of back-up from pit. There is an irrigation line running across top of cover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts F ,w Title 5 Official Inspection Form ciCi Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin , Owner Owner's Name r ' information is required for every Osterville - MA 02655 9-24-20. page. City/Town . ,. State Zip Code Date of Inspection D. System Information (conf.) 10. Pump Chamber(locate on site plan): Pumps in working order:" '�r �'' ❑ Yes.. ❑ No* a ,.-T Alarms in working order: ,.'' ` ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. „ 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 9a ® leaching pits :r;;., t ; : ' ,; riumber':.. - ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts r� Title 5 Official Inspection Form V -'i Subsurface Sewage•Disposal System Form -Not for Voluntary Assessments - Z� ` 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osterville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition with water level and stain line at 24" off bottom of pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top.of liquid to inlet invert ' Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts t 3 Title 5 Official Inspection Form r w., i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every osterville MA .02655 9-24-20 , page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): .r i Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 k Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts y/ Title 5 Official Inspection Form ,� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every Osterville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 1� 7 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form. C�i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Eel River Rd Property Address , Paul Bergin • , •. I - Owner Owner's Name information is OStervllle required for every NIA 02655 9-24-20! -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ,;, : ` , •ri - 15. Site Exam: ❑ Check Slope ,. �; . IrF_ .,,, , ,,: t• ❑ Surface water ❑ Check cellar t •, .. , ❑ Shallow wells r Estimated depth to high groundwater: �. , - 20+ feet Please indicate all methods used to determine the high-ground water elevation: ❑ Obtained from system design plans on record , , r r If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts j 9/ Title 5 Official Ins action Fora ? r�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Eel River Rd Property Address Paul Bergin Owner Owner's Name information is required for every osterville MA 02655 9-24-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist , Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ' ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TC? 1.48 ABLfi SEWAGE Loca��o�t � . .' � f: i 6l A ESSOR MST'' , T PtA1a PHGI l 0 dao FA 4i.''AP6. �O`'UFBOflDBS B�JItfl�Utz.�'f�k � 1EdATE•�_..- SbponD�tsncc$�re�n Edo. �� b6�ximumA�ustcdCif�'w�dwaie�'�+I'e�t�e,Bottom df�Sache��Fa:�l�ty Feat°I £ F�a�rat stater�uFF�.Y�Qreli ang ► mil►'tea esstt<� on�ta ar gtl�Io 2ENt that�r�b�ing f�w�jr) _ wettauds e.• •i edge o��ld amd Leachngit�t�"�f azb! .� . witt�iu 9QU�eCt b€:teachx�g� ' � t �r r1r`r 1 O a � o 3 � `f A ��� ASSESSORS MAP N0: l G/ ?PamNO DATE_ 6/24/04 PROPERTY ADDRESS: 58 Eel River Rd. _______________�_ .. Osterville, MA 02655 ------------------- On the above date, the septic system at the above addre so as Inspected. Z m = This system consists of the following: Do r n n 1. 1- 1500 gaeeon hep-tic .tank iD F , m 2. 1-d.i,stai&ut-ion Sox. Mz 3. 9-600 ga.eion eeach-ing pit with 3' of 1 z" '6tone D o Based on Inspection, I certify the following conditions: m 4. 7h.iz .iz a t.itie. rive zept.ic zy,3.tem (78 code) 5. The '3ept.ic '6y'3tem .iz in P/Lope2 wo zk.ing o2dea at .the p/ze-6ent ;Lime. 6. Oa.6.te wate¢ wah 42" geiow .inve2t Ripe in ieach.ing pit SIGNATURE: Company: .Tncepb g,_ &—Sgn, Inc. Add ress:_-p--._Bax-6-6i__-_-_-__- Conteryilis,—MA 02632 e066 Phone: THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY CH P. MACOMBER & SON, INC. Tanks-Cesspoo!Leachf[el.ds Pumped & Instal'led Town Sewer Connections x 66 Centerville, MA 02632-0066 775-3338 775.6412, 0 COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIR4NM`�N'I'AL AFFAIRS DuARTMENT OF NVIRONMENTn pROT CTION F TITLE 5 OFFICIAL INSPECTION FORM—.NOT.;EOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART.A. CERTIFICATION Property Address: 58 FP1 R; xzer Rcl Q a t a r v; 1 1 0, tvt_rz oz G-' F,— Owner's Name: Tnhu uo-rga:n Owner's Address: Date of Inspection: Name of Inspector: (please print) G. - - r' Company Name: , 10 .macom e2 .:Sion Inc. Mailing Address: Cen e/tvt e, u�,16..02632 Telephone Number: 5 0 8-.77 . 3338 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system.at this address and that the information reported below is true,accurate and'complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section.15:340.of'l itle 5(310 CMR 1.5:000). The system: E Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails rr 6/ u • v l " y l Inspectors Signatore: Date . — �-r -- The system inspector shall submit a copy of this inspection reporr-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 regionatoffice 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 ****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 game or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION:FORM.—NOT FOR VOLUNTARY ASSESSMENTS SVBSU.RF.ACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Eel River Rd. P Osterville Owner: JohrE Bergin Date of Inspection: 6/2 4.4 0 4 Inspection Summary: Check A,B C,D or E/ALWAYS-',-complete-,all of Section,D, A. System Passes: CV0 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.�04 exist. Any failure criteria not evaluated are indicated below. Comments: Sg,Q 4g 46j-64gg 46 is �paopoa ijnnk.n[C4 nnrlon f/f- Yh0 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: 5 _`) 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 r ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPIECTION FORM _ PART A CERTIFICATION(continued) Property Address: 58 Eel Rd. OsterviII Owner:. inhn Bergin Date of Inspection: 6 f 2 4.4 0 4 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further.:evaluation by the Board,-of Health,in or..der to:.determine ifahe 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 thel public health,safety and environment: 1 o The system has a septic tank and soil absorption"system(SAS):and the SAS is within 100 feet.ofa surface water supply or tributary to asurface water supply. rW The system has aseptic tank and SAS and the-SAS is within a Zone 1 of a-public water-supply. The system has a septic tank and.SAS and the SAS is within-.50 feet of a private water.supply well. The system has a septic tank and SAS and the SAS is less th 100 feet..but, 0 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: r Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT.FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: R F.P1 R l VPY Ra Owner:-d -l-C �1 . Date of inspection: n i A ' D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to.each.of the.following:for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool Discharge.or ponding of effluent to the,surface of the ground or surface waters due.to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due,to an overloaded or clogged SAS or cesspool _ Liquid depth in-cesspool is less than.6"below invert or available volume is less than 14•day flow 7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped _ Any portion of the SAS;cesspool or privy is below high ground water elevation. _ 7 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface T water supply.. Any portion of a cesspool or privy is within a Zone l of a:.public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. �- Any portion of a cesspool or:privy is less than 100 feet but greater.than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates 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 forrp..] (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. Large Systems: To be considered a large system the system must serve.a facility with a design flow of 1.01000 gpd to 15,000. gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in.add ition 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 in a nitrogen sensitive area()interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: s R F.e 1 River Rd_ . r astervi 1 1 e Owner: Ifs—Rergiu. Date of Inspection: ti /2 d 1 n'a Check if the following have been done.You must indicate"yes"or"no"as to each.of the following: Yes N9 ✓ Pumping information was provided by the owner, occupant,or Board of Health um 'ed out in the revious two weeks? i/ Were any of the system componentsp p p ✓ — Has the system received normal flows in the previous two week period? -Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system'obtained and examined?.(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? ' ._ Were all system components,excluding the SAS,located on site? _� Were the septic tank manholes uncovered,opened,and the interior.of the tank inspected for the condition of tthe b_affles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? V Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems?' The size and location of the Soil Absorption System(SAS)on the site-has been determined based on: Yes no Existing information.For example,a plan at the Board of.Health. ' Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL IINSPECTION TORM`—NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISFOSALSYSTEM INSPECTION FORM � PART C SYSTEM:INFORMATION Property Address: 58 Eel River Rd. Osterville Owner: John Bergin Date of Inspection: 6/2 4/0 4 , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desip):.,3 . . Number of bedrooms(actual); �r Q DESIGN flow based on'310 CMR 15.203 (for example: 1 TO gpd x#of bedrooms): �1J0 /,f, Number of current residents:. Doesresidence have a garbage grinder(yes or no): _P Is laundry on a separate sewage.system(yes or no):. [if yes separate inspection required] Laundry system inspected(yes or no):C&C3r7flO i•S l (,,P.� Seasonal use: (yes or no): 2�0 3 ��' i Water meter readings, if available(last 2 years usage(gpd)): J 1, OQ 0 /1 &J,v . Sump pump(yes or no): Last date of occupancy: ls COMMERCIAII&DU TRIAL Type of estabbjhmt nt: Design flow(lsd on 310 CMR 15.203): fla gpd Basis.of design"flow(seats/pers9,ps/sgft,etc.):(1g Grease trap present(yes or no):IV Industrial waste holding tank present(yes or no):N) Non-sanitary waste discharged to the Title5 system(yes or no) Water.meter readings, if avails}le: Last date of occupancy/use: . .( OTHER(describe):. ' RQ GENERAL INFORMATION Pumping Records Source of information:5 a if kl Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: ( 0() allons--How was quantity pumped determined? Reason for.pumping: T E OF SYSTEM YVSeptic tank,distribution box,soil absorption.system . Single cesspool Overflow cesspool PPrivy • 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) �tJ Tight tank _Attach a.copy of the DEP approval Other(describe): Approximate age, f all components,date installed(if known)and source of:information: Were sewage odors detected when arriving at the site(yes or no):fil 6 No7OfII OF'FIC.IA;L.•I.N- pECT.ION FARM NOT FOR VOLUNTARY ASSESSMENTS ACE SEWAOE VISPO&AXE SYSTEM INSPECTION FORM PART C SYSTEM INFO R- ATION(continued) Properly Addresst Rd.., Qwuo.r: T..b.n Rorn; ., — - Dane of 5$PCVOO r, /2 44.9 4._,�.---- . .. BUILDING SEWER{locate On si.to plan) , Dcpth bclgw grade. Materials o`f canstrtiet one;,,,,,cast Trott t 40 PVC,r,,,athar. (explAln):. Disutnec V ;wprivou wotcr supply well or suetion.Ilse: ...: etc is(Q eandition Qf,j 41 vie v s ita Ir<ri ZoocamonIC T ANICt ) sEPT v DVth b.clgw 9r&4C Mztcrw.of constrvetion.: concrete Zmctm.l—ftbugltiss,, -polyethylene. othcrtcxp.itttn) ' 12 I uu11c is metal tlsa,age;� Is age ca�fumc. by a Ccr�l�aaie of Cgrnpl.ancc lyes or no):SUS,,(atiach a copy of ccniftc`ite) .� P; Discic depth: Dis.tancc.from top of sludge to bottom o oullci tee or baffle: Scum thickness:� �;T, Distance from to. of scum iC.top of outlet tee or baffle: Distance ffom.bonom of sewm to bottom of outlet tee or baffle: How w.e.re-dlmetisiatts detcrmtncd: d- e Commctrts.(on.pusn.pin.g re.c©.rtuncndaii_ons, yiact an gt�t.ei tee arbafila.eondi.400, structural integrlry, liquid levels as rclite4 as oulla.t tnvcrt, avi:danee of.lcal4agc.,W); GREASE TRAP:1U(locatc on site pl �, tom' +'�� "• Depth b.clow grade: Material.of co.nstruetion: &concrctc (�$,mFtal ;,fiberglass palyethylcne!,,tether (explain); D:imcns.lonv Scum tfi.itkrtcs.Tv ?. D-is-wee tro.m top of scum to top of outlet fee ttr baffle: Di;suncc from bctcom of scum to bottom of outlet ice or`baf, Date o!Lut purrt.piag: ,,, Cartttrt.e.nts(on.pumping rccomtttcndallons.,.lnlei and outlet too or baffle condition, structural integrity,liquid levels as relttcd to out ii tnvcrt., evidence df:leaka:gc�etc,}: Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C. SYSTEM.INFORMATION(continued.) Property Address: 58 Eel River Rd. Osterville Owner: John Bercri n Date of Inspection: 6/24,1 0 d TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: " Material of construction: ."S concrete metalYkN fiberglass polyethylene AN other(explain): Dimensions: Capacity: aallons Design Flow:. w\ gallons/day Alarm present es or no): a Alarm level: Alarm in working order(yes.or no):. Date of last pumping: Comments(condition of,q alarm andfloat sNyitches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 110 Comments(note if box is level and distribution to outlets equal,any evidence-of solids carryover,any evidence of Leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chain r�condition of pumps and appurtenances,etc.): i 8 o • Page 9 of 111 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued): .3 _ -Property Address: 5 R F.P 1 gywAs' Rd. 4 OstPrvi 11 A Owner: Tnh„ Rergin Date of Inspection: 614 2 414 n a SOIL ABSO TION S STEM(SAS): (locate on site plan,excavation not required) , If SAS not located a plain why: leaching pits;number: i N,6 leaching chambers,number: %0_leachu}g galleries,number: leaching trenches,number,length: A/0 leaching fields,number,dimensions: LSD overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(notd condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): . �. . Vo tyl 110 g 1 C,PTO Pool,te. n r3 narrYL.a CESSPOOLS:(�0Y.=(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:{ YIA Depth—top of.liquid to inlet invert: YLq, Depth of solids layer: Depth of scum layer: , Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes.of no):t&�, Comments(note conditiop of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: 161�(locate on site plan) Materials of c nstruction: Dimensions: Depth of solids: p' Comme�(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFI CIAL INSPECTION FORM NOT-FOR VOLUNTARY'ASSESSMENTS SUR;SURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART 0 SYSTEM INFORMATION(continued) Property Address:_ 58 E ei R i v e z /2c1. Owner: h a g�«bra Date of Inspection: 4,1 2 i ink , SKETCH OF SEWAGE�DISPOSAL SYSTEM "Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or bent arks.Locate all,wells within 100 feet. Locate where public water supply enters.the building. -6� 10 ' Page I•I of I I e e OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 58 F Ri VPr Rd. • C1st�svill.® Owner.: ergin Date of I05pectioo: SITE EXAM Slope . Surface water ° Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: _Obtained from system design plans on record • If checked, date of design plan reviewed: Observed site(abuning property/observation hole within 150 (eet.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, stabl's the Igh,gro.und water elevAtion: 0661 �+d i11t� �1 he ifs " IJ' ue.. L) ialft� "JU47—� S faJ Wow-- 04"� t ,1,4 Leaching Pit cct (� I Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimptcf Method Therefore, the vertical.separation distance between the bonom of the leaching pit and the adjusted groundwater table is / feet. , l� II . ' ':+•I'.R.TT�•-n,•f9T,''T 1rn.�mf'n TTn rrn*t dZTT•n:T.R I'.'n'*:Tafr:•naT<TT,'TT Tv T1`vJ T'TO'aTT,7 fPT1 1,owN OF Barnstable BOARD OF HEALTH SU,IISURFACE SFKAGE 0191-V9AL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION , ��, man•Tmr►n+Tt•.1TT.r'rn'.•.r.rrr•r•�• ,1..•�.. . .,I'^�.T',TST„I'N:TTI TIT ITTIT iTT� /^-S•1 r'IITI•V•7TTTR1-'Fm�R* . -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED ." `. STREET ADDRESS ASSESSORS MAP , ;D1QCK AND PARCEL # ' OWNCR' s NAME PA1?T' U - CERTIFICATION NAME OF INSPECTORSUG� COMPANY NAME Joseph P. Macomber &`-t6n. Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 street 11 To1m or clty scat• TIP COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1578 CFR'fI FICATION. STATEMENT I certify that I have personally inspected the sewage disposal system r p _this nddress and that the information reported is true , accurate , and complete as of the time ofiinspection, The inspection was performed and any 'recoinmendatiorls regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of or site sewage disposal systems . -Check one ,' System PASSED The inspection +rhich I have condupted has not found any information which indicates that th.e system fails to adequately protect public health or, the environment as defined in 310 CMR 16 , 303 , Any . failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , J. _ System FAILED* The inspection which I have condircted has found that the system fails t protect the i)ublic health and the environment in accordance with Title 5 , 110 CMR 15 , 3Q3 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection. form., - Inspector Signature . Date _2,.,, .,,, p ' me copy of this .cwrc.! fication must be provided to the OWNER, the BUYER ( where applicable`] and Ghe I30ARD OF HEALTH , * If the inspection• FAILED , tlh� ownor or•.I,operator. ehall upgrade • the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CNR 15 , 3.05 , partd , dc 1 ;SEWAGE INSPECTIONS DATE �OCAMN ' ASSESSOR'S MAP do LOT VIILLAGE INSPBCTOR . CApAC1� SEPTIC TANK (size) LEACIIINO FACIL Y. (ty No.OF BEDROOMS HMDER OR OWNER OWNER MAILING ADDRESS �� ,� � ��� j � � � � ,� r TOWN OF BARNSTABLE 4 ,J LOCATION & R>, t ) SEWAGE # s VILLAGErrtZ ASSESSORS MAP & LOT INSTALLER'S NAME & PHONE NO. /9 ILCW.A-s 7 SEPTIC TANK CAPACITY /.5 b O G,q LEACHING FACILITY:(type) &12 e4r;r Pi 7' (size) 3 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER //7'0 lk�t/e Sy y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f V � d CL � � M d � '\� Ve 2a "No.... L FIER.......7` ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .............OF....... fl/Zn��ST 'QG��r Appliratinn for Disliniial Workii Tonotrar#inn rumit Application is hereby made for a Permit to Construct (V) or Repair an Individual Sewage Disposal System at: ... __ ........................................................................ --••-.................................................•- Location-Address or Lot No. Owner Address a ..._....� -s/.................................................. ............................... Installer Address 3 36 Z d Type of Building Size Lot... 0•_.. ./.................Sq. feet Dwelling—No. of Bedrooms................ .......................Expansion Attic ( ) Garbage Grinder (L,,) `4 Other—Type e of Building ............... No. of ersons...._....._..........__.__.. Showers — Cafeteria a YP g ------------- P ( ) ( ) 04 Other fixtures ..-.-.•-----•-•................... W Design Flow..............SS._.............._.__gallons per person per day. Total daily flow__._.__...._3 30...._........-_-_-_.gallons. WSeptic Tank—Liquid capacity_�-SQ..gallons Length.!a'ta."�.. Width._�'e."._ Diameter................ Depth.. �,.3 x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___.._-.-___.__-- Diameter.._._ 4------- Depth below inlet_.-F..`.......... Total leaching area..3o 7•.!q•.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1-4 Percolation Test Results Performed b (n/. _.... ..........A�gu Date_ G-._. !U_-_�__._._... 1.4 Test Pit No. 1....:4.?n..minutes per inch Depth of Test Pit......1 Depth to ground water......f'B Gi,, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ---•-•--------- -----•-----------•••••••--•--•-••-••-•-••••••.......•••------••----•-----------....---•-•--•-------••.................•---•...._...---.....•. O Description of Soil......G"'_..2-lc...... Wg�A4� ...: .5vO•--SotL ...................................................................... U A-0 //Zo.v ooCCO '4T..�`. �r_ 7-z- 4>47z�e—_ 'sin F'6'Le ........ -------•-••--•-••-•--------•--•..... ............................................ W -•••7Zu-/°gy.... .....!`. ------ a-•- 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 TIT L4 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is-sued by th , oar f he � Signed .........................................-•-- ............................ •... f.-_.... Date Application Approved By...................... .-- -....�... ........... s �� /lam-._... .. Date Application Disapproved for the following reasons:--•-----------•---------------------•-------------------------•------------------------------------------....._ ...........................•-••-•-•---•-••••---•----•••..._......••••-•••-••--•••-•••----•-•-•----------........•-•....••-•.•••••-••••-•-•--•--•••--•-•-•-••-•--•-•-•--••••--•-••----•••••-•••••---...--- Date PermitNo.------..? ........ --Lj•-,�.....•--•----•--- Issued........................................................ Date FzaB.......7s». THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ?oWn1..............OF......, A2n�ST�ljG�' ........................................................................... Appliration for Disposal lVarks Tonotrurtion Vrrmi# Application is hereby made for a Permit to Construct (✓) or Repair (V� an Individual Sewage Disposal System at: E1Z ,e-'Ve 2Z ZIAD l�ST��2 Vi�.G.� Go T ....:...........___--__.---.....------•••--..._........._.................................. .---...._.............-•----••---........._....._.. --..............-----............---•-.•--... Location-Address or Lot No. --114P,o1_D_- ?Ik izAd:/4........................................... . ............................................. .._......- ---------------........_._..... Owner •-.---.Address a - .......... ..ST--•-•-••--•.............•-------------.......... ..............--•--- --.... Installer Address - 301.3� -�--�•�- U Type of Building 3 Size Lot. .Sq. feet U Dwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder (tom C14 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p" Other fixtures ----------------------••-----••----.......................•... Design Flow..............:5.........................._gallons per person per day. Total daily 330 .............................. Septic Tank—Liquid capacity�So..gallons Length.!a.'17...... Width..:�`li?.".. Diameter................ Depth.. s "8 10, x Disposal Trench—No..................... Width.................... Total Length........�........ Total leaching area...................sq. ft. Seepage Pit No.......�........... Diameter.....�¢....._. Depth below inlet-- F.L.......... Total leaching area.............8..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ''" Percolation Test Results Performed by G'Z�In/A?��J �� �� �._....... Date.�/°2iG..Z� Test Pit No. I................minutes per inch Depth of Test Pit...../...__........ Depth to ground water......-..._............... Gil Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-•-•..............•----------••----•---•.....------•---•-••---•-•-•-....._.._......---•-•-•,....-•......................................................... D Description of Soil......A"7 z4._ Wai•�Cal!!�....f...Syt�: -• ---•.-.. ►Y+ /1-n-D //Zo•v axyOG A7- 6y& .�¢.ii� 7Z�� CfiA'lLSI= /Ax.t�... �,C-i ti-w-Z V ................... -------• •••--------- --- -•••-•-••-• -• •-----............••.... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is .tied by the-board.Of4hh�lth_Signed � I:=f � :��.... . ��-.... ......_' !C� Date Application Approved By..................... ..... ..........................�- ........--•---.._. - \! Date Application Disapproved for the following reasons:..........................................................................................................___ ..............•--..................-•---•--.....----.._.......-----...--•--•---........._...----------...-•----...•.....................----•--•---...------------•----•--......--•-----•...••-•-....._ Date PermitNo.•-•-•-..?2.......Ly. .................. Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... 01rr#ifiratr of Tomplittnrr THIS IS TO CERTIFY.. That t e Individual Sewage Disposal System constructed (f/ or Repaired ( ) by................................. �.'.�..:L c. `: ..- .................................................I........-- •••..........--•--•-•-......_........ --..... %: ✓ L. �� I1�� I staller G�3 / /t c at................... f�................•_.... ...••-••••---•--•-•-•-•-••-•-•••-•-••-........-••••---.._.....-•••••-•-.......... . .•-----...._......._..••••-•.......-- --......--••••-•--•- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.............. .... .Y...?'. .. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................................................................•-•-•-•---- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FIM........................ Disposal Works Tono#rnr#ion Vrrmi# X) %z - "'-/ Permissionis hereby granted...-•-•------ ••-•----•-••----•-•..--••••................•-•••-•-•....--•-••-••••-..............::..........................__.. to Construct or Repair ( ) an Individual Sewage Disposal isposal System atNo......................... ......_..... ._..........-•---••-•--••••••-----..._..._..............._••••............. Street r_ as shown on the application for Disposal Works Construction Permit No.. .... "'��ated.......................................... ....... 3.................................................... . Board of Health DATE................ ................................... FORM 1255 A. M. SULKIN, INC., BOSTON i TOWN OF BARNSTABLE LOCATION IFE / Jvri� SEWAGE # — VILIAGE d„j"r-C 4_ IL9' � ASSESSOR'S MAP LOT INSTALLER'S NAME 6z PHONE NO. ptr..-s T SEPTIC TANK CAP$CITY /5 0® 6,,4 1 LEACHING FACTE�TY:(type) 42gt4.rrtnr i ` (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 1110 DL fr/e -ro DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:__ VARIANCE GRANTED: Yes No I_ I d M N t� i . c • Co.�plc:cc by - -- -- f HIGH GROUND-WATER LEVEL COMPUTA11ON y Site Location: EZ- 2/V67Z Z1:9 j e/&7, 7ZI//GL- Lot No. `s Owner: M/I. �1oruGiGSC�✓ Address: Contractor; E J�- �AXTi� L'YL Address V1 L� Notes: STEP 1 Measure depth to water table o nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¢/Z//8P 9 t _ date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and. determine: _ A) Appropri ate index well .7-SI.V. .89_ �/ 7 Z a./E /I B) Water-level range Zone STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well /88 mo yr STEP Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level 444 zone (STEP 2B) determine water-level adjustment . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estivate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 7 7 level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . figure 3 r :OP OF,�FOUNDATION \ \ Vt e CONCRETE COVER �y r CONCRETE COVERS _ _ ! - ` Q L �• � '�0 4"'1 AST IRON 12"MAX. �rrr 12"MAX. OR "C PE SCHEDULE 40 41"SCHEDULE 40 PV.C.(ONLY) •' IP PITtrH I/4"PER.FT PIPE- MIN. LEACH �►� ` \ k' S o PITCH I/4"PER.F7 PIT PRECAST ,p o' 1 a LEACHING 1 ' \-INVERT ` o EL.�3://••- INVERT INVERT e w ' PIT OR — o', SEPTIC TANK /L 5/ DIST. .• EQUIV. '_ 1 I / I : -41 c INVERT EL..... .. . .. BOX*. EL/z:.T.. v � p. fit• I �y /Z 76 Soo iz • -• GAL. INVERT a p e; EL-..-..•...... . . INVERT nt vW :i, 3/4"TO IV J ; r EL/?;off WASHED I � I I 0 __ i- y_� /• — — ° STONE cam.8.5o - ) �� r \ I r- i # .� -- �, , — / 1 t � ' • , 1y �- o•" • _ �-- �¢' DIA — PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE !c' I ti"� �o: /���� O. j► — -- --- %'- C� z I�ij � 1 t t so�c ; fi• /• / .�L — � fit_ C r�r✓.o BQruc � �R%Fs y�SOIL LOG WITNESSED BY : tic Z� /y88 TIME. �°.°U f►'7 .TL72/ZV �vivN/NG BOARD OF HEALTH 4! e � �3• / L — \ ,, LoTAt DATE ! / J I I p2oPoSG�D 1 / zL / TEST HOLE I TEST HOLE 2 ENGINEER . 1 1 17 A�oiTiow i — ELEV. .//. 8o ELEV. .. .. . . . . . . Vj o 24CAC / 'x 4.4• z " sv�-so✓G- DESIGN DATA ' Z' I_____ TAT 3 Co/i72SC NUMBER OF BEDROOMS `7 . .' . . . . . 1 4/ r1 ,5,q.io 330 1!r ------I--- - •Fl-s,c,r o.,r BR22ie� 14-41 _ TOTAL ESTIMATED FLOW . . . . . GALLONS/DAY 1 1 Go its ssji/a BOTTOM LEACHING AREA SO.FT. /PIT/C R.D r��' 1 ! — z3 — 77. SIDE LEACHING AREA . . . �5'3: 9. SO.FT./ PIT/-3848 01'". ZZma — — GARBAGE DISPOSAL . .YG:-�.-(50 % AREA INCREASE) �' / �G�- I`— 1. > , zo S .o TOTAL LEACHING AREA . . .3 7�8 SQ.FT / LESS 7;/Ar-' Tba/o — /og PERCOLATION RATE . . . . . MIN/INCH !oB .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE '`'zioB7SQ.FT-/C,P, z s f c 07iS`/o �\ NUMBER OF LEACHING PITS i APPROVED . -- - . . BOARD OF HEALTH . . . . . . . . . . . . . .����' ��� a.�-1♦ s �, i DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .' � � i ENT OR INSPECTOR ISM OF M ♦ t 1 ,/ i y ' y T o n ' • :eivc- o PL/9A/ OSTL-72!/iGLG—'�• �`7L�• �'�'r�sr ���'�j� - PETITIONER ,92oGD. •7;t/or21C/GS�7�/