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Important:When A. inspector Information cb 59 filling out forms on the computer, use only the tab Daniel Hawkins key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 - as Company Address - Sandwich Ma 02563 City/Town State Zip Code laaiv (508)477-0653 S114324 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 Dan Hawkins ti Digitally signed by Dan Hawkins 'Date:2020.09.1613,47:40-04'00' 9-15-2020 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 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 v r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma, 02655 9-15-2020 required for every 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:' ❑■ 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: The system was in working order at the time of inspection. 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 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 , c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l� 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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): 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: 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c Commonwealth of Massachusetts _ Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name nformation is Osterville Ma 02655 9-15-2020 required for every 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 m Failure Criteria Applicable to All Systems: Y PP Y You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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 El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El El than depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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.) ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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 �a p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive u Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ a 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 6 ) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ a Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms(actual): 3301GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes Qi 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 0 No Seasonal use? ❑ Yes Qi No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2018- 99,000gallons 2019- 69,000gallons Sump pump? _ ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 - ' t Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 2 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form AP1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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 E ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 1996 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑E No 5. Building Sewer(locate on site plan): 216" Depth below grade: feet Material of construction: ❑cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1811 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 1 Dimensions: 500gallons 5" Sludge depth: 3119 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? 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 tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 a Title 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 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is required for every Osterville Ma 02655 9-15-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): 'Depth below grade: NA 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.): 4 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑concrete ❑ metal 1 El fiberglass ❑ polyethylene ❑other(explain). Dimensions: Capacity: gallons Design Flow: gallons per day f t5insp.doc•rev.7/26/2018 Title 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 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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): Oil Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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.): NA * 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): r If SAS not located, explain why: i Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: (6)infiltrators w/4'stone R leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form t, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. No evidence of past back up was observed when viewed. 12. Cesspools (cesspool must be pumped as art of in spection)ection)(locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts r- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ r c , 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I �u— 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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 �yty.�"�vYr<. .grawiv or RNSTABLE - LOCATION jwne t� tJ!`t, SEW GE 0 _ YO_LA ASSESSOR'S MAP dt LOT.,/& JNSTAL• IM'S NAME do PHONE NO. t sEpnc TANK CAPAGtTY +. LEAC*UNG FACILTP7r--(type} ugs 4 r, Ey✓). �Ysize NO_OF B � ', 72 BUU_DEtt OR OWNER, �'.��� �' , y� ,rs 1 PERMTTDATEs _ COMMAANCE DATE: 4 —! Stgarwion Distance Between:the: Maxis nw=Adjusted GroandaraterTabte and Sons tt of Lmachiag Eon Private Watar SWply Well aad LaacMng Facility (If any welts exist on nut or within Zoo feet of teaching facility)ram Feat Edge of Wetland andIA—bing Flaci ty(if any vk+0.artoa exist within 300 feet of teaebing facility) Feet Fkwinisbad by r P 1( jS i t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form -Not for Voluntary Assessments MR L 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every page, City/Town State Zip Code Date of Inspection. D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar. ❑■ Shallow wells No GW @ 120" Estimated depth to high groundwater: 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: - 8-17-1995 Date ❑ Observed'site(abutting property/observation hole within 150 feet of SAS) r ❑ 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: t A plan on file at the local Board of Health was used to determine high groundwater. a _ 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 Commonwealth of Massachusetts v h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Fairwinds Drive Property Address Williams Nicholson Owner Owner's Name information is Osterville Ma 02655 9-15-2020 required for every 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. 0■ B. Certification: Signed& Dated and 1, 2, 3,or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed �■ D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included } t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No. 1� THE COMMONWEALTH OF MASSACHUSETTS� Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplicatiou for Migoml Op5tem Cougtructiou Permit Application for a Permit to Construct()()Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i i 4 FrA i A W i O)D S _D 12t V Owner's Name,Address and Tel.No. Lo+ 44 'f o5tarz_✓c L416 k)r LU A oVI N i c- l a Al i a� CT- Assessor's Map/Pcel IZ-5 J0rL -h ST1 wa+ex;b az 1. �I.�Q /Z3-Installer's Name,Address,and Tel.No. Designer's Name,Address aqd Tel.No. /�r C,�� �or)Sf72l�C oh f�/2/VE a),4 -f! �`�/1OSci2� �ar�e� ��!'lfltf /' 17 1 %L 0 19 Type of Building: � � Dwelling No.of Bedrooms �3 Lot Size sq.ft. Garbage Grinder ly ) Other Type of Building IJbrJP No.of Persons �Z. Showers(x) Cafeteria( } Other Fixtures Design Flow //0 gallons per day. Calculated daily flow 330 gallons. Plan Date 9?11 Number of sheets I Revision Date Title Size of Septic Tank ,C 5700 e.,q l/.O y s Type of S.A.S. I )")F 114'YCL€+6 YLS Description of Soil // U— L_Al , . - i) Nature of Repairs or Alterations(Answer when applicable) /V a Vtf 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 issuedi:by this Board of Healt p / Signed Date /2 Application Approved by 4Z49& Date /'fix y"-" �' Application Disapproved for the following reasons Permit No. Z A Date Issued /117 'A. � No. - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIppYication for Oigpogal *pgtem Construction Permit Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) El Complete System 0 Individual Components 4 Location Address or Lot No. FG t t't W i r 1 S 1712 ut Owner's Name,Address and Tel.No. L,} #`� OstER✓cc,c,E W,LciAl" rvic.holS0n/ Assessor's Map/Paz el I Z 5 /'JoOl." S;*i (A)a+en'�Wh GT 6�, Y.' 02/,00 o 1238 Installer's'JName,Address,and Tel.No. Designer's Name,Address and Tel.No. Hi C�'�J(-1 Cor7 Tfj2UC�oh,` /9fZ VC aU,4 LIq �OS 4 tZ9 LA✓1 P /'r A/'!/!tl / D /v C1?j2e CAA'v1 P?JCi�.eJ Type of Building: � � Dwelling No.of Bedrooms 13 Lot Size sq. ft. Garbage Grinder lY ) Other Type of Building tj6 fJ8 No. of Persons oZ. Showers(x) Cafeteria( ) Other Fixtures Design Flow //0 gallons per day. Calculated daily flow. 330 gallons. Plan Date _!9� Number of sheets I ' Revision Date Title Size of Septic Tank �S�U A R 110,J S Type of S.A.S. 1' JV -{'a&+o ms Description of Soil ' �- 3,;�i1 ,�... , 9,S �o% y �� ' D►/ SL s 11 - Z011 edjM sa ? Nature of Repairs or Alterations(Answer when applicable) . f e, to Date last-inspected: Agreement: ? � The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal syst'M. in accordan a 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 this Board of Healt1l. / Signed Date 12-1/-�to Application Approved by Date Application Disapproved for the following reasons Permit No. - Date Issued ,,z ——————————————— ——————— ————————————— i THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS Certificate of Compliance , THIS IS TO CERTIFY;that the On-site Sewage Disposal System`Constructed( ,!� )JRepaifed ( )Upgraded( ) Abandoned( )by ee V i n >�i ck 2 at y F i fZW i 1V D5 i a U-S'-�/Z✓j.G E iVl &'f Y x been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated �. -•'��'--- Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date I yl "-! ✓� Inspector Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Qigpogar */ pgtem Construction Permit Permission is hereby granted to Construct(V)Repair( )Upgrade( )Abandon( } System located at �y �Ar2�Jiryt73 �lZi V�, Gu /c:�// C Lt /9 �GDt y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thisrmit. Date: / / -Approved�,y v TOWN OF LOCATION / %VI vrSTABLE ) SEWAGE # - VII.LAGE U t G ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. - SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Z.l i.44 (size) NO.OF BEDROOMS :BUILDER OR OWNER ✓ 1 PERMITDATE:� -g3-0 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 / 111JYL1C11'1'lUN FOR 1'li1tC:ULl1'1'lUIJ '1'liS'1' AND OBSERVATION1'1'1'S V LOCATION L- " . l �' �'L�p,Gl� � NO. � VILLAGE t L DATE � � APPLICANT FEE ADDRESS TELEPHONE NO. (Non-refundable) ENGINEERr TELEPHONE NO.g�7 ' DATE SCHEDULEDf Q// (Applicant' s signature . . .. . . . . . . . O O . . . . . . . O . A O . . ... . . . . O . . . . . . . . . . . . O . . . . . . . . O O O . . . . . . . . O . . . . . . O . . . . . . . . ASSESSOR'S. bIAP & LOT NO; ' SOII, LOG r� A SUB-DIVISION NAME �AJz�,a,�s r r y�L� DATE / ./ TIME EXPANSION AREA: YES � NO _ _ � ENGINEER TOWN WATER Y PRIVATE WELL BOARD OF HEALTH P��,�-rv�rnTt EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES : / 3 5 5� Ffa��Zw.►�ps � 1� ►Z�`►r__- "t ih TA 2 TH I 1.0 L,>T S PERCOLATION RATE: TEST HOLE NO: 1 ELEVATION: TEST HOLE N0: Z ELEVATION: s,. Ar Y Y 30„ 2 5 5 z. -LOAMY 9 g Ito" 10 SA...t� 1�5•� 10 ..,rl 11 �N Of 12 12 13 13 � ARNE 14 _ 06M" ay ctvlL 15 .c-o� 15 � � Nap7>a't 16 16 AL Y 1pNAl SUITABLE FOR SUB=SURFACE SEWAGE: LEACHING FIELD _LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON .PERC TEST APPLICATION ORIGINAL: . COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH COPY RETAINED BY APPLICANT -,... . ,.,. <.;. .,... } .,:a.., ,. ,: . . r.a•.ry N: i1 d Y. � 'k. >..;:. A ""Y [''":" .TtF - rK^•',:.1,rM'i .. .. , , ,. ,.. -, Y . +r. .. c,• .:rl 7 ..:' .:-...0 ,•';`< ,k. }.bJ,•'1. ',Y ,k..�j- 1 '�``. a .. .. }.. '. �• yr - .. ,.. ;- _. 1 ... .,_ .., .. ,...... ,. ._. .:- .. _xJi., .._, •,....:..,. .. .. .. ,. �...+ ., .r 1. c. is yy , _ SEPTIC PROFILE 1. , TEST HOLD •Lt�G� r,• , • . . ' r: .. .,;;. T.O.F. AT EL. 51.50 ACCESS COVER TO WITHIN G OF FIN. GRADE (NOT TO SCALE) At ` r 50x1 ACCESS COVER (WATERTIGH1) to ENGINEER: ARNE OJALA DCE t a /� WITHIN 6" OF FIN. GRADE ED BARRY - BOH' LOWS 5OX1 MINIMUM .75' OF COVER OVER PRECAST 2lf; SLOPE REQUIRED OVER SYSTEM 50X1 WITNESS: J_ , y _ _ DATE: 8/17/95Ar _ RUN PIPE LEVEL t DOUBLE WASHED PEASTONE I \_48.00 FOR FIRST 2' <2 MIN./IOCH 1500 3' MAX. PERC. RATE = 4.: PROPOSED .. GALLON SEPTIC 47.55 47.6 CLASS .rpLI 1 SOILS P# P--8554 > 47.80 TANK (H- 10 ) f , GAS BAFFLE 47.37 -� 47.20 4 47.00 ' ( 2 % SLOPE �6' CRUSHED STONE OR MECHANICAL / r COMPACTION. (15.221 [21) 4 2' L71 ELEV. 4 1 DEPTH OF FLOW 4' S P -2_x SLOPE 0" 50.1 0" 50.1 EAST U >r (--r SLOPE) ( ) y BAY TEE SIZES: " 0 45.00 5» 0 49.7 4" 0 49.8 / INLET DEPTH 10 - --- r I { r` s.; OUTLET DEPTH = 19" 3/4' TO 1 1/2" DOUBLE WASHED STONE 12,, A 49.1 5" E 49.7 LOCATION MAP SCALE 1" 1$00' a 12' LEACHING B 1 A ASSESSORS MAP 165' PARCEL 21 FOUNDATION- 10' SEPTIC TANK - 4' D'. BOX FACILITY 2» . S.L. 2.5Y 6/8 47.4 lift S.L. 49.2 PCL ,106 ZONING DISTRICT: RC Cl 4f PCL 43 42» S.L. 2.5Y 5/6 46.6 S.L. YARD SETBACKS: .t C2 FRONT = 20' a Y 47.6 SIDE-` = 10' MED. SAND 30" REAR - 10' : 5.30 Cl 4 �1 80" S.L. 2.5Y 5/6 43.4 44» S.L. 46.4 REF. L.C.PLAN 26824E r i �o L.S. 10Y 4/4 FLOOD ZONE: C 4 \ 89" 42.7 ,...... .. C2 PCL. 99 MEDIUM MEDIUM FINE SAND a " SAND 39.7 120" 40.1 125 39.7 / BOTTOM T.H. 2 NOTES: NO WATER ENCOUNTERED ALLOWED 1. DATUM IS ASSUMED FROM HYANNIS QUAD MAP , ER IS ) OT 3 _� / _ Df SIGN FLOW N- (BEDROOMSOS 110 GPD = 330 GPD 2. MUNICIPAL WATER -IS AVAILABLE ( ) / G _ _ rn USE A 330 GPD DESIGN FLOW WITH `Mii'J. AREA`:_44� S.F. ` 3' MINIMUM PIPE R ALL B PRECAST UNITS FOOT. BE AASHd H- 10 � 446 S.F. X 50% - 669 S.F. REQUIRED. 4. DESIGN LOADING0 T /� N SEPTIC TANK: 330 GPD { 2`) = 660 X 200% = 1320 GPD REQ. t 5. PIPE JOINTS TO BE MADE WATERTIGHT. I 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 48,852t s.f. USE'A 15_0 GALLON SEPTIC TANK ENVIRONMENTAL CODE TITLE V. (1.12 cc.) LEACHING: 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING. PCL. 100 SIDES: (2)(45.5+11)(2) = 226.0 (.74) = 167.2 GPD - 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. BOTTOM: 45.5 X 11 = 500.5 (.74) = 370.3 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT TOTAL: 726.5 S.F. 537.5 GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. USE 6 MAXIMIZER INFILTRATORS WITH 4 OF lu �ut4.1 (A vw�n -e�..r.-1 W 5 STONE ALL AROUND. � ,F.�.t C�,_,Li •4� t aM._. Y q-. FAIR WINDS _` �,� �` / LEGEND SI1'"E ANC SEWAuE PLAN DRIVE' �Pg�' / PROPOSED PROPOSED SPOT ELEVATION OF 3 BDRM. LOT' 4 FAIRfl'INDS DRIVE -DWELL, a 100x0 EXISTING SPOT ELEVATION - W � -------- � 'o IN THE TOWN OF: rn TOP OF x 75' 100 PROPOSED CONTOUR BARNSTABLE (OSTERVILLE), MASS. 5,x� �+ FNDN = S1.50 50 - 100 - EXISTING CONTOUR PREPARED FOR: WILLIAM NICHOLSON ft 5, EXISTING TREE 1, o' o 30 0 30 60 90 Feet N �1 PROP DRIVE 'L�\�1 0 (�nIN) PCL. 122 L=46.21 w „ BOARD OF HEALTH R=52.50 T.H• ` 51 HOLLY RESERVE z � TREES .APPROVED DATE MA SCALE: 1" = 90' DATE: N'b�'�[BSR 18, 199�' 45,5' CV / off 500-362-4841 , X5 j0• 1oz 'S(� 382-R!t80 5, ELEC.,7FC., & C (MIN} / I ABLE AM Of 265.89 down cope engineering, inc. LOT 5 CML t' 19GINEERS �w� = `" r��L LAND 8URVEYORS � r• it 50 939 wain st. yarmouth,` ma 02675 _ JOB 95-28D - ARN JALl, : . #'L.S. "'� DAT1� x y' t<