HomeMy WebLinkAbout0339 EEL RIVER ROAD - Health 339 Eel River Road
Osterville .N
f,
A= 115-030
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��. Fee
Entered in computer:
HE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftptiLotlon for Construction Permit
r
Application for a Permit to Construct( ) Repair( ) Upgrade(. Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No.-331 EC\Q1VEk RPND Owner's Name,Address,and Tel.No.
oscegvluk,morn �W1Y}I L
Assessor's Map/Parcel 1�5-030
Installer's Na Address,and Tel.0 Desi ner's Name,Address,and Tel.No.
dwce rULC AI,`S I S cP��fd�-5:)J r S`fl`�I�
H2��e„�sT- o:s j �.�,. S US�crv�l �►'lf�- 5o�-4Zf�33yy
Type of Building:
n �
Dwelling No.of Bedrooms�� Lot Size y U13SD sq.ft. Garbage Grinder lid)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)ge1,w -0-?Ok w I
k ptw-W H-Lo SLAM dym trhai PITS Q)
Jute last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certificate of
Compliance has been issued by this Board H lth.
Si ed %? Date
Application Approved by � ._,,� Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued G
: No. 1 Fee �� k
HE COMMONW-EALTH,OF MASSACHUSETTS Entered in computer: Yes
PUBLICItHEALTH DIVISION`TOWN 11OF BARNSTABLE, MASSACHUSETTS
Zipplication for Misp, 41 9ppstrin (Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade(--y"Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No.33 1 G 6 R\VL- Owner's Name,Address,and Tel.No.
on�_:Rv ILL E S5m/}1L �.
Assessor's Map/Parcel \5-03 0
Installer's Name Address,and Tel.No. Desi er's Name,Address,and Tel.No.
U�wC, R0.,,_iI SIC- J�� �IJI'-5�'1� S`�,'�1Y\ ��S�ujCer(\� 1�C'
Type of Building:
-Y
s ft. Garbage Grinder Q)
Dwelling No.of Bedrooms CD Lot Size y�,3 S q. g (H
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
J
Design Flow(min.required) (c(0 gpd Design flow provided gpd
Plan. Date Number of sheets Revision Date
Title
` Size of Septic Tank 6 Type of S.A.S. _
'Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 'RC�Ijt(G �—��
�. ..
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certificate of :
Compliance has been issued by this Bo d H!lth. ,3
PIVAI
ed4441) a Date
Application Approved by ,�� Date
Application,Disapproved by Date
for the following ieasons
Permit No. Date Issued
--------------------- ----------------------- ------
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
I
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaire ;(V) Upgraded,f_�
Abandoned( )by S t-L�C,,Vx t CQ"�,
at `53 Eel kk -er R,,-.k has been conWinacco with the provisions of Title 5 and the for Disposal System Construction Permit No.Installer,^macs. � GCG( S (� Designer , ,_ , , (�� �t
#bedrooms k Approved design4ow .T, n/ gpd
The issuance of this perm h 11 not be c6nstrued as a guarantee that the system wil fa cti�n as designed.
Date pl Ins ector l
Y
No. �043 � &—q Fee lOd
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal *pstem (Construction permit
--•Permission is hereby granted to Construct( )R Repair( ) Upgrade( ) Abandon( )
System located at 33`t Cd f uv
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructi h must b c1oeted within three years of the date of this perinit.
Date / Approved by ,
6//
I
Town of Barnstable
Regulatory Services
Richard V:Scali,:Interim Director
BAMSTaaM
MAM Public Health Division
1639- p�lP
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: a� a a-/3 Sewage Permit# a D(.3-y Assessor's Map\Parcel
Designer: 5��� _ ,�c- Installer: vc t HaeC:r//,6%
Address :L•�X ��`�. : Address:. o
OAT\\Q-, el�u..-
(�S d e
On /,2-cZO- !3 cr ��1G,c c �,S its was issued a permit to install�- /{'d o S�y�S
(date) (installer) /`dew ar'si 3o�C/f-d�
seP464 at 33� C tcrvAg- based on a design drawn by
(address)
dated
( esigner)
certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory. ok L �� cep,, l
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Local Regulations. Plan revision or
certifiedas-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in compliance with the terms
of the IAA approval letters(if applicable) Mgssgc-
�o� JOHN C. yGJ,
z OTDFA
(Installers Signature) CD
No 4.3168
�0 9FGISTER��
FFssl ni i
(Desi er s tune) (Affix Des p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
COMMONWEALTR OF MASSACHUSETTS '
:EXECUTIVE OFFICE,OF ENVIRONMENTAL'AFFAIRS
DEPARTMENT'�OF.ENVIRO'NMENTAL':PF ObTECTION',,
q.
° M TITLE.Sr
®I'FICL4I,:[NgPFCTION FORM-NOT
OT FOR VOLUNTARY.-ASSESSMENTS
- S'U�SgII�FAC:I±.S�,OVAGE•DISI'.OSAL SYST-ElVI
PA
-_ —. _ . - -
CIJI TIFICA-TION
ry
y r
Pi o ee ti Address 39 Eel IZn er Rda
ICI . .. - -
Oster�idle.A14 Q-2b35
- Owii.e,'s Nanie - :Inn:es&`John h`ior lurz-.- -
Owner.'s Address
Date of Inspection: SentemGer lU �U12
Name of.Inspe,ctor:(Please Pant) Junzes'tYl. Ford
Company Name: :, `Ta,nes 1Vl Ford
Mailing Address P..O.Brit 49
Oster•ville,MA 02655-0049
Telephone iVumbe,.:: (50�4J 862=9400
CERTIFICATION STATEMENT
I certifythat I'have personally tnspe.cfed the.se��,age disposal`system at this address acid that the mformauon reported '
p p. ,sp. p. formed based on in}' ,below is true;accurate and c.om lete:as of the hue ofthe inspection.',:The inspection was er
training and.experience m the proper function and maintenance of on ite sewage dis osal s stems I'am a pEP.`
g p i P p g p y
approved systeni:inspectot purs►ant to:Sectron 15.340 of Title�5(310 CA\ R I QOP). ,The'systems
'Passes l
;Conditionally Passes
✓ Needs Fui then Evaluation by the Local Approving Authority
Fails
Inspector's:Signature. Date September 20,2012
The system inspector shall st in a copy of`th,s itispecttori report to'the Approving Autliority.(Boai-d of 1Tealth or
DEP)within 30 days;.of completing this inspect�on. .If the system is.aaharedsystem or has•a desrgn flow of'10,000
d or greater,th inspector and.tlie'system owner shall submit the report to the appropriate:.regioil office of the L
gp... e
DEP. The original''should'be sent to.die system owner,and:copres sent to the bu er;if a hcrble and`the 1 rovuio
authority, w:
Y pp PP a
Notes and Comments
****This'repoo t only describes eondrtions-at the time of inspecti®nunder the costditians ot`:use in that
trine. This inspection does not add ss how the system will perform in the future under the same or different
conditions of use.
Note.'-'The two older original:pits'are under'or on the`edge the driveway:«They are under.the asphalt driveway so I could not
confirm if they are H-20.heavy dut}+loading:The D.box is on the edge of the drrvewiiy and ts'H-1 O:The circular driveway
could have been added after... "
Title 1nslieetion Foiii�.: '6/'15/2000
PT - — s • ,
i - Y
Page 6 of I I
1
OLUNTARY ASSESSMENTS
OFFICIAL INSPECTION FORM NOT FOR V
_.
.,
SUBSURFACE SEA AGE'DISPOSAL'SYSTEM INSPECTION'.FORM '
SYSTEM INFORMAB
Property Address 339 Eel Rwer Road 4 rt"
Osterville :W
Oiviiei, h'torlien J
Date of Inspection-' Septenibe� 10 1012.
--
FT'nW CI�NIILTIO--N
RESIDENTIAL.
r
Number of bedrooms(design);6= -`'Numbe of bedrooms(actual) 6
-:
DESIGN flow based on,31.0;C1vM 15 203 (for example 110_gpd x#.of bedrooms) 660
Number of current:residents:, 0
Does sidence have a garbage grinder(yes or no) N/a
re
Is laundryon-a separate sewage system(yes or no) yes'separate. inspection required].
Laundry system inspected(yes or no): rra
_ Seasonal use-(
yes or no): `no
' Watepr meter readings;if availabl (last 2 yeai=s usage'.(gpd)) Unavtrtlable
Sum Pump(yes or.no). No
Last:'date of occupancy. Unknown
k ;
COMMERCIAL/INDUSTRIAL.
Type of.establishment. F ``
Design flow(based on 310 CMR 15.203) =gpd
Basis of design flow(seats/persons/sglft etc.).; ;
Grease.trap present(yes or no
. :
Industrial waste holdin tank present(yes or no)g
No waste discharged I to the Title S:system.(ye
s or no
Water meter readings,if available: r. "
Last.date of occupancy/use: {
OTIiER,(describe), a
GENERAL:INFOR1b1ATION ;
Pumping Records8
Source of irifoi7nation: Unavailable' - x
Was system pumped as part-of the'inspection"(yes or no)
If yes,volume,.pumped: gallons-=How was.quantity pumped deternuned?
Reason for pumping:
TYPE OF:SVSTEIVI ,
Septic tank;distribution box'soil absorption:sy .
stem ':
Single cesspool '
Overflow cesspool
Pl'1Vy.
Shared system(yes or:no) (if yes,attach previous inspection records,if any)
huiovative/Alternative teclu�ology. Attach a copy of the current operation and maintenance contract.(to be
obtained from system`owner). ,
- Attach Tr ht Tank a co pyofh F
approval
,. Other(describe). :.
t
Approximate age of all'components,date installed(if known)and source of information:
-Date ofinstallatton-`Me never hit i-vas added on jj2'1 9 ycr`as bcalt
Were sewage odors detected when arriving at the site(YeSL or rio): No
i 'a
L�_
, ..
, ..
..,II
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Page 10 of 11 _.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS_ ,
.
- F "
SUBSURFACE W i, . . .SE. G A E LIISPO AL S
- S YSTEA�IINSPECTION
..
I,OR'V
PART C:
SYp T'El1'I:INF®121�1A'I ION(oontmuecl) K
I i opel tti Addl ess 339 Eel R'iver`IPbad I.
W:N _ -Osten�lle.h1�. k k ; ..
__
®�VIICI r "-K10111e11" :::i, A :
P.1 of Inspection Septenilier '!0;2912 . s
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�7�E f�3� 3�d�LE <)ISFflSAL SYSTEAT
r?'0yld�3 SICPtCl2 of rile SCVUagC �IS'�OS11°ySfCin I'ICIl1di1`g* S 0 3t 1 .S+iV'o pe , 1C„t fe,eace ialldiTiariiS of
rbeiiclin�arlcs. Locate`ail�s'ells��'Ithui 1:OU feeu Locate.«'here public water supply enieis the building
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SHOREY 72" COVER
PRECAST
H-20
CONCRETE
PRODUCTS
24" DIA.
WEIGHT=194LBS
r
8„
72 DIA. COVER
72"
WEIGHT = 1550 LBS.
SHOREY PRECAST CONCRETE PRODUCTS
351 Whites Path
S. Yarmouth,MA 02664
(800)439-0965 •(508)760-1070
Bedroom #1
Bedroom #3
Living Room
Bathroom
Kitchen
Laundry
Hall
• Bathroom
Garage
Bedroom #2
4
Bathroom Bedroom #4, Bedroom #5
0
Bedroom #6 Hall o
0
3
Floor Plans
Peter & Maria Smail
339 Eel River Road
f
COMMONWEALTH OF MASSACHUSETTS'
a - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF,ENVIRONMENTAL: PROTECTION
TITLE 5.
i OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION,
Property Address: 339.Eel River Road
Osteiville.MA 02655
Owner's Name: Janes&John Kiorlien �
Owner's Address:
Date of Inspection: " Septeniber 10, 2012
i Name of Inspei:tor: (Please Print) Janies M.Ford:
{ Company Name:. JantesM. Ford
1, Mailing Address: P.O.Box 49
i Oster ille,MA 02655-0049 '
l' Telephone Number: . (508) 862-9400
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 a DEP .
i
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR.15.000).. The system:
t
Passes
Conditionally Passes
✓. Y Needs Further Evaluation by the Local Approving Authority
j Fails
l ,
i Inspector's Signature: Date: . September 20, 2012
The_system inspector shall s it a copy of this imp.ectiori 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
d or rea.ter,the'ins ector and the s stem owner shall submit the report to the appropriate re ional office of the
� gp g p Y 1? g
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and.the approving
authority.
! Notes and Cornments
****This report only describes conditions at t.he'time of inspection and under the conditions of use at that
time. This inspection does not address holy the.system will perform in the future under the same or different
conditions of use.
'r Note-The two older original pits are under or on the edge of the driveway.They are:under the asphalt driveway so I could not
confirm if they are H-20 heavy duty loading.The D-box is on the edge of the driveway and is H-IO.The circular driveway
could have been added after.
Title 5 Inspection Form 6/15/2000 page 1 ( �
` Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR-VOLUNTARY ASSESSMENTS '
SUBSURFACES
EWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 339_Eel River Road
Ostery the MA
Owner: KiOlien . ,
Date of Inspection: September 10, 2012
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 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.i 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�s 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 sewa
ge e backup or break ou
t, r high
h static wa
ter level in thedni distribution
on 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(' 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: '
2 • .
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
'C.ERTIFICATION (continued)
Property Address: 339 Eel River Road
Osterville,MA
Owner: Kiorlien F
Date of Inspection: September 10;2012
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 manfler which will protect public health,safety and the environment:.
Cesspool or privy is within 50 feet of a surfac. 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 within50 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:
*SEE THE FRONT PAGE FOR COMMENTS. t
p
i
Page 4 of 11
OFFICIAL INSPECTION] FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued]
Property Address: 339 Eel River Road
Osterville,MA
Owner: Kiorlieri
Date of Inspection: September.l0, 2012
D. System Failure Criteria applicable to all systems:
You must indicate either"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 groundor 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%z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped i
✓ Any portion.of the SAS,cesspool or privy is below,high ground water elevation.
✓ Any portion of cesspool or privy is within,100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a.cesspool or privy is within a Zone 1 of a public well
✓ Any portion,of a cesspool or privy is within 50 feet of a private water supply well:
✓ Any portion of a cesspool or privy,is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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.]
No (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 systein fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.:
. Y
E. Large System
To be considered a large system the system-must serve a facility with a design flow of 10000 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 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 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 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.
41y
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B ,
CHECKLIST
Property Address: 339 Eel River Road
Osterville,MA
Owner: . Kiorlien
Date of Inspection: September 10, 2012
Check if the following have been done: You.must indicate"yes"or"no"as to each of the followin
i
Yes No
✓ Pumping information was provided by the owner,occupanCor Board bf 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'? a.
✓ _ Were the septic:tank manholes uncovered;opened,and.the interior of the tank inspected for the.condition
of theffl baes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(aiid 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)].
I
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
I! -
Property Address: 339 Eel River Road
i
Osterville,MA
Owner: Kiorlien
Date of Inspection: September 10, 2012
FLOW CONDITIONS -
RESIDENTIAL
Number of bedrooms(design): 6 Number of bedrooms(actual): 6
I, DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): .660
Number of current residents: 0
Does residence have a er rind
garbage g (yes�or`no):` .Ma
I. Is laundry on a separate sewage system(yes'or no): N/a [if yes separate inspection required]
Laundry system inspected(yes or no): no
I Seasonal use(yes or no): no
Water meter readings,if available(last:2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
w ,
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
p Design flow(based on 310 CMR 15.203) gpd
Basis of design flow(seats/persons/sq/ft 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):
GENERAL INFORMATION
Pumping .Recordsa
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons=-How was quantity.pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,,if any)
Innovative/Alternative technology. Attach'a copy of the current operation and maintenance contract(to be
obtained from system owner) '
Tight Tank Attach a copy of the DEP approval
Other.(describe)`. #'
Approximate age of all components,date installed(if known)and source of information:
.Date ofinstallation-the newer pit was added on 5112189 per as-built
Were sewage odors detected when arriving at the site(yes or no): No_
' Page 7 of 11
�. OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART C
SYSTEM INFORMATION'(continued)
Property Address: 339 Eel River Road.
Oster Wle:MA
Owner: Kiorlien
Date of Inspection: September 10.'2'012
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: ._cast iron 40 PVCa other(explain):
Distance from private water supply well or suction line:
;j Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate.on site"plan)"
Depth below grade:, 14" ; 1 t. '
Material of construction: ✓ concrete i__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`. 1500 Qal.
Sludge depth: 2
Distance from top of sludge to bottonfof outlet tee or baffle: 30:'
Scum thickness: 1„
Distance from top of scum to top of outlet tee or baffle: 6."'
Distance from bottom of scum to bottom of outlet tee or baffle: 1011
How were dimensions determined: ' Measuring stick
Comrents(on pumping reco.rn endations,.inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.). .,.
The tees were present. The liquid level was even with the outlet invert There did not aPpwr to be any siins of leakage
F ,
GREASE TRAP: None (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: s{
Comments(on,pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet'invert,,eviderice of leakage,etc.):
tu; 9r
` .i1e 1 1•'t
Page 8 of 11 r
f OFFICIAL INSPECT ION'FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART C
F 'SYSTEM INFORMATION(continued)
Property Address: 339 Eel RN'
er Road
OSterville,MA
Owner: Kiorlien
Date of Inspection: Sevtember'10. 2012
i TIGHT or HOLDING TANK: None (tank in
ust,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 grder(yes or no):
Date.of last pumping:
Comments.(condition of alarm and floatswitclies,etc:):
DISTRIBUTION BOX: ✓ (if present must be.opened)(locate on site plan)
Depth of liquid level above outlet invert,,. Even-
Comments(note if box.is level and distribution to outlets equal,any evidence.of solids carryover,any-evidence of
leakage into or out of box,etc.): r f
The D-Box was'norinal and the cover::is I below. Note The D-boy is ri ht on the ed.e o the drivewa,and is H 101i hi dut
loading.
PUMP CHAMBER: None' (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.)
111
'ilt r ;.E ,
1
Page 9 of .11 1.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 339 Eel River Road
Oste�-ville.`MA
l Owner: Kiorlien`.
Date of Inspection: Seyteinber M-2012
SOIL ABSORPTION SYSTEM(SAS):, (locate on site plan,excavation not required)
If SAS not located explain why: '
r -
Type
leaching pits,number: 3- 1000 gal. nits The wvv&pit has 2'ofstonz hand probed
leaching chambers,number:
leaching galleries, number:
leaching trenches,_number, length:
leaching fields, number, dtfie ions:
overflow cesspool, number:';" ! r
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.):
77ie Pits ivere drv. The two original pits are under or•on the edge of the asphalt drivevvay 77ze»eiver one is'under a bush Then e tivas no sigrz
of failure from the Pits.A camera ivas used to inspect the Pits
CESSPOOLS: None (cesspool%inusl.be pumped as.part of inspection)(locate on site plan)
Number and configuration'r '
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: None`(locate on site plan)
EH 041tte. i
Materials of coristruc"tion: t �'
Dimensions
Depth of solids:` t
i
Comments(note condition of soil;signs of hydraulic failure,level of ponding,condition of vegetation;etc.): '
eE 9,
ti
i
I Page 10,of 11
OFFICIAL`.INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYO :EM INFORMATION (continued).
Property Address: 339 Eel Riven hood
Osterville,MA
Owner: Kior lien'
Date.of Inspection: September 10 2012
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.
lay
- A
p a 3 a3` as
3 S 3S L!►
573
_... ! 1°
. !
i
Page 11 of I I t'
OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 339 Eel River Road
Osterville;MA
Owner: Kiorlien
Date of Inspection: September 10'2012' ,
SITE EXAM
Slope
Surface water
" Check cellar F
Shallow wells
Estimated depth round water •15+/-
P to g V feet.
I
Please indicate (check) all methods used to determine the high groundwater elevation:.
rObtained from system design plans on record-.If checked, date of design plan reviewed:
i' Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked wiih local Board of Health-explain: Topographic and water contours laps
f
Checked,with local,excavators;installers-(attach documentation)
Accessed USGS database-explain.
t
You must describe how you established the high ground water elevation:
Using Barnstable'top raphic'and water'contour's in the maps were showing approximately 15 +/--to ground water at this
r site.
tit
AI JI
,
r
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected.gnd,rzeeds fzu•ther evalzto iorz as of the date of inspection:This report is not a warranty or•guarantee that the system will
ficnctio.rz proper•ly.in the fictzn e There have been.no warranties or guarantees,either expr•essecl, i-vritten or implied,
r elating.to,tthe septic system; the inspectio
n,, this report and/or any components of the septic system.which have not
been located and inspected
E
F
Board of HepW6 b
No.... .. ": Flyannis, Massachusetts 025501 Fmc...........ZQ.,,S)Q....
THE COMMONWEALTH OF MASSACHUSETTS'
BOAR® OF HEALTH
------------Tof1...OF...........OF.........BARNSTABLE--------------_----................................
Appliration for Disposal Works Tomvtrurfiott Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (g)o an Individual Sewage Disposal
System at:
...... 3g.. L�t.RY.ER..R9AD, .OTERVILLE
Location-Address or Lot No.
--....K �R E �I� ��.. ........................................................ .........339 ELL RIVER ROAD, OSTERVILLE
. . ---•--. •........... ...............................
Owner Address
a .._..A._&-_B..CAl�dCO.................................................• --....._.350__MAIN..STREET�..WES.. YARMOUTH-_.._____......_.
Installer Address
Type of Building Size Lot............................Sq. feet
U DwellingNo. of Bedrooms............................................Ex ansion Attic— p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------------------------------------------------------------•------------------•-----------•--------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons:
WSeptic Tank—Liquid capacity............gallons , Length................ Width................ Diameter----------_..... Depth................
x Disposal Trench—No..................... Width.... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by------------------....................................................... Date......................................
Test Pit No. h...:..........minutes per inch Depth of Test Pit.................... Depth to ground water----____-__-__-_--_-__--
ri, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water______...__-____---.___.
9 ......................................................-.....................................................................................................
0 Description of Soil.............................................................................................................................................----------•-•-•-----•-----
x
W
x ----------------------------------- --------------------------------------------------------------------•-------------------------------....----------------•--------------------•-•...................
U Nature of Repairs or Alterations—Answer when applicable._..INSTALL---1OIlO---GAL_.LEACH__P-IT..WJ---STORE........
.... S---MQUIRED---------------------------------------------------------------•---------------------------------------------------...------------------------------------.......---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
`' -•--•-------....-•---•----•-----•-....-
Signed. �.... � .. --BAY- gA--1989---
Date
Application Approved By.......... .ZM44:!s-tft�................................... .........LTI-_1P.....s-?......
Date
Application Disapproved for the following reasons-----------------•-----••---.._......------•-----.....--•------•------------.................................... .
-•.......................................................................•------.....---.......-----...----------------.....-----•-•-----•-•----••------------•------..................................
PermitNo.....9.�-----------------------•--.....----•---..... - Issued.......................................................
------
Date
t
No-----1' 1�. FEs............4).s. -Q..._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------......Tn'".T..�k'...........O F....... P A.."..C.'x.��':T:E
. -------------------------------------------------
Appliration for Disposal Works Tnnstratrtinn antit
Application is hereby made for a Permit to Construct ( ) or Repair (;") an Individual Sewage Disposal
Systein at:
339 RIVEn........................... .................... --••-•------..............---.....-----....------.........--------------...._....-----•--------••-
Location.Address y _ a r or.Lot No.ti
-J0 L:.Ii',, C. J. -,:,L �%1V."_.Z I( ,T;J, vStt:` VILLE
•-----------------•-----------•-•-----------•-•----.....------................--•----•-•-••..-•-•- ..........------------••-•--•-•--•--•-.....--•--•-•................._...._..-•-•--•--•••-•-•....--
Owner Address,
W A �: �t CAiiCO 350 .:.'tt3.. ST-R— , �T Y,^!�'. 'tFT
Installer Address
d Type of Building Size Lot---.------_-------••-_.---Sq. feet
V Dwelling—No. of Bedrooms.................................. .Expansion Attic ( ) Garbage Grinder ( )
�+
Other—T e of Building ---------------------------- No. of ersons..........--..._............ Showers —
a Other—Type g p � ( ) Cafeteria ( )
Otherfixtures ---------------------------------------•---•----------••••-•---•---------••••••----........--•••••••••••••--•••••-•••••--......•...-----•-•••••.......
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length-----------_--- Width................ Diameter.......------.-. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter..----...--......... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
Test Pit No. 1----_---------.minutes per inch Depth of Test Pit.................... Depth to ground water..-.-.----.........--..-
�2;.4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----.-..---------------
94 •-••--••-•••.........•-•••••-•----•-----•-••--•--•-•-••••••••••---•••-•••--•......_----•••-•-.----•-•---------•..........--••---••----------------
----------
0 Description of Soil........................................................................................................................................................................
V ---------------------------------------------------••------•-------••-•--------------•----•-•-•---------•---•---------------------••-------...---------•----------------------------•-••------••----••.
W
U Nature of Repairs or Alterations—Answer when applicable----111 T T,T. 100;? "' l TJAC" ?1" -7/ ST077
all) a.L� •••--•••.
...................................................................................................................•----........................--.........-----.--....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of r T t Lt 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.................................................................... .i iAY 9. 19890
................................
Date
Application Approved BY �� ._ ,4c.,_--------•-•----------------------•- -_.�o.'_..
------T Date
Application Disapproved for the following reasons-------------•---------------------------------•--------•--------------------•------------------••-••--......----
..-••-•••••••-•••---•---••---••••-•--••.......--•--•---••-•-••-•-••••••••-•...•--------------------••-••--•-•-•---------•--•-•-•--•-•••••--•-•-••••--•-----••••••••••---••••--•--•------•••-•--......__.
�(� ` Date
VL Issued Permit No. ......................•----------------._...... .......................................................
Daze
`.JOSLEIN/EB NORRIS THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Wl1,;
..........................................OF.....................................................................................
Trrtif irate of Tomplitanre
THIS 1 TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( - )
by ' f)s--•••--C,��.of�----------------------------------------------------------------------------
at �1-l...__....."'r': _....... •...S ...........&*_!_Inst ller�---•------D ............................................................
has been installed in accordance with the provisions of TIT]14_ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._._.2 .... ....... 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
:UO2LEIV/EB NORi IS BOARD OF HEALTH
T01IN O F............'l1 :: .Ar�LE
................................. ..........-•••••••••••........ 20.00
NO.._..._...• ... FEE...................
Disposal Works Tuonstri ioll rrntit
Permission is hereby granted.........-'_-l.b...... �'G .................................................................................:.......
to Construct ) or Rep�a* ( an Individual Sewage Dis osal stem
at No.. .Cl �� '' `Q't ................
---------•. � 'r L ---------------------•----••--------------------------------
Street
as shown on the application for Disposal Works Construction Permit ... Dated..........................................
.............................................................
DATE................................................................................ Board of Health
FORM 1255 HOSES & WARREN, INC.. PUBLISHERS
TOWN OF BARNSTABLE
_LOCATION 339'FC/ R/1"Z %aD C SEWAGE#
VILLAGE QSTeru.��c ASSESSOR'S MAP&PARCEL /t5- 3O
INSTALLER'S NAME&PHONE NO. 7E, NQ_r_0J L �
SEPTIC TANK CAPACITY /)oq.41 (,gyi1 the 1)
LEACHING FACILITY:(type) Pr,cc,gJT'(� (.c C3 (size).3-/DOG `(i
NO. OF BEDROOMS
OWNER
PERMIT DATE: /.)--a c-(3 COMPLIANCE DATE:. (a- yals
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
Ro ih t -
. L
i�_�
o
3 ac s,. Alf
S
3s6--Sy,dV Sao
�� �ewyaosf�ds
TOWN OF BpAJRNSTABLE
Z,OCATION 3�"\ �C�I �UL( IBC SEWAGE#
(VILLAGE 0 S1Zr\,J6, ASSESSOR'S MAP&PARCEL. t 15 d 30
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY S� '
LEACHING FACILITY:(type) l (size)3 rMAU
NO.OF BEDROOMS
OWNER K,O( W\
PERMIT DATE: 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 Tns e,r,Ti u J Ford 1 10 I a-
front A �
► 1o" 13 0
O a 3 a36 a
3 S 35 IT
mAj
(o
S
Ae.T�
TOWN OF BARNSTABLE
LOC;hT ON Vf ee/ A-ye-f 9P &dgnSZAeoe, SEWAGE
VILLAGE Vi Aa- ASSESSOR'S MAP & LoT 5 0 30
INSTALLER'S iiAME & P:iONE NO.X-,4' 6 64nco
SEPTIC TANK CAPACITY p __
LEACHING FACILITY:(tgpe). � ®' (size) 4, &uo
NO..OF BEDROOMS PRIVATE WELL OR PUBLIC. WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COLiPLIANCE ISSUE::
VARIANCE GRANTED: Yes No ��
M
V "'
II/
J `
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION ;;eel oe1 rice Ri?,.&=-/o /e_ SEWAGE # 1�1-
VILLAGE Ajj& Vt'�_ ASSESSOR'S MAP LOT
'. 'INSTALLER'S NAME & PHONE NO./-•"',6 e-,#Aco
SEPTIC TANK CAPACITY D
LEACHING FACILITY:(type) •/' (size) A�X�
'NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No r�
60
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=115030&seq=1 8/30/2012
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ASSESSORS REF. � A ti - > f '
g OVERLAY DISTRICT: 1 Panel 30 1.) The structures shown were • located :on- the round. r; /
v methods on 2Q SEP 12 '
b conventional sur eY j . <. AP ;` Aquifer Protection` District /�'
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Map 1 5
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2 The ro ert: . Ime information shown hereon .was
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vailable •record informatloh. _ - FLOOD ZONE ( )
:compiled. from. a : I` .' .'. . - - tF ' ,� � o,: -
Zone A11 :& B (seep )
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, . �o. __..._. _ used for constructton layout or. d.e,ed .: p .. 1u1 :,2, 1992 �.
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