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HomeMy WebLinkAbout0015 FARM VALLEY ROAD - Health 15`FARM VALLEY`ROAD;rOSTERVL� 0 i 0 y v i ti h i I` o I! a �w to%) r i e ti S J � Y No. � Fee THE COMMONW&TFI OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(pplication for Disposal *pstpm' Construction Permit Application for a Permit to Construe ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No./5 czr►n vo Owner' ame Address,and Tel.No. Assessor's Map/Parcel / to I Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. -Odllj✓c, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 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) f0V-W'ec.T LAIt 1pVC v-a,n C � �c� G2) @)0-32Z K gleo � 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 Health. Signed Date ' 2 C?°Z Application Approved by Date 1 � Application Disapproved by Date for the following reasons Permit No. �'� Date Issued [ 1 1 No. � 1 v �.� Fee THE COMMONWALTHJOF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS t application for Misposal 6pstem (Construction 30Prmit\`, Application for a Permit to Construct ) - Repair( ) Upgrade( ) Abandon( ) ❑Complete System tj.Invidual Components ' is is Owner's.Location Address or Lot No.15 kat �`' lrLL. ame Address,and Tel.No. Assessor's Map/Parcel lAo P 14/7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. wt" Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) d 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 SoilM .y Nature of Repairs or Alterations(Answer when applicable) ,. 0IDA IA lec_" L41� PVC TOtn �::-; @)el_)77�j t_f iN ,j Date last inspected: 4Ag'reement: 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 nottto place the system in operation until a Certificate of Compliance has been issued by this Board of Health. t Signed :. -_._�_.._ Date 74 l'.'kAt. � Application Approved by Date IZ—A� �f/ C,;L0 Application Disapproved by Date for the following reasosn y Permit No. Date Issued sq- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THISJS TO CERTIFY,that the On-site Sewage Disposal system Constructed(A Repaired( ) Upgraded �,. ( ) Abandoned( )by {. ``, . .- O N trJ _U t� �at; /i` 1����+� 0,1 t.Vv ( !Z,,ti,� has been constructed in accordance r with the provisions of Title 5 and the for Disposal System Construction Permit No�-0:k�ated Installer V_I t C VQV V 00 )S' Designer #bedrooms Approved design=floe 1 gpd The issuance of this permit shall not be construed as a guarantee that the system w6l function as designed. f M � a l/f Date '�`'���# 0 Inspector , ��►_•.a --- --= ------------------- ----- -- --------- No�f Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Disposal 6pstem Construction permit Permission i h by granted to Construct( Repair( ) Upgrade( ) Abandon( ) System located at t and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. w. Date ( r Approved by� iL Commonwealth of Massachusetts ,oZ a��7-- . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4"1 v� 15 Farm Valley Rd: ' Property Address Johns; Owner Owner's Name information is ✓ �. required for every Cisterville MA 02655 7/26/19 page, City/Town State Zip Code Date of Inspection c.r I 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. A. Inspector Information �l /�y03a— Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13016 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 16.000); 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 1 have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8/8/19 Inspector ig a r 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns - • Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown 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 inspection was performed on 7/26/19 and pg. 7 amended on this day 8/8/19 to reflect the fact that the system is now considered adequate for a 4 bedroom home.This conclusion was reached by Chief Health Inspector for the Town of Barnstable. His decision is backed by a letter he provided. The letter is attached as the last page of this report 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 i Commonwealth of Massachusetts (o Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown 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):. El 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: ; 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections:' Yes No ❑ Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd: Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owners Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components-pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ElHave 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)) Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owners Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped summer 2018 per homeowner 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 �n ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1995 per BOH record Were sewage odors detected when arriving at the site?- ❑ Yes ® No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' 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 i? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 21 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet and outlet raised to 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g 6, . ` Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12' Scum thickness trace-1/2" >2, . Distance from top of scum to top of outlet tee or baffle >2„ 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feetn Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions:enslo s. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑ fiberglass -❑ polyethylene ❑ other(explain): Dimensions: f Capacity: gallons 4 Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01. 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.): H-10 d-box is 3' below grade, carryover in box, no indication of past hydraulic failure t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts lF Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owners Name information is required for every Osterville MA 02655 7/26/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2, 40'. ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown 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.): Trenches were video inspected and are damp at this time, piping is clean with no high staining, no indication of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts - (o Title 5 Official Inspection Form J; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. CityTrown 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. 15insp.doc•rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 .r J - lfA/PId� t/46e, ;,F BARNSTABLE �1 LOCATION LOT � �Y"�srCtkCl��Ga`! �D SEWAGE# VILLAGE OYTeLurl/t ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ISM uuxYun- LEACHING FACILITY-(type) —I rcy L . (size)Yo�Xd NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER -BUILDER OR OWNER— Sl LUi A 4-Si LuiA DATE PERMIT.ISSUED: jig DATE COMPLIANCE ISSUED: 9- �'` p VARIANCE GRANTED: Yes No . t ' 0 rG . - - f ,�' tit� •,:>�- Commonwealth of Massachusetts lF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owners Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: No plans on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping,the site is at 30'msl and nearby surface water is at 4'msl You must describe how you established the high ground water elevation: See above I 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 ,io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Farm Valley Rd. Property Address Johns Owner Owner's Name information is required for every Osterville MA 02655 7/26/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of Barnstable Inspectional Services ��. Public Health Division NAM i639 ,►``� Thomas McKean, Director 200 Main Street,Hyannis MA 02601 Office:508-8624644 Fax:508-790-6304 Mrs. Jennifer McCartin August 5, 2019 851 Main Street Osterville, MA 02655 Re: 15,Farm Valley Rd, Osterville Dear Mrs. McCartin, This letter is to confirm that the Health Division does allow 4 bedrooms maximum at 15 Farm Valley Road, Osterville, Map 120, Parcel 147. In researching the property, there were several factors involved to come to this conclusion. In 1998 Health Inspector Ed Barry approved a building permit (#33188) which indicated the house had 4 bedrooms and as part of his sign off he listed 4 bedrooms. The Town assesses the property as 4 bedrooms. The original asbuilt card was listed as 4 bedrooms and the original design plans show the septic has a design capacity for 4 bedrooms. In researching the property further, the property is part of a subdivision that included a large (27.26 acres) "open space" in the plan which other properties (i.e. 24 & 56 Farm Valley Rd) were also granted additional bedrooms with the consideration of the large 'open space" attached to the subdivision. If you have any questions, please feel free to contact me. Sincerely, 4 ,e David W. Stanton, RS Chief Health Inspector Town of Barnstable Public Health Division l Q:1Dave1l5 Farts Valley.doc ; } f 1 ri. -ter'}...:p�= ,, p 14] 'l^ .`?s,'.>1i,0 I ron j W - U J.' •+•: N'C�`�.. iy/ .,F r 1 4 -`aw 1 + " `• 1 j r. ✓;`, 5 � Ji ' - t ,I T �� fir "y kl�I� .S fi .ram -ill '��' , 1 a >r:. a"x 1. ° r'i �a I it r1. r c ] - ti� N 1 Ti J . -(. Jf r bt v 'i b Y �,. r!`r �. . T �,..q, ;,_ n u fa 1� sl, ` A A• �I .+rr;1 Iay` �'� .? r { tP. L, , 1 �p ",r c-E F *j'. S ra •rya r :u -p �. b r � J. 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'� _ �t P ✓ � ( f 1 fir.,.1-r, 11 tit 1. T '111,1 �- I. a - + ..t ' U 1 L '+ -IrJ t i JY * 7{ y y r,y ; .1 r ­11� s J �t - Y y y 1 r t ' '1 k h y "' r.. 5r t " rrrA r n •` J r ,I r d :t ly 'y a t-"y - ..cF -r I tr It ;� �l :f - - (, z }4 j i h' ^✓ 1. C A 1.N,y .f. n 1. . ,,I, , I . , — ., ,-�, "C"; f 1J _ t 17s.H` S 1 1. !' �, h: L •,J M. t' - I - -�.. - - I 1 _x J:. �. of Fl . , I s - H. ` .t i 'it. � , y Town of Barnstable i `�1ro Inspectional Services BAPNSTABM Public Health Division Ar i639 aim Thomas McKean, Director fD MA'S 200 Main Street, Hyannis MA 02601 Office:508-862-4644 Fax:508-790-6304 Mrs. Jennifer McCartin. August 5, 2019 851 Main Street Osterville, MA 02655 Re: 15.Farm Valley Rd, Osterville Dear Mrs. McCartin, This letter is to confirm that the Health Division does allow 4 bedrooms maximum at 15 Farm Valley Road, Osterville, Map 120,.Parcel 1.47. In researching the property, there were several factors involved to come to this conclusion. In 1998 Health Inspector Ed Barry approved a building permit (#33188) which indicated the house had 4 bedrooms and as part of his sign off he listed 4 bedrooms. The Town assesses the property as 4 bedrooms. The original asbuilt card was listed as 4 bedrooms and the original design plans show the septic has a design capacity for 4 bedrooms. In researching the property further, the property is part of a subdivision that included a large (27.26 acres) `open space" in the plan which other properties (i.e. 24 & 56 Farm Valley Rd) were also granted additional bedrooms with the consideration of the large "open space" attached to the subdivision. If you have any questions, please feel free to contact me. Sincerely, 41b, vid W. Stanton, RS Chief Health Inspector Town of Barnstable Public Health Division Q:\Dave\15 Farm Valley.doc I . Commonwealth of Massachusetts �a0 —/t/7 77 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 15 Farm Valley rd C Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. City/Town State Zip Code Date of Inspection CV Inspection results must be submitted on this form. Inspection forms may not be altered F,any way. Please see completeness checklist at the end of the form. Important:When A. General Information _57* � filling out forms 41 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain Company Name 8 Johns path Company Address B S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 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 -y the Local Approving Authority 8/3/16 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 (�S Commonwealth of Massachusetts ` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M a - 15 Farm Valley rd 'rg Property Address Connie Johns Owner ""1 Owner's Name r, informatioWis required for"every Osterville Ma 02655 8/2/16 page. City/Town 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: System contains a 1500 GI septic tank as well as a Distribution box and two leaching trenchs. 40'x2' 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): t5ins•3/13 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 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. Cityfrown State Zip Code Date of inspection- B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ 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 a❑::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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ ' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 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 M e 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. City/Town 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 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. 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Ins ection Form _ p i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osteryille Ma 02655 8/2/16 page. CitylTown 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: ' ❑ r ® 'Any'portion of the SAS; cesspool or privy is'below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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, you 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 15.3.04. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every osterville Ma 02655 8/2/16 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 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs.of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with El ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1500 GI septic tank as well as a Distribution box and two leaching trenchs 40'x2' i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ 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 r f• Last date of occupancy: Date 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y Y M 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped every other year since 01 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 + Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ' ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 9 of 17 P Y 9 Commonwealth of Massachusetts o W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is Osterville Ma 02655 8/2/16 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 24 Y Scum thickness 42 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 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 Level and at normal level Comments note if box is level and distribution to outlets.e ual, an. evidence of solids carryover, an ( . q Y rY Y evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 40'x2' ❑ 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.): None 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is Osteryille Ma 02655 8/2/16 required for every page. CitylTown 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.): No ponding no break out 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. CitylTown 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: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: System is pipe in stone for maximum distance between ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 8/3/2016 Assessing As-Built Cards • l�}A � '� aF BARNSTABLE � �" p. LOCATION LOT- � �c,hu�.���.y �p SEWAGE # l�'IS-0.7 VILLAGE_ n' >mc a;ij< ASSESSOR'S MAP& LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY 1$oJ ullbun. LEACHING FACILITY:(type) —rrcod,,, (size) 0ly-j NO.OF BEDROOMS_ �Z PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER S,LUi A 4_Si Cut A DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:_ VARIANCE GRANTED: Yes No 0 �G http://www.townofbarnstabl e.us/Assessi ngtH M di spl ay.asp?m appar=120147&seq=1 1/2 L-- •t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Farm Valley rd Property Address Connie Johns Owner Owner's Name information is required for every Osterville Ma 02655 8/2/16 page. Citylrown 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 t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CO-AIT 1•'i O VTALTH OF KISS ACHUSETTS _ c ( EYECUTI�E OFFICE OF E\�ZRO� -_rE� l �AF_ DEPARTMENT OF DwIROtirVIENTAL PROTF'('TIO_\t TITLE 5 OFFICIAL. INSPECTION FOR—M.—NOT FOR VOLU 'TARY ASS MEN SUBSURFACE SEWAGE DISPOSAL. SYSTEM FORM PART A C CERTIFICATION J LL� / Property Address: :�J / r, P', �oi�fe Rp� a 6SS Owner's Name: fle 2r c Owner i Address: /.S Date of Inspection: Name of Inspector?Ie�se print) o r_e_��/ F y , Company Name: -/(/l�/ Mailing Address: jL ';N-r Telephone Number p CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system ai this address and that the Ln-o_=a'tion teno Led below. is true, accurate and complete as of the time of the inspection.The inspection«-as performed based on rn,. 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): TheSNI st-em: Passes _ Conditionally Passes deeds Farther Evaluation by the Local_4pprotina_�utho_ity Fails __ _ Inispector's Signature: G -� Date: �17 -0e The system inspector shall submit a copy ofthis inspectionreportto he Appro'-_n� ��thor_� (Boa_` o-li_a'_1 DEP)within 30 days of completing this inspection. If the.system is a shared system or has 21 des: n to,, o t0•fnLr ; gpd or greater, the inspector and the system owner shall submit the report to the appropriare regi on._+ o DEP. The original should've sent to the system owner and copies sent to the buyer, if apnl=cable, ar e a authority. o Notes and Comments *---, *This report only describes conditions at the time of inspection and under the conditions of use at Char time. This inspection does notaddress how the system will perform in the future under the same or aitferent conditions of use. Title 5 Inspection Form 6/15%2000 page 1 r Pace 2 of 11 OFFICIAL INSPECTION FOR_VI—NOT FOR VOLU\'T_4RI'<kSSESS:kIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I\SPECTIO\ FOP-Al PART A CERTIFICATION(continued) Property Address: S �Gird'1 �a1 �/e env, �--�a�bs Owner: j 0 Date of Inspection:— Inspection Summary: Check A.B.C,D or E/ALWAYS complete all of Section D i. A�. S�-st ,asses:.. vee not f asc found any mfonrahon which uidtcates That ant of the failure rites a d. nt, a __L 310 C IR 15.303 or in 310 CMR 15304 exist.Anv failure criteria not evaluated are indicated belo-�s-. Comments: . B. Svstem Conditionally-Passes: k/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 H ahn, ,`1 pass. AnsNver yes,no or not determined(Y,N.2ND)in the for the followina 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 si.acnuaily unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System-,ill oars inspecnon 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 Corti i .ate oF Co— rict ir_dicati.ng that the tank is less than 20 years old is available. \D explain: }' Observation of sewage backup or break out or high static water level in the distribution box due to __o obstructed pipe(s) or due to a broken. settled or uneven distribution box. System will pass inspection approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obs-ucted pipe;s s li pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ti ND explain: f Paoe 3 of I 1 OFFICIAL. INSPECTION FORM-NOT FOR�'OLLIT:AI2�'ASSESS �IE\TS SUBSURFACE SENVAGE DISPOSAL SYSTENT T SPFCTZ®-N FOR_\r PART r CERTIFICATION(continued) Property-Address: /J �c,�v�'] VG Ile 4c) Owner: I oa 64,r Date of Inspection: /p C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation b1 the Board of Health in order to d..i s: r_ is fai.lina to protect public health. safety or the environni--nt. 1. System will pass unless Board of Health determines in accordance with 310 CINiR 1`.303(1)(b)that the system is not functioning in a manner.c-hich will protect public health,safety-and the environment: Cesspool or pray is within 50 feet of a surface water — Cesspool or privy is w ithin 0 feet of a bordering vegetated wetland or a salt marsh 3. 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 i'n n GO = et of a surface water supply or tributary to a surface Nvater supply. The system has a septic tank and SAS and the S AS is within a Zone d of a pubt.c :,ater suppl-�. . The system has a septic tank and SAS and the SAS is% thin 30 feet ofa priyat. water sup; - .;e11, The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or rnore ros"^_a private water supply well":Method used to determine distance X*This systeri passes if the yell water analysis,performed at a DEP certified laborato= for coiif.Dr u bacteria and volatile organic compounds indicates that the well is free Eom pollu icn frog Lhat f at i:_ a the presence of ammonia nitrogen and nitrate nitrogen is equal to or 1 ss-d an pp---.,-providedit at-o o;_er failure criteria are triggered.a copy of the analysis must be attached to tss form. 3. Other: � Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLtiNTARY A_SSESS�IE\TS SUBSURFACE SEWAGE DISPOS:LL SYSTUM INSPECTION Foln-1 PART A CERTIFICATION(continued) Property Address: Owner O /Vr Date of Inspection: o D. System Failure Criteria applicable to all systems: z You must indicate "yes" or"no"to each of the following for all inspections: Yes 'o _ � ._Backup of se,v acre ii:ro facili of system component due to overloaded or clog2ea --`S or ce, e of V Discharge or pondinL, of effluent, to the sur-iace of ille around or surface waters due?O 2_Ov2ri0eQe or logged SAS of esspool V Static liquid lei 1 :n the distribution box above outlet invert due to an overloaded or closse.d S aS or _ �esspool iquid depth in cesspool is less than 6"below invert of available��olutn is less scan day f ow JRequired pumping more than 4 times in the last year NOT due to clogged or obsz.-ucted pipe( 4 Numb , /�times pumped ` v v 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 rater supply or trbutan-to a surface eater supply. _ v porton of a cesspool or privy is within a Zone 1 of a public well.. v portion of a cesspool or privy is within 50 feet of a private eater supply�et_I. i� .Any portion of z cesspool or privy is less than 100 feet but greater than 50 feet-From a prig ate w ater supply«-ell with no acceptable water qualitl-analysis. [This system passes.if the R ell Rater anah°sis,. performed at a DEPL certified laboratory.for coliform bacteria and volatile organic compounds indicates that the rvvell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 55 ppm.provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] V (Yes/\'o)The system fails. I have deternuned that one or more of the above failure criteria exist as described in 10 CMR 15.303,therefore the system fails.The syste n owner should contact ilie Board of Health to determine what will be necessary to correct the failure. E. L Large Systems: To be considered a large system the system must serve a facility vdth a design floe-of 10.000 Qpd to IS.000 Pd. You must indicate either"yes"or"no"to each of the follo v�ing: (The following criteria apply to large systems in addition to the criteria above) yes 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 suppl<< the system is located in a nitrogen sensitive area(Interim Wellhead Protactior__area—I,1 � , c,r =_._ Zone 11 of a public water supply X ell If you have ans«-eyed''yes"to any question in Section E the sestet i i5 considered z siMir�.ca_; yes"in Section D above the large system has failed. The owner or operator ofanY large s;a, significant threat under Section E or failed under Section D shalI upgrade 1 304: The system o:�ner should contact The 2 the'1'"n`in aCco,d�__ _h. ppropriate regional office of_ DepaT r - r Page 5 of 11 - OFFICIAL INSPECTION FORM NOT FOR VOLUOTA-RY ASSESSME\TS SUBSURFACE SEW,,kG.F DISPOSAL SYSTEIM IN-SPECTIOA FOR-Nz PART B. CHECKLIST Property Address: /J� �'giv�l �/� AeQ� S ✓�'� ©ot b�57 Owner: J 0 /(i; Date of Inspection: p p Check if the followuia have been done.You must indicate"yes"or"no as to each of the follow ng: Yes ,-o Pumping information-,vas provided by the owner,occupant. or Board of Heald !/ Were any of the system components pumped out in the previous t. o w.eks Has the system.received normal floes in the prey ious r o week period Have large volumes of\eater been introduced to the system recently or as part of this inspection'% (/ Were as built plans of the system obtained and examined? (If::hey-oere not avaiiabl� no e as_N A:r t/ Was the facilitv or d-, ellina 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,ooened.and the interior of the tank=-snecttid for the con. on of the baffles or tees. material-of construction;dimensions, depth of liquid;depth e sludge and depth cf scum:' Was the facility owner(and occupants if different from owner)provided width information on T! proper maintenance of subsurface sewage disposal systems? he size and location of the Soil Absorption System(SAS)on the size has been dete:-t~s_,,d basad on': Y"eS o xisting information.For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Par C is a issue app_0_6_-atiio�_o _s > is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSATLNT_S SUBSURFACE SEWAGE DISPOSAL SYSTE-11Io�SPECTTO\ FORIT SYSTEJI INFORALATION Property address: —�0 O«ner: Date of Inspection: l0 03 FLOW CONDITIONS RESIDENTIAL _� �Pr✓v►,}� \umber of bedrooms(design): Number of bedrooms(actual): DESK\ flow based � �on � O 1�._0_ (for example: 110 god x;; of bedroom;): \umber of current resrcents: Does residence have a garbage..grinder(yes or no):A� /10 Is laundry on a separate sewage system(yes or no)./'TV [if yes separate inspection required, Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(,yes or no): 1�i1 Last date of occupancy: C \I1^IERCI_�L/T\D O STRiAi Type of establishment: Design flow(based on=10 CMR 15.203): clod Basis of design flow(seats persons/sgft,etc.): Grease trap present(yes or no):_ Industrial«taste holding tank present'(yes or no):_- Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFOR-IATIO!' Pumping Records Source of information: O(j'/— Q(,✓y�r NVas system pumped as part of the inspection(ves or no): 4 r If yes; volume pumped: gallons--How was quantity pumped detertruned? Reason for pumping: v TY OF SY STEPvi Sepic tank, distribution box. soil absorption system Single cesspool Overflow cesspool _Priv Shared system(yes or no) (if yes, attach previous inspection records.-if an-,,' Innovative/,Mternative technology.Attach a copy of the current operation and maintena c.. _on i obtained from system ovmer) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all co on sndare installed if own)and source of informa;on; `V � _ ere,sewag�e odors daected when arriv`i 1g at the site(yes or no):&V T; l. G i c o t;nn F �/i rrinnn F Page % of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FOI01 PART C SYSTEM INFORM-2kTION(continued) Property Address: J� �Gii✓"1 C, R�j S rti o v�-- Owner: TO ivf Date of Inspection: /v p� BliILD.ING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition ofjoints,venting,evidence of leakage, etc.): SEPTIC T.A!'K: :ocate on site plan) —( p ) Depth below grade: Material of construction:_cvercrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a cop} of certificate) / l Dimensions: Lf� Sludge depth:: 'Distance from top of sludge to bottom ofoutlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet tee r baffle: �� How were dimensions determined: 0'0�2 �q 2vie el Comments(on pumping'recommendations,inlet and ctih e.t tee or baffle condition,structural integrity, liquid lc els as r�l ed to outlet invert; evidence of leakage,etc.): as re�led to ou / 2s kr GREASE TRAP: 11/ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): _ Dimensions.: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ' j Distance from bottom of scum'to bottom of outlet tee or bafte: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition.structural lntz.=l '-o_u..o i� els as related to outlet nv Y; evidence of'leakage, etc.): Page 8 of i i OFFICIAL, INSPECTION FOR-ill NOT FOR VOLUNTARY_�SSESS�IENTS SUBSURFACE SE«AGE DISPOSAL, SYSTEM INSPE.CcTIoz,, FoR-x,-� PART C SYSTEAl INFOR'IATI®\ (con_nuedj Property Address: / �vl Owner Date of Inspection: p TIGHT or HOLDING TANK: k(tank must be pumped at time of inspection)(lo^ate on si<e Depth below_grade: Material of construction: concrete metal_fiberglass_polyethylene o rer(exolai^) Dimensions: Capacity. }all oils Design tiow: _ —_Qalloris,day Alarm present.(yes or_.o : Alarm level: Alarm in-, orking order(yes or no): Date of last pumping Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid-level above outlet invert: p4o. ^hL Comments(noL-e if box is level and distribution to outlets equal; anv evidence of solids carryo:;r, .--d_n= -of . leakage into ou of box, -tc.)- �a F PUMP CH_AAMBER:Zooc ate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber; condition of pumps and appurtenances. etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR V OLUN T.ARY AS/SE S S i`IE N TS SUBSURFACE SEWAGE DISPOSAL SYSTF.Mr INSPE.CTTO71,T FORN-11 PART.0 SYSTEM INFOR IAT'IO\'(continued) Property Address: Owner: TO /f/ Date of Inspection: !o/( SOIL ABSORPTION SYSTE`+i (SAS): (locate on site plan, excavation not required) If SAS not located e-: Jwr T`p e leaching pits. leaching han leaching[retie n.<, o ., ieng' : � X leaching fields, mt rnber. dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Cominents (note condition of soil; signs of hydraulic failure.level of ponding, darns soil condi ion of ve2etaron. etC.): �" `cam. G ✓1�j sm, I �LGG[�1 G vL G Ci/ f h /cs a q 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 laver. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs ofhydraulic failure; level.of ponding, condition o f.eg�tat,on. etc.): PRIVY:k(ocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil,signs ofhvdraulic failure. level of pondina, cond,tion o- Page 10 of 11 OFFICIA-L I\SPECTION FORM-NOT FOR VOLU "TARY ASSESS1 EATS SUBSURFACE SEWAGE DISPOSAL SYSTE_17INSPECTIOti FQR-NI P ART C - SYSTEM INFORe1_kTION(continued" Property Address: �J �iv� (/G,Ile 0, e �- Owner ✓ O Date of Inspection.: /p SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sew ate disposal system including es to at least two permanent re_e_ence ar_Lm-arks or benchmarks. Locate all wells t-�-ithin 100 feet. Locate where public water sLTply enters the building. RIS-erf au- , a - Qy- s� T41. ; �nb.,onti nr �nrm till r Dade I 1 of 1 i OFFICIAL INSPECTIO FORM—NOT FOR VOLU TARY"ASSESS:-IENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM I\'SPECTION FOR>I PARE C SYSTEM I\'FOR-AlATIO!(continued) Property Address: /J �G,/✓''I ��+I �� L� Owner: �� ��.� t 2C_j Date of Inspection: !a SITE EXA12 Slope Surface matey Check cell ar lay Shallow wells Estimated depth to ground v ater r v feet �es 0,1 Please indicate (check) Lil I nnethods used to determine the hish Around water elevation: Obtai on, s�s em design plans on record-:i checked.date of design plan re v-iev=ed: O en ed site (at�urtii.J propem!obser�a ion hole jai 1 50 feet of SAS) Checked with local Board of Health-expiaia: G ✓jam Checked wri h local excavators,installers (attach documentation) Accessed USES database-explain: You must descr how ou established the i�h arov d«ate elevation: � �P/ 4P7 i rS O w -_- - 1 4 F'fI "UNN UHt-t= tNU I NtGK 1 NU our3 SbG 7C5 tY Q7 t".qG tet. SOS 36 •a a a , s39 main street rt Be t ) s Ofmouth port fax(506)362.9880 e'M 02675 dowry Cape e�gi�t�e�e�� Civil engineers& land surveyors rueturet design tune 29, 2001 Arne H.Oja,a P.E.,PLS, Daniel A.Ojata.P.I.S. ,and Court surveys Barnstable Health Department 367 Main Street site planning Hyannis, MA 02601 Attn: Glenn Harrington,RS sewage system designs Re: Lot 119,Farm valley Road, Osterville Dear Glenn: inspections Please find enclosed the site and septic plan for the above-referenced lot. The lot lies within a'iVell Protection District" and as such is restricted as to the number of ¢ef"';'s bedrooms per acre. This 1.11 acre lot is a portion of an open space subdivision whose total acreage is 27.26 acres. Whereas there are 12 lots within this subdivision,and taking the open space acreage into account, each lot is"apportioned"2.27 acres of land. Therefore, a 3 bedroom dwelling can be designed for the subject lot. ' Ve truly4 PUrs, Arne H. Oiala,PE,PLS Down Cape Engineering, Inc. -TIIE COMMONWEALTH OF MASSAClo1Sr.T{S ,. • x BOARD OF HEALTH ?_ TOWN OF BARNSTABLE '�4 , All flIirtitiult for �li�i}lttlsui �Glucl CtIuut;tcurliu`n �;Icrntitl. a �€ ^ Application is hereby Made fora Pcrutit to Con?tract ( `)'or Itcpuil ( ) an Imli.il6l:d `,:Igr I_ ' osal/3+r System y -.- V AI at ..............F��-gin. �..t�..-�-.<.-.. �......-!�,.t�:.��.-.-....... ............................! :-.r:.:...-.. .....- � ....- ......................-----•-- .................- .................................-................ 0 W .............................. ........ .. .9.n .............................. nelallrr � A•I•I,... �� .r; Type of Building _ �¢j _ ti•.r I.nt........'.J� ....'..$q. c'f�� U J .Fxp:ulsion Attic ( ) : (::nP 1 irlllrr, ( ) .. Ua•clling—Nu. of ISalrnonls..................._.....-...-........... pa, Other—Type of Building No. of persous......................_.... a' Other fixtures - -- l� Design Flow....................J.S.................gollons.per person per day. Total daily flow............................ \giJ,l R Septic Tank—Liquid capaeitc/SGV..gallons Leugtll................ Width................ D611'etrr.. -. .Ilrpth......_..:.. xDisposal Trench--No......�.........--Width.-.-...4.........'1•otal Length........eV.-.:Total learhing area...... 4c?srl.It. Seepage Pit No.................... la nlctcr.................... Ucl,th below illid.................... I o(al Ir:lcllil-g:11Ca........L........Sq. It. z Other Distribution box ( l Dosing tank ( ) / Percolation Test Results Performed b t/ f �✓ tr 4�<. 3 J ��y...-.Ij/l-.XI. �.............t/......-----..............-........ 1)air..................................... Test Pit No. I................minutes per inch Depth of Test Pit.........-L...... Depth to gruilod wnter.......:............. a WTat Pit No. 2................minutesper inch Depth of Tcst Pit._..............-:. DvIld, to.grounll u•ntrr .................. -.......-.. ....................................... ........�, is O — ).lit)/.. l Description of Soil....-......Q---I......1-'�LG.-----.......I.-.7....-. ..................................•..-:..........................5........ x .. W ................................................................................................s...........................................................................................:......... U Nature of Repairs or Alterations—Answer whin applicable............:....................................:............................................ r .................................................... Agreement: Theundersi)ned agrees to install the aforedescribed Individu:ll Sewage Disposal S•vs(em In accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place Ihr system in operation until a Certificate of Gmipliaoce has been issued by the board of health. Signed,..__..... ....... . Application Approved By ................... Application Disapproved for the/nllnuin•e rr,unn.r: ........ . .......................................................... . Permit Nu. issued THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE- QIertificate of Qluutpli:l►fce - THIS IS TO CERTIFY,That(he Individual Sewage Dispns;ll Systrol construucd( 1 or Rcl+:fired 1 t by............ ... . has been installed in accordance with the provisions a '1 ITH: 1 n(Tll( .'I;oc Fit ilonnu•In d(t dr;,a drat ribed it, the application for Disposal Works C-U1lsrruction Permit No. d:nrd .THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. » DATE inspc•ctnr. .. ..... --——---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF "HEALTH TOWN OF BARNSTABLE [� FEP........................ No......................... �8i�.�u�til„�urit� (nntttt#ritr#iuu �irrittit ' a .................................................................. Permissions isJlereby gnnted................................................................. , to Cons ruet (`1) or Repair ( ) an Indivi'll Sewage Dispwrd System ........................................... at N ' oz sl.r<[ as shown on the application for Disposal Works Construction Permit No..................... llatnl ;•. i .......................... ........ n.ui or n..nl rDATE............................................................................................. ' „ rorlM 36509 H06e9& A.nt".IHC..PUEL19H Cn9 5iW64..s FAMIL`f 3 F3EDac r E PLa I-1 oN BAGK uErzF " I3° GAOF3AZ�7- 6¢IQD MV- �- VA I� �D Os T" 'Dpl L_y F1-o 1c/ = 3 x I I o = 33D G rb r �-Dr �3�j f �l�M �/ u5& I Soo GAL. 1...1=AGl{lw, 5`(5rnA vESIGW 2- 4xdp x2 T>'eucNES D1 ST, , FFU GATIOh! AEr--A F-O< � °'14- � SF -� do I'� EEF Pv E '33DGPD ISF _ ddG APP LIGA-ri°N Ay-a� �F5 161J ----- --- - 40 51t�EWALL AL71=A x x2= 32oSr' dp'.cd,c2 g2p SF � �'Af L °F LEAGF�tIJG TOW-4t,OT T'OM A� = -- -TML � = Goa SF ,;oI'" P 6� PE2GOLbTIN SOIL 4 CL.4�j 1- Of Of IL:L PETER RICHARD ': $' SULLIVAA. N -A-------------- BAXTER 29733 �. ems•,� �'s� � � . 32 INv �•' 30 �S A`+7-� 1-�l� T�'�J�� �9 2q 1 � Z9 29'L (ram ✓1•b G�zp�Et. Bo,c -CAL a. ��21 5Q(7G SPu� P. C>=�T1 RP—D ROT P_.AQ �a WATI=7L- Lo a.T ia� OST Tr L - p PzoPosEo I r_szT1 F'Y T.HAT THE �w -LNG SE�O1c�N (�LA�1 IZE EY�t�1G�- 4aZF�hJ th-`15' �vt'ttl `74E SIDeL-jws A►>D Lo-r l33 LGG S125 SO x;M BAG IC. .zsry u i z s.AA JT E F, T"-I E TO KP4 OF MAn t 2a FA Zcp-4-L. ,141 BArUJSTASLG A1110 l5 Oor Loe-,ATr=D WIT'I.41N A Sp6ca 4L FlsbD HAZAZ-tD Z.ON E. 'aAXT � N`/E I NG €, LAUD SU�;'l=�c25 • ��I f1 EIr;� -PATI: 4,90,.(o, M f l �I -e�l G e./.,�i- G5 OFFSETS. NOT B E �nrj�IGA.�IT: �_,i,/1 d s. S'LVI a, QC,VSE3D Tb ' �T1'1BL15� f�OFE2T`� Lr►JES, 1 {A� f"F BARNSTABLE SEWAGE # • • `f/C AS MAP & LOT l4"r l VILLAGE DST r 'S NAME & Z• 7' �ev�L INSTALLER PHONE NO. SEPTIC T ANK CAPACITYall LEACHING'FACILITY.{ �Pe NO, OF. BEDROOMS___—PRIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNER Si L Ui A 4- Si Cut� DA TE TE PE RM ISSUED: DATE COMPLIANCE ISSUED: PARLANCE GRANTED: Yes No G' DATA �MEET i OF °5111&Ls FAMIL�f 3 F3EDRGtwA Z�,ME PI_A V4 oN BAGK. 1469ZVF I,lo GAVOMA Q- 6V-IQV SW- �7A-I Ly FLOW = 3 x 110 = 33o G Pp Lp'1" 1 �j I:AW-AA VA L E y. �D � OS T S zrn G 'T7A N L ` 33 d x'boo s,640 6 pc) uS& I Soo GAL. Lruct} w, 5,fs l=-m t s1�N w 2- 4'4 o x2' T��uGuEs ArLIe-ATIorJ AMA EELPb, r7�� 4 l7C• d0 r E�rl9E a --------- - ---- - APPLIGAnoN40 d26A ��516r•! -t -t t�— Sltj--WALL AV2_--4= 6D x2.x2: 320 sF Ds7A►L OF LEACA ut- TOWA IFOTTON1 AM4 = dp td x 2 320 sr P•b,. -TOI(- AIZA : 64v 5F .;oL. F'E¢GpLATION V41>r 2; a:.(y SOIL CL,4� or -- k• � L:VA � Jq � i a�4-I'�s STou6. PETER RICHARD G^"; SULLIVAN A. a; d � : 29133 eAzrER Nam. �� -,EcTIoN oF -IYr`►.L^� No 2tase r ,1;= Sum aAr 411.44, �SL-2`,� FGQ 32 .ter NacE- 12 FG -- r;a — ,; 1: SAi � gut �i 271, q4 24.G tt; (,a2PtlEL. �9 �1, BOf( �L E SPUR A. �'VELOPED �OFIt�--, cF-e-nFtGD PLOT PLAt.! io EL=�2 �v Vt/aT�7� 1_0GAT►OW oSTErz.VI L-L-E P 840 Gam; 3 2�95 SG,d.L� 1 '- da SATE PP��G,Ft4 S pzoposE� I G T7FY ~T-OAT TVE Dw 'NG StAvN PLAN TZ NGE- F4t=17.EDN coMFI-ys WIT µ -T-46 SIt>Et_lWr= AQC), �I- 133 I.GG S"725-SD SEtBACIC. ut2SM&PT EF T}IE ToK/W of f AfAP IZa, B A2fJ5TA a�� A 04D 15 Ovr LGtiATr D w I T'H41 N A SP�u AL I=tsbv HAZAz::;, 0. HyE I NG 1 r n LAND SLAZ '1=� 6 • F.1JG1 tilEEZS �DHTI `�.r'►���. 4(a, i��; �I C�l�e�1Gb��.���- _ OSTE��/I'�r •MA��i• ,, OFF SE="S Vr--/✓A -50IL.vltjr5 51bLXy NOT BE ��r,LIGaNT: ���wla VSED 'Tb , uSN Pr2D?EE2Ty LIQES, F S LILVIA �ILVIA 4,1- ,q . V 4 p.�Z / ram ' io AO / PRE. T N ? 43 q4c TANK- Ac r Of OF M PpO"A pH rg� " ^�D �y SULLIVAN SAXTER u No. 29733 TONAL f. J Engipepring Dept.(3rd floor) Map Parcel 47 Permit# House# Date Issued 9' Beard of Health(3rd floor)(8:15 -9:30/1:00-4:30)� .< t.rd-3 Conservation Office(4th floor)(8:30- 9:30/1:00=2:00) li�qe _ ..�- Planning Dept.(1st floor/School Admin. Bldg.) ��►�►o, Definitive Plan Approved by Planning Board 19 INS ALLE ST BE IANCE TOWN OYBARNSTABLNVIRONIMEN COME AN Building Permit Application ' Project Street A press V*f-t Village 0S7Z-4(OlLLC Owner 2&7M © Hy S Address s°r�ri2tt Telephone Permit Request ( ` J ©AL First Floor 6 0 10 square feet Second Floor square feet Construction Type Gt/ Estimated Project Cost $ `3 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family lil' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House El Yes LKo On Old King's Highway ❑Yes Basement Type: (9<U-1l ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing -' New Half: Existing _� New No.of Bedrooms: Existing New- - Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air Lk<es ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes p-Wo- Garage: ❑De ached(size.) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) ❑None ❑Shed(size) Ll Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name O E 1`�AJ �(- - Ia KL-yU I-A Telephone Number �O7 4� 0(o5�/ Address /`-(�_ /�p' %J-� _ License# f Y q D a C Home Improvement Contractor# / C �(D. M05 7rYv�' MILL 5 M Iq Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. }. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO tY SIGNATURE DATE LZ BUILDING_PERMIT DENIED FORT FOLLOWING REASON(S) 4) I' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 15 Farm Valley Road, Osterville, MA 0265Sv 3• 'leg Address of Owner: (if different) f9Z9& Date of Inspection: June 14, 1998 Name of Inspector: Michael McDowell am a DEP approved system inspector pursuant to Section 15.340 of Title \ -Ca .000) P , Company Name, Address &Telephone Number: The Building Inspector of America 2 Brookside Circle Wilbraham, MA 01095 1-800-626-4408 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a this odfdress.ai nd nthat The the information reported below is true, accurate and complete as of th inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: % Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Date: 6115/98 Inspector's Signature: 1�lichael McDowell MM/jk The System Inspector shall submit a copy of thisction report to the sharedroving system or hority asa within thirty (30) days of completing this inspection. the system is a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional officeeonf the ownerDepartment copies sent to the buyer,Protection. applicableand The original should be sent to the syst the approving authority. Copy to: Board of Healthy ^ Original to: . Catherine & Paul McDowell. Town of -0sterville P. 0. Box 1225 Barnstable Board of Health 0sterville, MA 02655 P. O. ,Box 534 Hyannis, -MA 02601 (Return Receipt Requested) Copy provided for buyer (revised 04125/97) _ s INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM-PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Comments: i B) SYSTEM CONDITIONALLY PASSES: N/A 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 ND). 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 ex-filtration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming 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 pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed A distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed - (revised 04/25197) r 2 _ . , C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in.order to determine if the system is failing to protect the public health, safety and the environment. 1) System will pass unless Board of Health determines that the system is not functioning in a manner which will protect the public health and safety and the environment: Cesspool or privy is within 50 feet of a surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. (2) System will fail unless the Board of Health (and public water supplier, if appropriate) 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 to 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 1 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. _ 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 (approximation not valid). (3) Other - (revised 04125/97) ` 3 D) SYSTEM FAILS: - You must indicate either"Yes" or"No" as to each of the following: N I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N/A Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ N Any portion of the Soil Absorption System, cesspool or privy is below the high ground water elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 P the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. N/A = non-applicable,. no (revised 04125/97) 4 E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 1,0;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 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. 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). x The owner or operator of any such system shall bring the system and facility into full compliance with the ground water treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) , 5 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: Yes No Y Pumping information was requested of the owner, occupant,and Board of Health. Y None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. ,Large volumes of water have not been introduced into the system recently or as part of this inspection. , Y _As built plans have been obtained and examined. Note if they are not available with N/A: Y The facility or dwelling was inspected for signs of sewage,backup. Y The system does not receive non-sanitary or industrial waste flow. Y The site was inspected for signs of breakout. Y All system components,.excluding the Soil Absorption System, have been located on the site. Y 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: y The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. y Existing information. Ex. Plan at B.O.H. y _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distanceis unacceptable) [15.302(3)(b)]. (tevised.04125197) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION . FLOW CONDITIONS, RESIDENTIAL: Design flow: 330 g.p.d./bedroom for SAS per Board of Health records Number of bedrooms: 3 Number of current residents: 2 v Garbage grinder(yes or no): No Laundry connected to system (yes or no):-Yes Seasonal use (yes or no): No Water meter readings,if available (last two (2) year usage (gpd): as per water department, 432,000 gallons for 1996 - 1997 Sump Pump (yes or no): No ` Last date of occupancy: currently occupied a GENERAL INFORMATION PUMPING RECORDS and source of information: , Never pumped as per owners. System pumped as part of inspection: (yes or no) No " If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM X 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) , I/A Technology etc. Copy of up to date.contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Original with house, approximately 2 rears old ash Pr Rfardl of Hail th r13COrds & owners. SEWAGE ODORS detected when arriving at the site: (yes or no) No (revised 04125197) - 7 ` a J BUILDING SEWER: (Locate on site plan) ,. Depth below grade: 20" Material of construction: cast iron_X 40 PVC_ other (explain) Distance from private water supply well or suction line Diameter 4 Comments: (condition of joints, venting, evidence of leakage, etc.) Building sewer exits right side foundation wall 17'S" in from rigbt front corner. SEPTIC TANK: X (locate on site plan) Depth below grade: 36" Material of construction: x �concretemetal_Fiberglass_Polyethylene_other((explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 10'L x 5'W x 5'D approximatel 1500 a Sludge depth: 1-2" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 20" How dimensions were determined: with a tape measure & pole Comments: recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level ( etc. in relation to outlet invert, structural integrity, evidence of leakage, ) Septic tank & PVC tees are sound. Fluid level was correct - that is equal with outlet invert. Septic tank has 2 r' __grade. Mandato um in s { (revised 4125197) 8 DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Fluid level was correct, that is, equal with outlet inverts. Distribution box is sound and level There is no evidence of solids carj3z n��Pr, SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, if possible, excavation riot required, but may be approximated by non- intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number aching galleries number: leaching trenches, number, length: two, each 40 feet long leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition bf vegetation, etc.) There is no evidence of hydraulic failure Vegetation is normal. (revised 04125197) • 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two (2) permanent references, landmarks or benchmarks. Locate all wells within 100' (one hundred feet). (Locate where public water supply comes into house.) NOT TO SCALE A = inlet cover C XA = 56'1" .YA = 17'2 B = outlet cover XB = 5912" YB = 25'0" C = distribution box XC = 51"4 YC = 4116" A.S� S.A.S. S+ t _ A f. r StW - GGrage Tom WQ4er 15 Qrm voney i?od. )revised 04125197) 10 I . DEPTH TO GROUND WATER Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record Observation of Site (Abutting property, observation'hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Date Describe in your own words how you established the High Groundwater Elevation. Must be completed) f No groundwater at 10 feet per Board of Health records'. No sump pump in basement. N (revised 04125197) 11 , . v i rf l /XWfF BARNSTABLE LOCATION �� Ualte,`l X9, SEWAGE # IS-0.7 VILLAGE ASSESSOR'S MAP & LOT l ZZ INSTALLER'S NAME & PHONE NO. IZ. -g2y i lcc� ia SEPTIC TANK CAPACITY i S `�u; vit LEACHING FACILITY:(type) (size)Yo'X�) ` NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER t BUILDER OR OWNER (,uCA -f- St Lui DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: '^' VARIANCE GRANTED: Yes No \A J Ol Q?�l rf ' r� MAP I'Zo PAL 1,--7 No.--•-•-•��._...../6 0 /" Fim......_ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for DinVm3al Works Tomitrur#inn Urrmit Application is hereby made for a Permit to Construct ( '--<'or Repair ( ) an Individual Sewage Disposal System at ........../_ Ar ilti �............ .__� T1% -------- ----------------------------�`T............................................................ Location-A ess --•• ----or Lot No. .......-'-----•- .- •- - - •-- .................... -•-----------'---------•. ..-._.."--"•--'--......---•--........-_ vn Address aW ---•-•--------------- ------•-----...-----------------------'-' '--'------'--•--•-••-•••------.........._.. Installer Address / Type of Building Size Lot....45t.______-�--Sq. feet ►.. Dwelling—No. of Bedrooms------------------ --------------_---------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures _______________________________ _ _ W Design Flow....................�P .................gallons per person per day. Total daily flow....._...._..___..__.._._.____�d....gallons. WSeptic Tank—Liquid capacity/SCV_.gallons Length________________ Width----------------- Diameter---------------- Depth____-________-... x Disposal Trench—No- -----2........... Width......4--------- Total Length--------60.... Total leaching area______ .sq. ft. Seepage Pit No......................Ylameter----------.--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) / �� /�� ,3 2,7 9°� Percolation Test Results Performed by......84,?� --_t__/_V_Y_ ...... _______________ Date-___________.__..._._________._._._.._.. aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---__.---._-_________... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------•-------------------------------- - .................................. -•------' •------------ _ SAM0 Description of Soil....-------�--/-------2 ------------ �-Z J f 2'.. x W ---------------------- -----------------*............................................................................................................................................................... VNature of Repairs or Alterations—Answer when applicable.-_............................................................................................. . •-------•-------------------•------•-- ---------•-----------------------------------------------------------'--.... ----------------------------....------..-------------------------._..........•'••-_. Agreement: The undersigned agrees to install the aforedescribed I' ividual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental i he undersigned further agrees not to place the system in operation until a Certificate of Compliance ued by the board of health. Signed - ----- ------------------------------------------------------- 1. l ................. e Application Approved By ............ ..._....... - VCR ie Application Disapproved for the following reasons- -------------------------------------------------........ ... ..----__.....--. --...... ........ Y Dace Permit No. - --------- ----� � ----..-- Issued ..... �1.-.. �l� Daze No........ ..:_- �r0.v_ FRs...... ... 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dhrip ial Works Tomitrnr#inn Vasa t Application is hereby made for a Permit to Construct ( '') or Repair ( ) an Individual Sewage Disposal at System.. "�n1Z \fAL o,.>a �T� �. e 33 Location-A dI ess ^---- r Lot=No.. � �� .= ... .�_ c�------ --------------------- ---------------------------•-----------------------------.....----....._.....------------..-...... ;- Own Address i� ------•----•------.- Installer_ AddressPO C UType of Building Size Lot..--.�........--��_.Sq. feet Dwelling—No. of Bedrooms........:.:.......�._----------..........Expansion Attic Showers Garbage Grinder Other—Type Type of Building No. of persons............................( ) ( ) g ( ) WDesign Flow-Other fixtures ......-----___gallons per person per day. Total daily flow---------------------------32P.._gallons. WSeptic Tank—Liquid capacity/mil .gallons Length---------------- Width_-------------- Diameter_---_---.-.-- Depth................ x Disposal Trench--No. -----I........... Width......---.-.-.- Total Length..----.. D---- Total leaching area-.----4 sq. ft Seepage Pit :Vo--------_-..------- Diameter-------------------- Depth below inlet................................ Total leaching area..................sq. ft. Z Other Distribution box ( Vr Dosing tank ( ) Percolation Test Results Performed by. �` d.X ---f-!�! `--•----1AJC ✓� ' L� a --•-- Date ---. ----•--. -- ,� Test Pit No. I-------------*_minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit..............-----. Depth to ground water........................ C) Description of Soil-••-••-••:.n.-./ EC.L ............._J1 i....r/�rZ..---------....=---lv.........Jl /......S/..tt/.... x U ...-•-----------•...----••••------------------••-•--•--••-•-----••••-•------•-•--------•••••----------•-------------•-••----•---•-------••-----•-•-•----•----••----•••--••-•••------•---•--•----•--•---- w U Nature of Repairs or Alterations—Answer when applicable.-................................................................................••--.-.-.-.--. --------•-----------------------•---•----------------------•-----------------------------------.....--- --------•---------------------.....-----------------------------------------------------••-•--_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental d The undersigned further agrees not to place the system in operation until a Certificate of Compliance h e ued by the board of health. Signed .. ... .................... ...................................................... U -------- Application Approved B �.,-«- ,...- ..e. �,..-z�. . ----------------------------------- (--w,---- -..... PP PP Y ...... Nate Application Disapproved for the following reasonf- ---------------------------------------------------------------------------------------------------------------------------------- ....... ...................................................................... ... .................................... . ........... ---------------------------------------- Date Permit No. � C .. .... ........ Issued - -.. .�.-..... �� Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifirate of C ompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by -------------------------------------------------------------------------------------------. --------------------------------- ------------..................._....--------------------.....------------------------------..----:--- y-. /� installer A at --------------------- t)1 -.'33.. ........ .�'_�/l.fn-------.�/�.L� C ........�.`/0 --------- ---r----------------------_---------------- has been installed in accordance with the provisions o TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated _�.5............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT E SYSTEM WILL FUNCTION SATISFACTORY. _ DATE......�.. _............... . - Inspecto,�Cf _... - - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.�.V 5----..,.. 3 FEE.....L 0.0....... Miji sat Warkii Tnntrurtinrt "amit Permissionis hereby granted---------------------------------------------------------------------------------------------------------------------------••----••-••---••-- to Construct (L,�or Repair ( ) an Individual Sewage Disposal System atNo..C!?`� roil lz . L/a L-G`?, 11A 1 T '<' ----------------------- ...........................•.................................. 7 Street / �� n as shown on the applicatio •for Disposal Works Construction 'ermit No.7J�_I%-��Gllated.f.... .....�?..-.....•......._1L.. ..........��.1'I/ --------; ---•..___.. Board�of -Health v DATE......................... --/j--� .. -•---•- - FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS i C � s 7� 7 3 , 6 ye� i 6 �j —' � = Nam' �QDA� ttr _� 1 � inQA El 9 ip d b z as N � Prnk w u 8 Z P d N Z M �► m Q 1% ..a C— m -� m -� F1% D ° ON .�► z- m in 1 Ln LA � Z � I� m � .a�.. q .tom 't•o, '.+ :'s• _ N- �; ;ui• 1 tl SILVIA �ILVIA 46 4,G- q41 do' d,A- 13 ? i 43,g45 SF TA►,u- F N I F T'i—min , ii ii . s ♦ / � FxP� v E-VI K ' OFOF , I PETER g.�/ OT we.LAXTM 4.�, SUUIYAN 'tUpOi,2A�Crl� 1 1161Zfj No. 29733 pp, r -� C3`�OPIAI F``''•. 1 AP.PLICATTO ( FOR PERCOLATION TEST AND OBSERVATI PITS LOCATION Q r `5 °' 1` v� ��cte" IC 04::J NO.! "' VILLAGE.``: DATE ✓-rm' e APPLICANT S 1 L:V 1,A- S IL.i/)4 . FEE �G�Sa Ali ADDRESS` f ' TELEPHONE NO. (Non-refundablF ENGINEER L I g 4C- TELEPHONE NO. �_7_6'q)' l DATE. SCHEDULED MA ZC? (�cL (Applicant's signature) • • • • • • • e e e e e o • e •'o o n e o e • e o.• • • o e o • e e e • • • • • � o • • • e • • • • • • • e e C e • • • • • • • e • e • � • e s o • • • • o ASSESSOR'S biAP <LOT NU: SOIL LOG SUB-DIVISION NAME_ �i�1'Lin�_ DATE_ 2�7— TIME //-Ar2 EXPANSION .AREA: YES NO �AXi �1 � 1� GI - ENGINEER:*N* ' TOWN WATER PRIVATE WELL �7 PJp n,�t .� BOARD OF HEAL? EXCAVATOR SKETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: 1 2 �z 3� of I� ?0`�� )4­ l 6' ' PERCOLATION RATE:: rN 11AArN L�►SS TEST HOLE NO: ELEVATION: TEST HOLE NO: 2-- ELEVATION: 2 , .c-uny �rca✓. 2 3 �-- 3 4 4 _ 5 �� 5 SAwT 6 A 6 ' 7 S14v�• , s 9 9 10 10 • 11 li 12 12 13 13 14 ~' 14 15 15 16 16 SUITABLE FOR SUB-SURFACE. SEWAGE: . LEACHING FIELD_ LEAC NG PITS LEACHING TREN:CHE9 UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEEtRING PLANS MUST SHOW NUMBER ASSIGNED -ON PERC TEST APPLICATION `- ORIGINAL: COMPLETED IN ENTIRETY BY P. F AND RETURNED TO BOARD OF HEALTH COPY: . RETAINED BY APPLICANT i NOTE: DIRECTIONS: ZONE: 1 The property line information shown was - RF-1 ) P P Y From Hyannis — Follow Falmouth Rood / Route compiled from available record information. Area (min.) 43,560 SF P 28 West towards Osterville; Take a left onto �> ti 2 The topographic information was obtained Frontage (min) 20 ) South County Road, Take a right onto Form }„ from on on the round survey performed Width min 125' ' j 9 Y P Valley Road; Site is on the left, #15. Setbacks: ) I on 14/OCT/2019. 3) The datum used is Approximate NAVD '88 Front 30 Per G/S Benchmark. Side 15' � j Rear 15, E LOCATION MAP: 1"=2,000f' SESSORS REF.: l Map 120, Parcel 147 / OVERLAY DISTRICT: WP — Well Protection RPOD - Resource Protection Estuarine Overlay F r V411erRoad I FLOOD ZONE al Zone X (Min Flood Hazard) Community. Panel No. I 8 47• ( #25001 C 0544 J July 16, 2014 i Paved Drive:\ 46„E \ N54• 9 1 0 �� I \u' Lawn '..: '..• W �' REFERENCES: 1 h/ Deed C149785 Plan LCP 5725-50 1 Lawn ! - f Walk �00o N ro 04 Paved Drive I orch , CoiNn �t I'll N 1 a x } 31.4 j # 15 � OPO ED FEN E f � 2 Sty w/f ) Ik \` Dwelling 1 , PROPO sEfl ! J`� r 58 6' If � / ..'SPA 11 0 PROPOSED.) f �\ Deck POOL q Lawn ` Lawn � I .--` ._... ............. 0 �Existing .....__......... ... .._._. .._._. _. .... . ..............._:................................ ............... Septic Tank \ , \ j INV. EL 25.72 PROP o PROPOSED l i I TO BE OSED S IN EL. 27.8 �y PATIO CONFIRMED i 9, /'/TCy w R L/n/�c PROVIDE \ 4 PRIOR TO 'y/N CLEANOUT pAt: } o CONSTRUCTION / j 71.2' PROPOSED ; ` CABANA oca CA , ,j•. ..... ........................................ .. . l :..........:. ... ....... . ...... ..... ...Lawn PROPOSED FENCE / 'J � 1. 00 230.53' � LEGEND. 1 S68' 11' 06"W / I 0 CDT Cedar Tree n 230.53'.� ` S66' 11' 06"W -- HT Holly Tree Property Line Bearing Error DT Deciduous Tree er Land Court Plan OF kA Be Confirmed CT Coniferous Tree c 7D Utility Pole �y ;LAaE -E— Electric CfV °, 699 "' —G— Gas ` a n�!- Wetland Flag GIS7ER \�444 ? Light Post `r� l43NAlE��'2020P Adjust 0 CB DH just Cabana atio Locations 05 19 � / / / OHW— Overhead Wires Adjust Pool, Spa, & Cabana Locations 0311612020 25 Elevation Contour REV.: Adjust Pool & Spa Location 1012912019 TITLE: PREPARED FOR: PREPARED BY. Site Plan Proposed Improvements Edward F. & Jennifer 0. DeGroan Engineering & mmi p p 14 Hill Top Road At p consuitinonc. p Hingham Moss. 02043 Farm Valley I-7 508 428-33" • R.O. Box 659 • 711 Main Street Ostervill M �5 a Road c ) e, A 02655 0 seci@sullivanengin.com • www.sullivanengin.com -TI Barnstable (osterville) -Mass. Field: CTR/ WHK 20 0 10 20 40 60 DATE: SCALE: Draft / Review: JOD October 23, 2019 1'►=20' Pra j• # 27026