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HomeMy WebLinkAbout0068 EVANS STREET - Health 68 Evans Street, Osterville A ��� TOWN OF BARNSTABLE LOCAT1 iN /A.4001 r1W4e,7 SEWAGE # VULLAGE ASSESSOR'S MAP& LOT d S 94STALLEWS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) G_"�� /D� (size) NO.OF BEDROOMS J; �r BUILDER OR OWNER 44ba 4i W-5 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(ff any wetlands.exist within t f chin f ility) Furnished 6` t/d!G� P . (p$ 7 r 1!wAm .. f sit 68 Evans Street Ostery 11le,Mass. 02655 s� � 4y t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. Citylrown 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. Important; A. General Information .. When filling out forms on the r n computer,use only the tab key 1. Inspector: to mc.,e yr%ur pMfriclr AA .. cursor-do notuse the return Name of Inspector key. Septic Inspection Services Co. — — — Company Name, 189 Camrnett Road Company Address Marstons Mills MA _ 02648 nrtan City/Town State Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the ; information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Loc pproving Authority October 24 2011 Job# 11-182 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins-11/10 Title 5 Official inspection Form Subsurface Sewage Disposal System-Page 1 of 17 L4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is Osterville MA 02655 October 24, 2011 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Tank had liquid only, leaching chambers had no standing water at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration 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): 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is Osterville MA 02655 October 24, 2011 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced LJ 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): 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 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. CityrT'own State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The..5 has aseptic tank and.SAS.and the SAS is within a Zone 1 of.a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water . supply well. ❑ The system has a septic tank and SAS and the SAS is less 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ® 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_day flow !Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17. Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any ncrticn of cesspool or-privy is within 1.00 feet of a surface water supply or Eltributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool or privy is within 50 feet of a private.water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, your must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health El 0 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? El ® 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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Lt5in. /l0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 3 Months prior to Last date of occupancy: inspection. 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is Osterville MA 02655 October 24, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 11/28/07 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 0" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is Osteryllle MA 02655 October 24, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 0" 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 How were dimensions determined? Measured- 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 had liquid only, no solids. Liquid level was found at bottom of outlet invert and tees were intact. 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osteryille MA 02655 October 24, 2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) R Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 1. 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.): No solids or high stains present. Liquid level wbs found at bottom of nutlet pipes. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 68 Evans Street _ Property Address Jean Lootz Owner Owner's Name information is Osterville MA 02655 October 24, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: Two 500 gal ® leaching chambers number: drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching chambers were empty at time of inspection, observed a high stain line 8"from bottom of chambers. 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 l5ins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): x 15ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name ------- ___..-..-------._.__...---..---._.-..------'------'— information is Osteryille MA 02655 October 24, 2011 required for .__.-..__—.__.__.____.. every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of,the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 9 16 23 48 ':' 'id s Evans Street Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is required for Osterville MA 02655 October 24, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 2 fe eett 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 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: Perc test performed prior to repair found no water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Evans Street Property Address Jean Lootz Owner Owner's Name information is Osteryille MA 02655 October 24, 2011 , required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate.file 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable: w P# ` °� � ��7 Department of Regulatory Services t �� Public Health Division I STABLAI _ _ Date 200 Main Street,Hyannis MA 02601' - z .Fee.Pd.- Date Scheduled0107-�Wyo' Time Y 1 ;foil Suitability Assessment for Sew age Disposal I Performed By Ay10'- b, �oIJG N(�✓lZ �Csj_ " -Witnessed By: - - LOCATION& GENERAL INFORMATION t _ C Owner's Name CY1 h 1.�I�t? ,., i t Location Address 7 1'�f`" S f 'Address - s - Assessor's Map/Pdreel: 14-IN;7 Engineer's Name NEW CONSTRUCTION - REPAIR,-~ V Telephone# Land Use T.�sr w�l I ' Slopes(�'o) 0 Surface Stones 0 ` Distances from: Open Water Body©� ft Possible Wet Area 0(, ft Drinking Water Well"` ft - - Drainage Way s ft Property Une ft Other ( ;-- 9 M • SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to oles) �-' 134.86 Ft J/ °)' rn ®' Em GROUNDWATER ADJUSTMENT ,I V l I� ®N t' EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARNSTABLE j GIS DEPARTMENT RECORDS. INDICATED GW 5.00 INDEX WELL M1W-29 ` ( ZONE C REEADING DATE SEPT. 2007 READING g,5 ADJUSTMENT 5.1 rn ADJUSTED GW 10.1 Parent material(geologic) I "it Os� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: ILA D n e- - Weeping from Pit Face In• Estimated Seasonal;High Groundwater@edge DETERMINATION FOR SEASONAL HIG- H WATER TABLE Method Used: o e qb® _in Depth t0 Sall tnottl In. Depth observed standing in obs.hole: . p Depth tomeeping from side of ohs.hole: in. `®roundwater Adjustment t A factor Adj.Groundwater Level, Index Well# Reading Date: Index Well levelm� �) - toll�la) S�In ! 0 PERCOLATION TEST Date . Observation [ Time at 91, Hole# Depth of Pere 62- r) 'Time at 6" 41 Start Pre-soak Time:@ -- - L. End Pre-soak S.a �0 . 2.irol Q i Rate Min./Inch Site Suitability Assessment: Site Passed—Y-11 Site Failed; Additional Testing Needed(Y/N) Original. Public He*lth Division Observation Hole Data To Be Completed on Back-------- ***If percola#on test is to be conducted within 100' of wetland,you must first notify the Barnstable C4iservation Division at least one(1)week prior to beginning. Q:\SEPTICIPERCF�RM.DOC ; SOIL TEST LOG - T - -- I DATE OF TEST: OCTOBER 26. 2007 APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. #461 WITNESSED BY: DAVID STANTON. HEALTH DEPT. PERC NUMBER: 12005 i I NO 1 TEST PIT I PAARENOTUNDWATE MAATERIA EPROGLAC ALD OUTWASH. 1 PERC AT 62 In - 2 MIN/INCH IN C SOILS j ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 40.75 0-6 Ap - LOAM _10 YR 2/2 NONE FRIABLE { 6-36 B LOAMY SAND - -10 YR 5/6 NONE _ _ FRIABLE. 37.75 y 36-138 C MEDUIM SAND 10 YR 5/4 NONE LOOSE ( 29.25 NO GROUNDWATER ENCOUNTERED TEST ' PIT 2 PARENT MATERIAL: PROGLACIAL OUTWASH, _ 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE;-' (MUNSELL) MOTTLING 40.80 0-6 AR LOAM 10 YR 2/2 NONE FRIABLE 8-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE C 37.60 - + 36-132 C MEDUIM SAND ' - 10 YR 5/4 NONE LOOSE 29.80 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel 'DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsi ienc ra el Flood Insurance Rate Map: I,. Above 5,00 year flood boundary No_ Yes .Z R Within 500 year boundary No L/ Yes- C, �! Within 100 year flood boundary No Yes, �r Depth of Natutaft Occurring=Pervious Material ....� _ t . Does at least*r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? `�eS If not,what is the depth of naturally occurring pervious material? Certification I certify that on, s (date)I have passed the soil evaluator examination approved by the 1 Department of environmental Protection and that the above analysis was performed by true consistent with . the required training,expertise and experience described in 310 CMR 15.017. Signature Date QASBPTICwERCMRM.DOC No. �J ! �.� e « t Fee 0 r cog y ! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Mid ool *patent Cotts;trurtion Vermtt Application for a Permit to Construct( ) Repair 0 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components LovanEv 0-sno�Lo N Ogg Q ��11 Owner's name,Address,and Tel.No. ll!!/% ``�� 1L� v JQCJt�LR� L� 1 Assessor's Map/Parcel 64 a q-7 p '4 van-D ��-� �7.� I 1� - 7�- �77/_ Installer's-Name.A drgss,and Tel.N � (D Desi ner's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (K)q 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 Q �-V �e � ���5 a� CLc�-� e-Tt'-- a7q9 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 Heal lb. Signed s Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. ��? ? ­W10 Date Issued �� O v� /No. Fee ' r' U Entered in computer: if .THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication for Mi.5p-ogar *p5temc Corigtruction Permit Application for a Permit to Construct O Repair) Upgrade O Abandon O ❑ Complete System ❑Individual Components LocatioiLAddress or Lot No. rl Own is Name,Address,and Tel.No. Assessor's Map/Parcel ;t-t"�� 7 (0 cs-�fx V I e, 3�H-0�y Installer's Na a Address,and Tel.NA. Designer's Name,Address and Tel.No. VU on . Type of Building: J' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (UP Other i'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) / gpd�r Design flow provided gpd Plan. Date 1 Number of sheets Revision Date Title Size of Septic Tank s/ t Type of SWS.' Description of Soil i /f Nature of Repairs or Alt ret atio s` nswer when ap 1, -Le)_�1 f1� 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 Hea . Signed Date G., Application Approved by Date Application Disapproved by: Date for the following reasons - Permit No. �.� "� - Date Issued ! ,!�'.�l_36�. 0;- ' THE COMMONWEALTH OF'MASSACHUSETTS BARNSTABLE, MASSACHUSETTS LOC z.. Certificate of Compliance THIS IS TO CERTIFY,that t^hee Own.-1site Sewage Disposal System Constructed ( ) Repaired (X ) Upgraded ( ) Abandoned( )by 9f- C,,, at&9 E VCV)5 54-.X—j i !{I e— has been constructed diin accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �X 7`q-4 C9 dated 1613*�9 Installer Designer 11 #bedrooms Approved design flow , gpd The issuance of this permit shall not be cpnstrued �s as gua ante/e t,at the system ill f n/cation as desig ed. /f ` Date )� l I " A �/I �i1' 1!/l.' Y Inspector' No. I FeeP!t0. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS L.DU i -Z' Iigpo al *p$tem Congtructton Permit Permission is hereby grantte-d-to Construct ( ) Repair (x, ) Upgrade Abandon. ) ( ) System located at S`�-a i 0'ij \) \(\1�e„ and as described in the,above Application for Disposal System Construction Permit.The applicant recognizes his/her duty d; to comply with Title S and the following local.provisions or special conditions. Provided: Construction must be com leted within three years of the datc�this ermlt 0/30 ` Date Approved by TOWN OF BARNSTABLE �LOCA- hON U Y�G`�S #fir►$� VILLAGE C;S 1-e N�Ida ASSESSOR'S MAP&PARCEL INWMTtJtWS NAME&PHONE NO. tIL 0 (,,ika f i SEPTIC TANK CAPACITY /500 LEACHING FACILITY.(type)d` /10t wlb.1_:-, (size) .:500 9 NO.OF BED/ROOMS OWNER 007Z. PERMIT DATE: C DATE:An5P /d O ,I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Y \ \ \ Y ♦ Y k Y r\r'r\ Y a \ \ \ � f F i f rhfyJ r F J fM1! f F f f f ""O f f f f f f r f f f f f / f ! f F '" •r :I' 'f F 1 \ \ f f ! f J r f f f J f f f / i f r f ! ! r ! ! f f f r f 9 16 s 48 23 2 Evans Street TOWN OF BARNSTABLE LOCATION GVAN' SEWAGE# } _VILLAGE 05-7-e yiLLC ASSESSOR'S MAP&PARCEL Nol - 97 INSTALLERS NAME&PHONE NO.-lum.c•&bmA&A. SeAhL.S ,, ,cr -StF77c-9 776 ' SEPTIC TANK CAPACITY ISM LEACHING FACILITY:(type),9x,= (size) NO.OF BEDROOMS -3 OWNER PERMIT DATE: /0/,3 o-7 COMPLIANCE DATE: 1 V,95 07 Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �� ¢�P Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching.facility) Feet Edge of Wetland and Leaching Facility,(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Des 0-? Fev�`t v� �tays� 3 Fo T't"�4 " (3_f:d'S`lo �,11�`�why 0-oz. 3° A-3^ I bi 1$°16 ` / ' own_ of Barfistable F I�Q ato Services Geller,IIirector :. Publi H h Divisio� 's6y4• 1 C ealt � ...:.. Arm A ... _ . Tt ©mas.McKe Director " 200-Main Street;-H:yanuis;MA.42601. . Office:.508-862 4644 ... _ 6304 Fax:_508 790= Installer&-Designer:Certificatiou Form Date: 1 2,S Sewage.Permif# -: �( 0� a W°�G Assessor's MapTarcel � Installer:-. ti Address: . �-��J.: �►( /►�1,(a � . �.:. Address:: Cey . pn lip as;ssued a pernn to install.a - r (date) (installer) septic system at � L- vans _Cv Zed o a desrgn drawn by ::... .:_.(address) ' a- etdazed .6 tha Vie septic system referenced above was installed substantially according to the:design;.which may_imclude�inar:approued"_changes such-.as.lateral-:relocation of the distributing.box:and/or septic tank:` I certify that, septic:system_ref erenced above-was installed with major changes_ greater than 10' lateral relocation of the SAS or any vertical relocation.of any component of tile's tic- etn3 but-in accor ce with Stag`&:Lacal Reg afians: Play :zevisian of certified as built by designer tofollow. - �`��SN�F M4s�o ' W. o AU N .o 'COUGHANOWR... taller's.S; afore lv©_ 1093 l ) cJ si E Signature)-:----, (Affix Desi er'.s Stain Here (Designer's � }.; � P ):. PLEASE RETURN :TO BARNSTABLE_: PUBLIC . ALTH .DMSIO CERTII ICATE OF � COMPLIANCE .WILL.-NOT:.BE..ISSUED.UNTIL BOTH THIS-TORM..ANU :AS-BMT: CARD: ARE_:::... RECEIVEID:BY THE BARNSTABLE PUBLIC HEALTH DIVISION:-THANK YOU . .... Q:Health/Septic/Designer Cemficahon Forrii3-2 doc := ".- ...... COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,.BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 68 Evans Street O s t e r v i l l Name of owner Noel Collins Data of 4rspection:12/11/9 8 Mass .Address of Owner: Name of Inspector:(Please Print) Joseph P.Macomber J r. I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000) Cornparry Name: J.P.Macomber & Son T n c - MarTingAddress: Rox 66 C®n.te-Ville-,Nase 02632 Telephone Number: 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 2 sewage disposal systems. The system: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Data:.4=4 'JJ" v The System Inspector all submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department ofrEnvironmentai Protection. The original be sent to Vx system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS �k l�7 t revised 9/2/98 Page Iof11 �,Printed on Recycled Paper k SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropeetyAddr—: 68 Evans Street Osterville ,Mass . Own": Noel Collins Date of'spection: 12/11/9 8 INSPECTION SUMMARY: Check A, A, C, o/ A s A. SYSTEM PASSES: I have not found any Information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: —A26_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y,N.or NO). Describe basis of determination In all Instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) t- 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 i - The system required pumping-more than'fourtimes-a yeardue to broken or obstructed pipe(s). The system Willpess� Inspection if(with approval of the Board of Health): - broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Evans Street Osterville.,Mass . Owner: Noel Collins Date of Inspection: 1 2/1 1/9 8 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: AV 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 W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL.PROIF=THE PUBLIC HEALTILAND SAFETY AND THE ENVIRONMENT: 1t Cesspool or privy is within 50 feet of surface water &0 Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. A,D The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presence of-ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance AM (approximation not valid).- 3) OTHER r Q revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddress:68 Evans Street Osterville ,Mass . Owner: Noel Collins Data of Inspection: 12/11/9 8 D. SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into "er-system component-due%to an overloaded orclegged-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. 41, Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q. 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 60 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 organiacompounds,ammonia nitrogen-and nitrate nitrogen. - E: LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: A/?-� The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes N�o�� /al the system is within 400 feet of a surface drinking water supply /!lE! the system-is-within 200 feetofat«�utar oewrfaoedrwnkingwatersupply•••• - _ . . .__... ... _ ._ /lll� the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area r IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Information. I revised 9/2/98 Page 4of11 1 i i SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Evans Street Osterville ,Mass . Owner: Noel Collins Data of Inspection: 1 2/1 1/9 8 Check if the following have been done:You must indicate either "Yes"or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant,or Board of Health. _ None of the system tompooants.haw.bean pumped4opatJeast'two•aweeks and-thwaystem h"AmbewsceiaiagawsmW Aow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. _Ali _ As built plans have been obtained and examined. Note if they ere not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components,joacluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on•the site has been determined based on: Existing information. For example,Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owaar.(aad.occupants,.if diffara g frnot.o=er)Auars4uavided with Informat oann thw guo er mgptnnawa of SubSurface Disposal Systems. i I revised 9/2/98 Page sorii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Evans Street Osterville ,Mass . Owrrer: Noel Collins Date of Inspection: 12/11/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: /0 g.p.ddbedrssPpm. Number of bedrooms(design): a Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes or no):AO; If yes,separstaInspection.required Laundry system Inspected Itps ore Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): I / � �� ri .— �0 �. Last date of occupancy: COM M ERCIALANDUSTRIAL: Type of establishment: NJ¢ Design flow: AlIV gad ( Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)." Non-sanitary waste discharged to the Titl��stem:(yes or Welp Water meter readings,if available: Last date of occupancy: AO OTHER:(Describe) AIA Last date of occupancy: GENERAL INFORMATION PUMPING JCO nd so rce of info mation: p System pumped as part of ins action:(yes or no1_&b If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) 1/A Technology etc.Attach copy of up to date operation and maintenance contract _Q1d Tight Tank V,4 Copy of DEP Approval Other 109 APPROXIMATE AGE of all components, date instaged{if known)-and source of4afornmtion: Sewage odors detected when,arriving at the site:(yes or no) revised 9/2/98 Page 6of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMATION(eondnued) Property Address: 68 Evans Street Osterville ,Mass . Ownw: Noel Collins Date of 4upection: 12 1 1/9 8 BUILDWG SEWER: (Locate on site plan) (I Depth below grader Material of constructio :Zcast iron_40 PVC_other(explain) IAKNr �a nr�o Distance from�pri to Ovate s p ly well or suction line�— Diameter Comments:(condition of joints,venting,evidence of leakage,-etc.) Joints appear tight ; No evidence of leakage ; System is vented SEPTIC TANK: (locate on site plan) Depth below grade: A4 Material of construction:/AconcretaiAmetaIN FiberglassN4 Polyethylene"other(explain) AJA If tank is Enetal,list age dZd Js.age.conformed by Certificate of Compliance,a(Yes/No) Dimensions: AM Sludge depth: m Distance fro top of sludge to bottom of outlet tee orbaffie: 1 —' Scum thickness:__ Distance from top of scum to top of outlet tee or.baffle: AW Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet toes or-baffles, depth of liquid level in relation to outlet invert, structureHintegrity, evidence of leakage,etc.) eptic tank is not present --- GREASE TRAP: Q, (locate on site plan) Depth below grade: Material of construction:A//.'concrete,VAmet&1414FiberglassA/,*Polyethylene/U4other(explain) WA Dimensions Scum thickness: Distance from top of scum to top of outlet tee or baffle: 41/4 Distance from bottom of scum to bottom of outlet tee or baffle:Ai Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet toes or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Grease trap ; s not prPcarit - revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Evans Street Osterville ,Mass . Owner: Noel Collins Dare of trnspection:12/11/9 8 TIGHT OR HOLDING TANK-A"(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:,VAconcrete4&dmetal.t�Y Fiberglass�ygPolyethyleneother(explain) AIA Dimensions: Capacity: AIA gallons Design flow: A14 gallons/day Alarm present AJA Alarm level:A(.Alarm in working order:YesA, # No&,# Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or Holding tapirs @.Pe AOt preseftt DISTRIBUTION BOX:,&/,IAV- (locate on site plan) Depth of liquid level above outlet invert:_A�4 Comments: (note-if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) — -Distribution box is not Rrespnt PUMP CHAMBER. /W4X (locate on site plan) Pumps in working order:(Yes or No) 4 Alarms in working order(Yes or No)- Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) ump chamber is notprPSPnt revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Evans Street Osterville ,Mass . Owner Noel Collins Date of Inspection: 12/11/9 8 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Syst m 1 nvatPrl Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: hi leacng fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: el Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) L o a m y sand to h Qney; mpdijim ;lil�si. r>rs o f hTd� u�.f tallure or pon inQ egetation is norm 1 . Soi1 no amn CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: 'V Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) 0 Intiow cesspools were ary. Did not ,pump . Comments: (note condition of soil, signs of hydraulic failure,level of pending,condition of•vegetation, etc.) Same as above PRIVY:Vie. (locate on site plan) Materials of construction: y� Dimensions: 41 4 Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not nrPsPnt - revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropenyAddre": 68 Evans Street Osterville ,Mass . Owner: Noel Collins Data of Inspection: 12/11/9 8 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate ell wells within 100'(Locate where public water supply comes into house) e t6V 49e i I revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Acklire": 68 Evans street Osterville ,Mass . owner: Noel Collins Date of Inspection: 12/11/9 8 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(�Iocal property, bservation hole basemoat ump etc.) Determined fromnditions Checked with local Board of health Checked FEMA Maps Checked pumping records �I/Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 •remr+rn.r-+�-n—arnrmr•rnsvrs�+nr�n..srsrn�+ar�r►rase*+.•nm tsrnt�t++�srt�rt�a •rn-'rr�r-:,.�-.r•` TURN OF Barnstable BOARD OF HEALTH `. ti- Trite -.•*-T"�_SUI)SUItFACF SEWAGE DISPOSAL SYSTEM IN�SPECT� ION FORM - PART D^- CEKTIFICATIUN�� ' 1 —TYPE 09 PRINT CI.EARLY— I PROPERTY INSPECTED STREET ADDRESS 68 Evans Street Osterville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # HD Z�S7 OWNER' s NAME Noel Collins PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macom.ber Jr . COMPANY NAME J. P.Macomber & SQ-w 'Inc . COMPANY ADDRESS Box 66 centerville ,Mass. 02632. Street Town or City State LIP COMPANY TELEPHONE (508- ) 775 - 3338 FAX ( 508 ) 790- 1578 >z CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent wi th my training and experience in the proper function and maintenance of on- site sewage disposal systems. Check one: System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con tcted has found that the system fails to protect the public health and the environment in accordance with Title 6 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date sr�arassxsu _ One copy of this certification must be provided to the OWNER, the BUYER ( where applicable) and the BOARD OF HEAL1'II. * If the inspection FAILED, the owner or""o" orator shall u within o'ne year of the date of the inspection, unless allowed dortrequiredm otherwise as provided 'in 3.10 CMR 16 . 305 partd .doc " h OAT E 10/4/96 1: [ ..i:,BW ,✓ m , A'v +,.4nJ PROPERTY ADDRESS',. 68; Evans Street; ' Osterville',3Mass. 0655, On the 'above 'date, I Inspected the septic system at the ab"oVd Address: This system consists of the`-foil,owing: . 1 . 3-Blobk cesspools. 61:F6t 2-61x81 Based bn my I,nsu:act Ion, I cortity .the following conditions: 1 . 'This is not a, title .five septic system. 20 This is a .sewage system: 3 _`" 3. 2 separate lines leaving. basement.'. Sewage :"goea to one cesspool and - .the grey water goes, to o j� °cersspooT:w Each of he's pools-overflow,,to" a third 'cesspool than "ie `"between or middle of the ��two". 4. The sewage system is in; proper. working order at the present time,; SIGNATURr: Flame J P Macomber Jr i COm com an J. P Maber & 'Son`-Inc Py�--- -- -- --- f Address:_-Bec—b6----- -� -- -- L r OOT 16 _ Cente_rville , Mass__02.632 -y 6 Phone: _-5Q8,.Z7,5.3338 _ THIS "CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY ,s- J'OSEPH P r MACOMBER & SON, INC. Tank -Ce"poolvLeachfields„ k Pumped � Initxlle�d �, ToWn Sewer. Connectlons P.O. Box 66" Centerville, MA'02632-0066 , .T, 5-33.38 ""175-8412 - s } Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of . Environ men fal Pro#e�I! wtlllam F.weld * ` 4 Trudy Cox@ i ciovrmor 8-jetuy Argo Paul Cellucci David B.Struhs U.Gowmw Commhalorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION f 68 Evans Street Osterville,Mass. Property Address: ,)0/!+/9 6 Address of Owner. Date of Inspection: (If different) Name of inspector..Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 _Centerville,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT „ I certify that I have personally ins the sews disposal stem at this address and that the information reported below is true accurate dY Pe Y P�� B? P�system Po r 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 sewa disposal systems. The system: , �s - - - Conditionally Passes - _ Needs Further Eval tion By the Local Approving Authority — -Fails r . ,{ �,(� Inspector's Signature: ` % Date: liU.":�+ ;✓ 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: Al SYSTEM PASSES: r 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, teria not evaluated are indurated below. BJ SYSTEM CONDITIONALLY PASSES: One or more m components need to be replaced or re The system,upon completion of the re lacement.or re . � Po P P� s3' � P� P P Pau'r Passes. inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If":tot determined",explain why not) i /l/e� The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is aL i imminent. The system will pass inspection if the existing septic tank is replaced with'a Conforming septic tank as approved 1 by the Board of Health. i (revised 11/03/95) 1 l One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-SM i'j Printed on Rayckd P.per