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HomeMy WebLinkAbout0390 EEL RIVER ROAD - Health 390e1°River Road- Osterville i►��� ;.. - - A =11:5 -014 I� �I TOWN OF BARNSTABLE UNDERGROUND FUEL-AND CHEMICAL STORAGE SYSTEMS of ASSESSORS MAP NO. / PARCEL NO.- ADDRESS! VILLAGE: Od'rc`R vi 4 L E 14AME;.-.. K o/?Oc�.y . ..._.. _. d CONTACT PERSON PHONE NUMBER LOCATION OF TANKS:. - CAPACITY: .TYPE OF. FUEL AGE: TYPE: LEAK OR CHEMICAL: SYSTEM!.DETECTION--- DATE OF PURCHASE OF EACH: 1. /9 .60 2.. 3. 4. S. 'DATE OF FIRE DEPARTMENT PERMIT: ? .TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. /yD v,s'E' .8u,�iF e �� �'ARAGL k OWN OF BARNSTABLE LOCATION ,t�r�Q SEWAGE# ,3.CJ(Q— J�PZ `JILLAGE� J f,- tom. 2 0�SSESSOR'S MAP&PARCEL QS"L—&,J0 y INSTALLER'S NAME&PHONE NO�- C. I • SEPTIC TANK CAPACITY p. LEACHING FACILITY. (size) J.4!J0°k ."_ NO.OF BEDROOMS OWNER PERMIT DATE: L -[I COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -sf- S Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) �I[ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ",'", Feet FURNISHED BY Xcr,0" Or O,P O� fir- (�0 6 • c�_ y J`, v7� y 0.2- 1-7' e j,_ is-9' 1J3- cc iy6�• . o+' 6.0 _ 1 t. TOWN OF BARNSTABLE LOCATION 3-Q lO �e,( .('1y bf SEWAGE# fi-VILLAGE 0STfV1J1t_ ASSESSOR'S MAP&PARCEL S— O I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S0 0 LEACHING FACILITY:(type) 0 �/��'1(T�A OfS (size) X1'0A Wy AdV NO.OF BEDROOMS .S ?v lA 0 0n cif.. OWNER SM-1po\ 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 B (, m a I o on I a3 Sa 3 a ag sy 3 as y y ay 39 s 31 as I Commonwealth of Massachusetts .►� Tit le 5 Official Inspection - Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 390 Eel River Road IM I, Property Address Tim Smith r Owner Owner's Name r. information is ✓ MA 02655 12-10-18 required for every OSterville page. City/Town State Zip Code Date of Inspection ;, . Inspection results must be submitted on this form. Inspection forms may not be altered in any' way. Please see completeness checklist at the end of the form. \\`�1Unnlumn,,, Important:When A. Inspector Information filling out forms •1 3 ``�� ••' 9�, �, on the computer, a o; `•yG use only the tab James D.Sears s: _JA M ES N key to move your Name of Inspector =00 SEARS ca cursor-do not Capewide Enterprises use the return -a key. Company Name .� T�•.,RTIC �o\��� �-h153 Commercial Street '''�ii F 5 I N S?�V\\\`�� ICI Company Address mlunnt Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number - B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12-12-18 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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 i— c Commonwealth of Massachusetts = Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: The system is a 1500 Gal.Tank D Box and three chambers. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or riot) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osterville MA 02655 12-10-18 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 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(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y .-❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Lv Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form l,a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in anjaped is less than 6" below invert or available volume is less than '/z day flow ..Wch/iw6 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates,absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,00o gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 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. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osterville MA 02655 12-10-18 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? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has . been determined based on: ® ❑ , Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: 1500 Gal. Tank D Box and three chamber's. , f Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2016-326,000Gal g y g (gp ))' 2017-180,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road �r Property Address Tim Smith Owner Owner's Name information is required for every Osterville MA 02655 12-10-18 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 L cam, Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every �Osterville MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Tank NA/Leaching 2013 permit#2013 - 12. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 33" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): _Peeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 23" 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. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 23" below grade w/both covers at 5". In and outlet Tee's. No sign of leakage or overloading. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every ,Osterville MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 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 is 20"xW'-40" below grade w/cover at 8". Box is clean and solid w/three lines out. No sign of over loading or solid carry over. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osterville MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ 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: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t8insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 390 Eel River Road Property Address Tim Smith Owner Owners Name information is required for every Osterville MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three 500 Gal. dry well chamber's. Chamber's at 40" below grade w/cover at 13'. Chamber's are dry-clean like new. 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Fis Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is Osterville MA 02655 12-10-18 requiredd for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form" Fla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osterville MA 02655 12-10-18 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 l t . Ili 0 97 , N t5insp.doc•rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 390 Eel River Road Property Address Tim Smith Owner Owner's Name information is required for every Osteryille MA 02655 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 10, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Auger T.H.10' no G.W..T.H.at 4' below bottom of chamber's. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form .� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 390 Eel River Road `J Property Address Tim Smith Owner Owner's Name information is required for every Osterville MA 02655 12-10-18 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 -T. y. �o� d GZ.A/ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I No. I D�Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLAtion for ;Disposaf *pstem Construction Permit Application for a Permit to Construct( Repair( ) -Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. '7� Q2f t � Owner's Name,Address,and Tel.No. ) Assessor's Map/Parcel �J �j , h - Installer's Name,Address,and Tel.No. / Designer's Name,Address,and Tel.No. /On 4 �, ����✓ ce ! � eCo PL1f Type of B ding: Dwelling No.of Bedrooms Lot Size 7ZO sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _1S92 gpd Design flow provided ��"�C7 gpd Plan Date Number of sheets Revision Date Title L, Size of Septic Tank /5-co Tr�=n /� Type of S.A.S. k. eZ Aon 6f,,)In Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of eal Signed Date ^ ` Application Approved by Date J/ �/ Application Disapproved by Date for the following reasons Permit No. . '— / Date Issued lit No. /r O 1Z Fee + THE COMMONWEALTH,OEXASSACHUSETTS Entered in computer: ,PUBLIC HEALTH DIVISION,- TOW . OP-BARNSTABLE, MASSACHUSETTS Yes 01pplicatlon for Vspo8AfL e;tim Construction Permit Application for a Permit to Construct(Ve Repair( ) Upgrade( ).;Abandon( ) ❑Complete System ❑Individual Components , Location Address or Lot No. D Qe� 1 Lp r (Z,( Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1+ Type of Building: Dwelling •No.of Bedrooms Z F-r Lot Size 7ZO sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow(min.required) (] gpd Design flow provided 5 C; gpd Plan Date Number of sheets Revision Date Title L/ Size of Septic Tank �;(� 1 (�_ Type of S.A.S. 7 1,7 k f� �3C� �c�. �Pr�Y,��*1f�✓j Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of E Compliance has been issued by this Board of eal v Signed ! Date Application Approved by Date �/ �l Application Disapproved by Date for the following reasons Permit No. Date Issued / �� l ------------- ------------ - `_=- - - - -= --------- ----- --- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance, - THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( Repaired ) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Ng.:j /3 —ZVO--dated ) ) /1 /, . -_—Installer Tb.,v4 �r';�<_/I✓.s - -- Designer PCa kc kc- Qi1J #bedrooms } Approved design flo� , gpd The issuance f this erry�it shall not be construed as a guarantee that the system w l fun on as desigped:- Date I 02-D t 1,- Inspector No. 13 ����-• Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposa 6pstem Construction Permit Permission is hereby granted to Construct Repair( Upgrade( ) Abandon( ) System located at ' e i u-� r GL 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:Construction rust completed within three years of the date of this pe Date i I I 1 Approved by TOWN OF BARNSTABLE k " LOCATION'^ /rC� '�'I I�tVe/' ;' SEWAGE# li� -VILLAGE `. ASSESSOR'S /MAP&PARCEL INSTALLER'S NAME&PHOTsMiN iL'P lr� d�f�rJr i SEPTIC TANK CAPACITY s: LEACHING FACILITY:(type). . 3 ' S(X; 6J (� r(size) I.} q?— k NO.OF BEDROOMS OWNER S►'� �'� PERMIT DATE: COMPLIANCE DATE: ` Separation Distance Between the: II <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 }, P G cov �3 l R3 - 17 ' � �.,r f - • ot� Town of Barnstable P# ' ' Departinnent of Regulatory Services r;&MffrABLA i Public Health Division Date�" 1, 2-0MAM 200 Main Street,Hyannis MA 02601 Date Scheduled Time / � Fee Pd. Soil Suitability Assessment for S e Disposal Performed By: Witnessed By: LOCATION& GENERAL INFORMATION Location Address /� t / 0 C� , 2 E v 2 Owner's Name (z�Mjc�'(� lto/c -I ©S_�a rV a Address 1er v e e l c-r ✓,2 r 2-1 Assessor's Map/Parcel: 'l ©5/ t !/�4 Engineer's Name ccd .— r Qabl NEW CONSTRUCTION V REPAIR ✓ Telephone# rS�e-6- 3 C G d ¢ Land Use Res i J e Y\+I et•( Slopes(` ) © Surface Stones C9 A e. Distances from: Open Water Body `d D + ft Possible Wet Area too Drinking Water Well d®'�_ft Drainage Way 5L ft Property Line 1� � ft Other ft SIMTCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) 1,1.7 . 2A N LOT 61 Parent material(geologic) 1 C(C1 l out LAS h Depth to Bedrock n� Depth to Groundwater. Standing Water in Hole: D Weeping from Pit Fpee Estimated Seasonal High Groundwater 2 J- ':o DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: S V rVey i h S+1-y M e y+ l fie tra i n Depth Observed standing in obs.hole: n Oh a -11 Depth to soil mottles: In. Depth to weeping from side of obs.hole: In, Groundwater Adj481ment Index Well#MIV- Reading Date: 12 201 Index Well,level q.t Adf,thctor 'Za 2, Adj.Groundwater Level v&V 1iA PERCOLATION TEST We Uw 1T5 que t©�j Observation 1 �� Hole# A / Tinto at 9" 21-C, Depth of Perc t +1 h Time at 6" H l�I H[ � V Start Pre-soak Time @ 6 '0 0 -0 a Tima(9"-6") End Pre-soak Rate Min./Inch h1 P( i!1 P t s� �;Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) ±`mj o�QriginaL�Public Health Division ` 'Observtition Hole Data To Be Completed on Back---------- C. t%aV ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1) week prior to beginning. J r?U Q:ISEPCIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# i A Depth from Soil Horizon Soil Texture .Sdil Color Soil- Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Corlsistency,%(3ravel) �3( Loolyn7 Gr44 f0 fa jCl �rigbtP —56 12G C 94.v sm Cxri4 10 .R to 4, t1 Loo s DEEP OBSERVATION HOLE LOG Hole# l f_3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis en %Gravel) 0-4 AP vn IovF- 3 Vf;abtp 36 -12G C- Uum 15444 10Yi?- 6/- tt Loose DEEP OBSERVATION HOLE LOG Hole# 'L Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsistencLO c DEEP OBSERVATION HOLE LOG Hole# 2 B Depth from Soil Horizon Soil Texture a Soil Color Soil Other Surface(in.) (USDA) f�T (Munsell) Mottling (Structure,Stories;Boulders. Cositn ®-l� mhkl LoAll 2�z �0t7 i b Id '3 Lo Mi, 10 It f0 Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No %/ Yes. . Within 100 year flood boundary No.V/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? 4Q S If not,what is the depth of naturally occurring pervious material? Certification 1 I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,a pertise and experience described in 10 CMR 15.017. H OF 4q q. Signaturelw� � � Datb `�c'h ' o DAVID ygr `��, o D. " COUGHANOWIR 4 go t: Q:15_EPTICTERCPORM.DOC• Ev s0� A L �&�uP 0� Town of Barnstable. oFWE roy� - Regulatory Services Thomas F. Geiler,Director } BAB MBLE. Y Public Health Division MASS iOTB039. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 5508-790-6304 Date: u C + 201-3 Sewage Permit# d Assessor's Map/Parcel Installer& Designer Certification Form F Designer: 1J�y+� `, CoJl��t�Voc•J� D�Installer: Address: �rl CI h l N Ci T Address: 1�;CiPI4 W IC� D�563 On "� 13 t 2— was issued a permit to install a (date) (installer) septic system at 10 E0-1 R10"r R094 based on a design drawn by c� (address) 1JaVi� �J`, COv��►�1vi.Dral6 .ILSdated lGm �ldd 2-01 (designer) -- I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify"that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout'(if req i ' spected and the soils re fo d satisfac� __--- -- -- � � OF'�ssgc DAVID y�v' o D. a COUGHANOWR N (In aller's Signature) . No. 1093 I FG/STe- ��. sgNl TARIPN (Designer's Signature) (Affix Desig tamp 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. gAoffice formsWesignercertification form.doc I ! COMMONWEALTH .OF MASSACH'USETTS a: EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF,ENVIRONMENTAL:PROTECTION. TITLE`-5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 390 Eel River Road Osterville.MA 02655 I 13 f Owner's Name: Elizabeth Smith Owner's Address: Date of Inspection: December 22: 2072 Name of Inspector: (Please Print) Lames M.Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville.MA :02655-0049 Telephone Number: . (508)862-9400 CF�RTIFICATION STATEMENT . -4 I cZtify that I have personally.inspected the sewage disposal system at this address and that the information reported r,LI . below is true,jecurate and complete as of the time of the inspection. The inspection was performed based on my ' Cn tra ing and experience in the proper function and maintenance of on site sewage_disposal systems. I am a DEP a roved system inspector pursuant to Sectioni15:340 of Title 5' 310 CMR 15.000 The s stem:ifP Y P. P ( )• y Pl r Passes Conditionally.Passes o`er Beds Further Evaluation by the Local Approving Authority r, F ils f-- �,� • Inspector's Signature: Date: December 31,.2012 The system inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or. DEP)within 30 days of completing this inspection. If the system is a shared systemor 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 a 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 same or different t conditions of use. Title 5 Inspection Fonn 6/15/2000 page 1 . ;. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART A CERTIFICATION (continued) " Property Address: 390 Eel River Road Osterville,M.4 Owner: Elizabeth Smith Date of Inspection: December 22, 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: s ' t B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years'old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s),or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken'pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: ; The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will . pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: . i 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'CERTIFICATION (continued) Property Address: 390 Eel River.Road . ............... ,-.. Osterville.MA — Owner: Elizabeth Smith Date of Inspection: December 22, 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 manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 apd 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 3 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM tl PART A CERTIFICATION (continued) Property Address: 390 Eel River Road Osterville.MA Owner: Elizabeth Smith Date of Inspection: December 22, 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 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%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 elevatiori. . ✓ Any portion of cesspool of 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 system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the systel must serve a facility with a design flow of 10,000 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 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 i Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 390 Eel River Road r Osterville.MA' Owner: Elizabeth Smitk Date of Inspection: December 22, 2012 Check if the following have been done: Youlmust indicate"yes"or"no"as to each of the following- Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health v' 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? N/a _ 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 9.igns of breakout? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal sys'tems'? 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 390 Eel River Road Osterville.MA Owner: Elizabeth Smith Date of Inspection: December 22.'2012 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 ` Does residence have a garbage grinder(yes'or no): My Is laundry on a separate sewage system(yes or no): N/a [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use(yes or no): no Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: 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 Records Source of information: Unknown " Was system pumped as part of the inspection(yes or no): If yes,volume pumped: sallons--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.in'stalled(if known)and source of information: Date of installation - 1996 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 1 OFFICIAL INSPECTION YORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 390 Eel River Road Osterville,MA Owner: Elizabeth Smith Date of Inspection: December 22, 2012 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). The Tees were present. The liquid level was even with the outlet invert. There did not avpear to be any signs of leakage The covers were 3" below grade.Note:all Plumbing goes to the tank front cesspool has been abandoned 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: Comments(on pumping recommendations,inlet and•outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 390 Eel River Road Osterville,MA Owner: Elizabeth Smith Date of Inspection: December 22, 2012 TIGHT or,HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: f Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no)- Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): F ' DISTRIBUTION BOX: ✓ (if present must be opened),(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-boy was normal. The cover was 24'ibelow grade.Recommend a riser be installed 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.): � r I . 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 390 Eel River Road Osterville.MA' , Owner: Elizabeth Smith Date of Inspection: December 22. 2012 SOIL ABSORPTION SYSTEM(SAS): ✓' (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: # a ✓ leaching chambers,number: - 8-infiltrators with Y ofstone and 14"ofstone under.Per info leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The Infiltrators were dry. There did not appear to be any signs of failure A camera was used for the inspection CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert; Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition.of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)' 9 ' 7 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 390 Eel River Road Osterville.MA Owner: Elizabeth Smith . Date of Inspection: December 22, 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. Ask ' 13r i ctS A t G. � Y+s APP• �OGArip^ a C , . . aagsy - , y ay 39 c s 3� a8 4 . 10 r ' Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 390 Eel River Road Osterville.MAC Owner: Elizabeth Smith Date of Inspection: December 22, 2012 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 18+1- feet Please indicate (check) all methods used to determine the high ground water elevation: 1 Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health'explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: r : You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 18 +/-to ground water at this site. s j This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. Therehave been no warranties or guarantees,either expressed, written or implied, relating to the septic system, the inspection,this report and/or any components of the septic system which have not been located and inspected. 11 f � _ ASSESSORS Iw" Q.W No. PARCS NO: THE COMMONWEALTH OF MASSACHUSETTS �'�`�, PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for �Digo!01 bpelem Construction Vertnit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. 3 y D �� t(/� �eP Owner's Name,Address and Tel.No. Assessor's Map/Parcel O �- Lou W`v 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. a Type of Building: jDwelling No.of Bedrooms S Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow C--Y—n gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterationsnswer when applicable) I�—o/C) 'Sc e j c_ ��w /u' O s...4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by �oard of Health. `. I Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. �` �� Date Issued �Q i No. � � Fee x THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Miopo.5al 6potem Cottotructiott Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. U 1-0 + ✓e t. R rJ Owner's Name,Address and Tel.No. Assessor's Map/Parcel /&`?` g ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 00 NL . lkr� P,r V! <G, a a Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers(� ) Cafeteria( ) Other Fixtures F R Design Flow S- gallons per day. Calculated daily,flow gallons. Plan Date Number of sheets Revision Date Title y Description of Soil k Nature of Repairs or Alterations nswer when applicable) %J 0 c-' .l ✓� f / 7 �"� ,�'�G J.. r ir�f sue. �, rC/ .} .11, 4 Date last inspected: �- .t , Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued by oard of Health. Signed Date Application Approved by If7 42Z Date Application Disapproved for the following reasons i Permit No. Date Issued 4 ------ —�p �-------- —.E--------. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif irate of (tompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( L,-)or repaired/replaced( )on � by Installer P61"V e ,A 4-t. at S 1 e c`c / A ter has-been� constructed in accordance with the provisions of Title 5 and the for Disposal System Construction rmit No. dated " Date Inspector`'R THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS migozal bpgtem Conotruction Permit + Permission is hereby granted to r '� �� / to construct )re, air( n-site Sewage System located at No.# .•P4 / l Street ., .�and as described in the above Application for Disposal System Construction Permit. y 0 N , Here The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be complete ithin three years of the date below; Date: F1eK Approvedayy l,��, Board of Health 9 /f I f CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, , hereby certify that the application for disposal works construction permit signed b me dated , concerning the P gn Y ti property located at Z o �G l A7 v� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNED : DATE: . Z� LICENSED EPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. ra z � �d Oc— cj� c , . ^� f/ I TOWN OF BARNSTABLE LC{%ATION X, SEWAGE # VL`,LAGE S '�"`��'� ' ' �'� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,LEACHING FACILITY: (type) cis }oe 0 S (size) NO.OF BEDROOMS �-'`BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by ! r^^�� ( � �. ^1f� Y�L )01 - TOWN OFF B,ARNSTA/BBLLE ®1� LOC,A►1 ION — � � � `�'' �`� SEWAGE ##EO/- �7 VB, �`►GE � � ASSESSOR'S MAP & LOT�� " IN-STALLER'S NAME&PHONE NO. q C TANK CAPACITY i HING FACILITY: (type) .-,? ).OF BEDROOMS ui1II.DER OR OWNER PERMITDATE: ��� � � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of ching facility). Feet Furnished by keloo, TROY WILLIAMS � MA SEPTIC INSPECTIONS R `� 1996 r� Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 conynorwvealth of MOSSOC usetts Executbe Office of Envkof mental Affalm Department of • Environmental Protection VAISIsm F.Weld °i"d B.Strubs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ,3't+0 E.- Address of Owner. Date of Inspection: 31,1 �g 6 (If different) Nana of Inspector— /'C+y Company Name,Address a(nd Telephone Number: Gg 5<-C- Ubo . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection..The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a'copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI `SYSTEM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: 1\1114 One or more system components need to be replaced or repaired. The system, upon completion of the reptacemocrst or repair, passes inspection. Ind-cate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all Instances. If'not determined', explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, a tank failure is imminent. The system will pass inspection if the exiuing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 1 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: c� 9 0 L c/ v— Owner: Date of Inspection: KO�pG� B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: All', Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within SO 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The Svctem has a septic tank ano soli aosorption system and is within 100 feel to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within SO feet of a private water supply well. The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPm- tl) SYSTEM FAILS: N11- I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool revised 8/15/951 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3� G r- Owner: Date of Inspection: DI SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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 dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: /,(///? The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 If of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/9S) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: O C o< e✓ Owner: Kv e Date of Inspection: Check'if the following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. vot�a'-¢ b ho5. None of the system components have been pumped for at least two weeks and the system has been receiving nemru1. kwj� cator. during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. "//?As built plans have been obtained and examined. Note if they are not available with WA. _he facility or dwelling was inspected for signs of sewage back-up. V/T The system does not receive non-sanitary or industrial waste flow ✓he site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been /located on the site. FIOL.TCL-SS�OO i Av— % LN'Tti C✓I I� G4J I/l NOT 43C. /o C/l'�C� 3� CKGVS C-LA N+C AM S A14 The septic tank manholes(were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility ownp• (a-d occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 570 r et l /l;v-s— Owner: KD�,oca Date of Inspection: 3 FLOW CONDITIONS RESIDENTIAL: Design flow: 5,qb allons Number of bedrooms: Number of current residents: 0 Garbage grinder (yes or no): iVo Laundry connected to system (yes or no):WS Seasonal use (yes or no):_I,/o Water meter readings, if available: /S, o ov 9y Last date of occupancy: , a -.+- qr.j. kS COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: eallons/day Grease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title. S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Nc.,-j"'-)—,&., 1. h s �b`* tetra i u�,1, ,4- it, System pumped as pan of inspection: (yes or no)L/d If yes, volume pumped _ rallons 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) Other (explain) APPROXIMATE AGE of all components, date installed,(i(known) and source of information: ��y��o� s <A r e- Sewage odors detected when arriving at the site: (yes or no) A/v [revised 8/15/951 S f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3y6 Owner: Date of Inspection: 3/6 C SEPTIC TANK: /Vtll (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance.from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:J,/�/ (locate on site plan) Depth below grade: material of construction: _concrete _metal _FRP _other(explain) Dimensions: scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of crtirn t- honor- of MOP! tee or banie Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. et(.) revised 8/15/95) 6 SUBSURFACE SEWAGE A E DISPOSAL SPOSAL SYSTEM INSPECTION FORM PART C ri SYSTEM INFORMATION (continued) Property Address: 3 / L'e-l �{•V e,✓ Owner. V pp G.H Date of Inspection: 3 TIGHT OR HOLDING TANK: /V/4 (locate on site plan) Depth below grade: material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gal Ions Design flow: —gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: A /9 ;locate on site plan) Depth of liquid level above outlet invert: Comments: mote if level and distribution is equal, e\idence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:�/9 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/1s/9s) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ PART C SYSTEM INFORMATION (continued) Property Address: 370F�.�-�{;��.,i Owner: Date of I KO le Inspection: 3/6/y G SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) if not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:6 Comments: (note condition of soil, signs of hydraulic/failure, level of ponding, condition of vegetatiion,etc.)_ •So t' w4 S CA-✓.,} S O h t r_ i/ �.. y� �✓�i o✓ CESSPOOLS: ,locate on site plan) 'umber and configuration: n,.`,ti GLS S u✓f f �ti L ( �Ur+ �0✓� 7K�� a AV'I i 1, b"�� Depth-top of liquid to inlet invert: G Depth of solids layer: S- " Depth of scum layer: IVO Dimensions of cesspool: 4' ' CEO /q x 6 ' i N ✓�-+. "aterials of construction: Z'a I o ndication of groundwateV_ o/y,_ inflow (cesspool must be pumped as part of inspection) /�� �r, �, c s c w s w .. , �� 4— �v (•,C S S ,a o o/ ems. i ti i t�-r ,� 7"r. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 046— ' _ r�i �e-�. W" S �7 /11 ✓✓✓t $ cti� J In o`J--✓��� v-! S l7 of w ✓ ` /J'rt . C L. �� a wG� !n o / h N G - t/✓r� /G / ; S �t t 7*'CGySPcol i(� If�c/ U`rdJSf-�.,y Ulf eyC�4_5. �/ia� ✓�`�w horn, ! Gi��✓� Sfs..,C�s d�fcr�+„c FZ }1f'Y• ,"�'` �.c.r�- > p a f !3N- 1, L u C c,r.:o.✓�,..+-'O�-, o,v l c l C-c S I 1 V L G V.L 4-0 locate on site plan) J` /y i✓; 1'� h o .✓��t�. ?z� 6� �vt✓�. �f , materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 8/15/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) + Property Address: 3 0 Ownen Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 3` 9y 6 3Y 3 s ' DEPTH TO GROUNDWATER JySy 1,tx)��Jo.lL, Depth to groundwater: " feet adjusted high groundwater level ,method of determination or approximation: E-�-c�c :mot c� � G cr c 11 J-'D O Gl,' C1� -Ta v h c� J .� v�w t !�t 44, l GSJL �• irevised 8/15/95) 9 ;" NOTE C14 BENCH MARK 0 o SEWER PIPE FROM NEW ADDITION TO RUN 10 TOP OF CONC BOUND STRAIGHT INTO SEPTIC TANK AS SHOWN. 21 117.80��� } ELEVATION = 20.46 FOR ANY OTHER ROUTING PROVIDE \ R, s N 0v¢ - 0 BARNSTABLE GIS DATUM CLEANOUTS TO GRADE AT BENDS. o s O 0 a CIO �Ia� p �(7 �p p NOT r �i y to / fyt \ �? TO SCALE w> _ w ' / r` POpD AVENUE w a :.: ;... O a 20-0 \ LOCUS 090 a 0 0 (Lu Lu w Z TP-2A 4 L V f t X 12.83 f l X 2 f t m N SAP OSTERVILLE. MA a N a° -- > o 0 ; G I8-P TP-2B E o LEACHING GALLERY aLOCUS 0 0 w w -SEE DETAIL ON BACK \ MINIMAL cr (� \ /�� L�1 z N TP-,A o ` CONTOURS GRADING V > 0 c-) R 0 ® \ 40-PROPOSED pp `A EXISTING 1-4p OO X �� � J CV a 2 ' 13 ft r••••..I--Z a Q Lu Z a — GARBAGE GRINDER Q� c� ~ / 1 IS NOT ALLOWED LEGEND j /� /�Q �v ON i0 -EXISTI,NN WITH THIS DESIGN L� L� G E V D Lu EA oTEM TEST PIT cc Za - i -• EXISTING . ,,, :�; �• DECIDUOUS CONIFEROUS vn Y } ;�. • :�: 2 •E•� ISOO . GALLON TREE q p TREE za M .� I ;aC Q: ° rr O o00 J Go ,� ,• •, ./ SEPTIC TANK don I2-M GIz-P w Q ran LA '- _ I ;/ { P2- -NUMBER REFERS TO DIAMETER IN O Oa 0 r� a ,,,/// •.•••'•-• INCHES. LETTER DENOTES TYPE. D w Z_ QQ •.•• ®CL O-OAK M-MAPLE P-PINE C-CEDAR w 2 LL ' FIR ••®'• ZLn per, - A L ANAL i � AREA " 0= I—a I R \� LOT 61 \� z -O Ln m N / 1 Bf)pROO�iI [I v 1AREA DEPIC TED Z Lu (�' ,^` Q O - 56720 sf +- 0 z� I ,� w / \ 5 UNE I �La N 0� +(D L_ •o / V vv FNpN , G GA ry O + � � W 'n \ 1 TOP 2.8� 21 > 20 x I \ 22 t EL = 2 / lk� \ j qb�� / PO O / \ 0 o 24.57 w L. O ' Q`�J \�' n pRIVEWAY EEC R ` �t Z J I / O STONE/ VER 80AD ALP � � � a Eli ��, �� a 0 e O m �0 o / `' - m CC �— SCALE: I in = 20 f t Be lu� Z o cII. Od ° 1 `" P D. o a / F �tj Vt- jH of ®- Teo SEWAGE DISPOSAL SYSTEM PLAN Q + / _� gcti w �� SIR -TO SERVE EXISTING DWELLING Srl . . I �o DAViD �� o� DAVID o D. �, �� �, EST ELIZABETH SMITH ET ALS 0 04 1 COUGHANOWR m D. n OWNERISI OF RECORD W COUGHANOWR N PL A N No. 1093 0 1995 390 EEL POND ROAD 00 zpy� 'n z z "p IqZ'. N s� 0, o 41C N G� OSTERVILLE. MA ¢OOQ`�`�� k - W W �®NNI�� PROPERTY ADDRESS n SCALE: l in 20 ft i H E. `�I ~ W pt o r`l (0 . ASSESSORS MAP I IS PARCEL 14 20 O 20 4.40 THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM 43 TRIANGLE CIRCLE DEPICTED ON IT. FOR ANY-OTHER CHANGES TO THE PROPERTY INCLUDING SANDWICH MA 02563 DATE. JANUARY 10, 2013 0 10 26 PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER-1 SHOULD CONSULT WITH A MASS.ACHUSETTS REGISTERED LAND SURVEYOR. 508 364-0894 ,foe ,ETE-3686 I PH 112 VERSION(1 O O S7 O DA`rE G�� TEST: 1ANUARY 9, 2013 D (�(� �p �p 0 O SU LOG SOIL EVALUATOR: DAVID D. COUGHANOWR, R.S. u y //-U //mil WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. DESIGN FLOW: 5 BEDROOMS X 110 GPD = 550 GPD P,ERC NUMBER: 13838 „ NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 550 GPD X 2 DAYS = 1100 GALLONS TEST PIT IA PARENT MATERIAL: PROGLACI•AL OUTWASH USE EXISTING I500 GALLON SEPTIC TANK IF IN SOUND ,STRUCTURAL PERC AT 64 in - 2 MIN/INCH IN C SOILS CONDITION. IF NOT, INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION DEPTDISTRIBUTION BOX: USE 3 OUTLET D-BOX. (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: A 41.5 ft x 12,83 ft x 2 ft LEACHING GALLERY CAN LEACH (INCH 20.55 Abot = (41.5 x 12.83 ) = 532.44 sf 0-8 Ap SANDY LOAM 10 YR 3/1 NONE FRIABLE Asdw = ( 41.5 + 41.5 + 12.83 + 12.83 ) x 2 = 217.32 sf 8-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE Atot = 749.76 sf 17.55 Vt 0.74 x 749.76 = 554.82 GPD 10.08 36-126 C MEDIUM SAND 10 YR 6/4 NONE LOOSE USE A 41.5 ft x 12.83 ft x 2 ft GALLERY. Vt = 554.82 GPD ) 550 GPD REQUIRED TEST PIT 1 B NO GROUNDWATER ENCOUNTERED 1500 GALLON SEPTIC TANK LEACHING (GALLERY A L 2 p CONSTRUCTION PARENT MATERIAL: PROGLACIAL OUTWASH 2 MIN/INCH IN C SOILS DIMENSIONS AND DETAIL DETAIL USE EXISTING TANK SHOREY PRECAST CONCRETE ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER LEA GALLON DRYWELL LEACHING UNIT OR STONE 20e30 I 1n(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING NOT EQUIVALENT TO 0-8 Ap SANDY LOAM 10 YR 3/1 NONE FRIABLE TAPER SCALE 17.80 8-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 0 0 b 36-I26 C MEDIUM SAND 10 YR 6/4 NONE E d _ :1 LOOSE o 10.10 o S ft- 0 8 in ago TEST PIT 2 A PAOREN T MAnTERIAL: PROGLAC ALRED OUTWASH N 0 PERC AT 68 in - 2 MIN/INCH IN C SOILS 8 �� c i ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER EC 4.0' 8.5' 4.0' 8.5' 4.0' 8.5' 4.0' /Q (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING ft-6 in 5 20.80 0-10 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE 41.5 f t INLET CENTER OUTLET 17.97 10-34 B LOAMY SAND 10 YR 4/6 NONE FRIABLE COVER COVER COVER LEACHING GA L L ER Y 34-126 C MEDIUM SAND 10 YR 6/4 NONE LOOSE �l 3 IN DROP CROSS SECTION VIEW 10.30 -► FLOW LINE FROM = USE SHOREY PRECAST SOO GALLON LEACHING NGROUNDWATERENCOUNTERED BUILDING; ID in O = 141 U TO DRYWELL OR EQUIVALENT (H-10 LOADING) D-BOX 2 /n PEAS 2 in PEASTOPoE TEST PIT 2B PARENT MATERIAL: PROGLACIAL OUTWASH 2 MIN/INCH IN C SOILS 48 in L/QUID GAS o 0 ELEVATION DEPTH SOIL USDA SOIL OTHER LEVEL BAFFLE 2 24In SDA SOIL SOIL COLO /4 i^ T EFFECTIVE 3/4 in To 26 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING i^ -1 in GRAVEL DEPTH 1-1 in GRAVEL in 20.85 0-10 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE 18.®2 10-34 B LOAMY SAND 10 YR 4/6 NONE FRIABLE 6 in STONE BASE =48 58 in 48 in 34-126 C MEDIUM SAND 10 YR 6/4 NONE LOOSE SEPARATION BETWEEN INLET AND 154 in 10.35 OUTLET TEES SHALL NOT EXCEED INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXTILE LIQUID DEPTH FABRIC IN PLACE OF THE PEASTONE LAYER SPECIFIED GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL CROSS SECTION VIEW 500 GALLON DRYWELL ON BASED ADJ LOW ENT SPOT GOLW ITH COURSE.WA TER NOTES � DIMENSIONS AND DETAIL DISTRIBUTION BOA USE H-lO UNIT INSTALL ONE INSPECTION OBSERVED GW NONE AT 4.72 RISER TO WITHIN THREE INDEX WELL MIW-29 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. INCHES OF FINAL GRADE ZONE A 2) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES DIMENSIONS AND DETAIL USE SHOREY DB-3 H-10 AND INDICATE LOCATION READING DATE DEC. 2012 BEFORE EXCAVATING FOR SYSTEM. -. , v, ON AS-BUIL T CARD. READING 9.0 ACOMPONENTSIN TA HA . .M T THE MINIM M R GUI REMEN T- 3) ALL INSTALLED S LL EE .- E U �. EOU E .. S TT TIT SEPTIC ( I MR f h OF MASSACHUSE S LE 5 SE C.CODE 3 0 C r 5 . ADJUSTMENT 2.2 � ADJUSTED GW BELOW 6.92 4) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF'"LOW FLOW NOT TO 12 in FIXTURES AND APPLIANCES.'/AND BIANNUAL,PLIMPING'OF THE SEPTIC TANK. t to SCALE MIN OQ 34 SEWAGE DISPOSAL SYSTEM PLAN 5) SEPTIC TANKS SHALL BE- LEVEL AND TRUE, TO •GRADElON �A.LEVEL ��Op 0OO In PAGE Z OF 2 SIX ISTAILE BASE NCHES OFTHAT HAS BEEN CRUSHE�'STONEMHAS BEENLLY PLACEDNTOCMINIMIZE U°EVENOSE TICH LING. O c TANK ` To O�pp�Op�00� ���� sAS o0o ao Ej 00 ELIZABETH SMITH ET ALS 6) SYSTEM IS NOT DESIGNED TO VIIITHSTAND VEHICULAR'LOADING..DO NOT Q ��Op�DOp �O PARK OR DRIVE VEHICLES OVER�SEPTIC ,SYSTEM. .�,f.,,w..;; ;` O ��� ! V\ ` `r , . 6 in STONE BASE J� 7) SEPTIC TANK TO BE PUMPED DRY ar'TIi�nE OF SYSTEM REPAIR a�ND_ CHECKED S /�2 !� 390 EEL POND ROAD FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. g5 CROSS SECTION VIEW OSTERVILLE. MA 8) EXISTING LEACHING SYSTEM TO BE PUMPED. AND REMOVED PER TITLE 5. /S•S in \ I� JANUARY 10. 2013 ETE-3686 9) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE.