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HomeMy WebLinkAbout0024 FARM VALLEY ROAD - Health 24 Farm Valley Road LA = lle 97 036 _ J a a Commonwealth of Massachusetts / �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 24 FARM VALLEY RD Property Address I .. BLAZE p- Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out S 1# 11329 forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 I l City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-24-15 Insp or'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. \o' Us t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 17 I� I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every 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 MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION THIS REPORT DOES NOT PREDICT FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE 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 Forth:Subsurface Sewage Disposal System-Page 2 of 17 a Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. City/Town 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 ❑ 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 GSM , 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityrrown 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 aseptic 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any 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 15.304. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "r 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityrrown . State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 5 DRYWELLS SURROUNDED WITH STONE Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundrys inspected? y stem ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2013-----279 2014---249GPD OWNER STATED HOUSE HAS GARBAGE DISPOSAL SYSTEM IS NOT DESIGNED FOR DISPOSAL RECOMMEND REMOVING Sump pump? ❑ Yes ❑ No 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 meterreadings, if ate ete available. t5ins•3113 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 M , 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: OWNER STATED PUMPING EVERY 2 YRS 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2002 AS PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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: 1.75 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: MODERATE/LIGHT t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a<o 24 FARM VALLEY RD ' M Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 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 Scum thickness LIGHT/MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK LOOKED NORMAL AT TIME OF INSPECTION WITH NO SIGNS OF BACKUP OR FAILURE 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 N Date of last :um in p p g Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24715 every page. Cityrrown 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.): 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 i 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M '( 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is OSTERVILLE MA 10-24-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): BOX HAD A MODERATE SCUM LAYER PROBABLY FROM GARBAGE DISPOSAL 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 - every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CHAMBERS WERE VIEWED BY CAMERA THROUGH THE D-BOX. AT TIME OF INSPECTION THEY HAD AROUND 1 FT OF STANDING WATER WITH I FT OF USABLE SPACE. NO SIGNS OF FAILURE OR SOLID CARRY OVER 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. City/Town 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: GREATER THAN 5 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of W E 4. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 FARM VALLEY RD Property Address BLAZE Owner Owner's Name information is required for OSTERVILLE MA 10-24-15 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 lt�WNUrn I•AI$Lb LOCATION SEWAGE#CL(JL —54C� VILLAGE, �(( ,,``!! ASSESSOR'S MAP&LOT t1 97-9 INSTALLER'S NAME&PHONE NO.W iW .Ubj . T Z l to SEPTIC TANK CAPACITY t'�00 481 ti -10 1` TA Z� . LEACHING FACR=.(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERwrDATE: 1-2ki—o1 COMPLIANCE DATE: Separation Distance Between the.- Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ^I C Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N Fee Furnished by �•-3 SZh, 1�0 (�1L. 31 6cyvc 1AMV, 0 I http://www.townof bamstable.us/Assessing/HMdisplay.asp?mappar=097036&seq=1 10/29/2015 Q} 'M Page. 2 'CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory RECEIVED Report Dated: 5/28/2004 Report Prepared For: IWN 0 7 2004 Gary Oakley Order No.: GO 252 COMM Water Dept. TOWN OF BARNSTABLE HEALTH DEPT. 1138 Main St. P.O. Box 369 Osterville, MA 02655 Laboratory ID#: 0425216-02 Description: Water-Drinking Water Sample,#:' 24B Sampling Location 24 Farm Valley Rd Osterville MA Collected: 5/20/2004 Collected by: Oakley House Received: 5/20/2004 Test Parameters ITEM RESULT UNITS RL NICL Method# Tested LAB: Metals . Iron 0.3 mg/L 0.1 SM 3111 B 5/20/2004 Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste,, odor,staining)due to Iron. Approved Bv: Director) I ' 1 Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 . .... TOWN R f"TtiBLILE �L :IT :19 - 4839 IcE ;Q. FT. D i 1.1' CRES rn , CIO -I- 17.Of ,1% �. Ss 0 43.5-` I& �*yL 5 (NJ1 4 N N, J �D 0% .10 N ' 37.50' Joe.# 01 038 FARM VALLEY BUD CER TIFIED FO UNDA TION i1.1111 AN FOR THE PURPOSE OF OBTAINING A a'U!! DlNG PERMI T Lo�'-� FAjw vALuy JSJ� r�. PREF ARED F� )R: 1°�"�'°N . 08TBJt"M , MASS. JERAI;D BLS IIZE SCALE 1'° = 60' DATE : SL'PTS1Ui '.I!'R 21, 2002 REFERENCE : L.C.P. 5725-45 SM. 2 ASSRSS. YAP 87 PCL : !i' I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAIN ►S LOCATED ON THE GROUND AS SHOWN MIEAEON. 1K Of Mq;a off. d�ooee 362-4541 boy► ARNE fox !i0!-SE2- 0 S OJA. LA down cope engineering, Inc. �o No.26348 � f , CIVIL 9eMIN)MRS '`Jf f 1S1 L"n SURVRYOAS ; T WN OF BARN TABLE Pool LOCATION SEWAGE VILLAGE ASSESSOR'S MAP &LOT_ 6 INSTALLER'S NAME&PHONE NO. ►l la Am D1�1Z 6C6 1Z t SEPTIC TANK CAPACITY tS®Q 6Aj �`` i LEACHING FACILITY: (size) y y A 2 NO.OF BEDROOMS BUILDER OR OWNER PEKMITDATE: ` ®o COMPLIANCE DATE: 'Separation Distance Between the-. Maximum Adjusted Groundwater Table and Bottom of.Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished by TOWS L 1 , J vovQ 4A I No. �Y `` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: + es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Miopogal bpgtem Congtruction Permit Application for a Permit to Construct)Repair( )Upgrade( )Abandon( ) Complete System O Individual Components Location Address or Lot No. Owner's Nam Address and Tel.No. - Assessor's Map/P 1 uI Aw Installer's Name,Address,and Tel.No. 1 ;� signer's Name,Address end Tel.No. Type f Buildin Dwelling No.of Bedrooms_ Lot Size d �((�sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date ( d Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Q Description of Soil t Aid 54ju 0 a Nature of Repairs or Alterations(Answer when applicable) inspected: ins Date last p 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 Ti Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has e b ealth. �y Signed Date ®� Application Approved by r Date ® - � Application Disapproved for the following reasons Permit No. � `" �� Date Issued a } - d f' w/W' 9,spy No. ` Fee THE COMMONWEALTH OF MASSACHUSETTS t F �Entered in computer: PUBLIC HEALTH DIVISION -,TOWN OF BARNSTABLEt MASSACHUSETTS 3 Zipprication fovMiopooa! *r5tem Cori,5truction Permit Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. / ,,'t Owner's Nam ,Address and Tel.No. y Assessor's Map/Parcel Wil tN � t^11� Instr ller's Name,Address,and Tel.Noi� Designer's Name,Address and Tel.No. - o 0cr 959 1 4 e 4 wle (6016q, f Building: Dwelling No.of Bedrooms i Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. a Plan Date (A.Jan)m Number of sheets + Revision Date Title Size,of Septic Tank Type of S.A.S. 5 h ,. UL&IT111 Description of Soil l « Nature of Repairs or Alterations(Answer when applicable) 1 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 0-the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has�een-*ss edMbis o ealth.Signed e Jate ✓ 91 Application Approved b- ye!Application Disapproved for the following reasons ` E Permit No. /'' " ' Date Issued -----------=----- `�=-------------------- f THE COMMONWEALTH OF MASSACHUSETTS-- z BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIF that the On-site Sewa Dis osal Sy stem Constructe .(� )Repaired(( `r)Upgraded( ) Abandoned( by t T at ' e has eep constructed in accor-dance with the piro'v`isions f Title 5 and the for Disposal System Construction Permit _�Nj Np' C3lf has/ Installer W ► 1,0_� Designer Uti.• The issuance' f this permit shall not be construed as a guarantee that the syste 'wi fu t a esigned. Date 2 13 y I z- Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migooar *pgtem Construction Permit Permission is hereb grantei�t Construct(( R pair( )Up r de( bandon�� System located at t t , ` � y` ,. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of t ermit. Date: Approved T WN OF BARN TABLE TION 1 �—� SEWAGE #2QL " 6 LOCA � VILLAGE I�VILUL ASSESSOR'S MAP &LOT -� 6 INSTALLER'S NAME&PHONE N0. Dt 6C 7�l i SEPTIC:TANK)CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER �-- PERMTTDATE: 1'2L-'®t COMPLIANCE DATE: — Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells existNO on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fac'li Feet • Famished bye C ki i 60.6 �� 1 L 1A-t1D 3 fix.- .tt y 7 - tel.(508)362-4541 939 main street rt 6a fax(508)362-9880 yarmouth m mass 02675t down cope engiaeeriftg civil engineers& land surveyors structural design June 29 2001 � Arne H.Ojala P.E., P.L.S. Daniel A.Ojala, P.L.S. land court surveys Barnstable Health Department 367 Main Street site planning Hyannis,MA 02601 Attn: Glenn Harrington, RS sewage system Re: Lot 119,Farm Valley Road, Osterville designs Dear Glenn: inspections Please find enclosed the site and septic plan for the above-referenced lot. The lot lies within a"Well Protection District" and as such is restricted as to the number of permits 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 5 bedroom dwelling can be designed for the subject lot. Very truly y urs, Arne H. Ojala,PE, PLS Down Cape Engineering, Inc. '7AI o9 p,ee AM dP-0' O Y4 9'-0' 2'-0' d _ ---------------------- ----------------------- 's a , s a � m , ' ° o'-a u4 11 o vs' y._p �yQ null 7 A N bz' ^ w 8/B GASW QM'6 • k __________ i Y4 U 0 A aO;iBa} �Qt\ d T I , •----• ao c.o. 4" - ------------- i ------------ a a @ N m yU � eex D Ito 111@ M 3 IW T Z t" `( O -------------------- W to m m 9 W ` d � a i6 x 6ia W w b IN II b 7'-0' 94' MAO' 24' Q _ 3 ----------------------------------- P 9 vexes � rn 3 , o QN Q Q % > t, 218 OPEN r-y-- 7'4 Y4 { BLAZE RESIDENCE ` Tee � mb,•�•he , of ft-roeN6o ARCHI-TECH A550CIATEE .. _ .. of 'A,hft—t ac l H-to .. LOT 119,FARM VALLEY ROAD the"Aht Prot dW Works � O I t Protection Acl'at N `°��' archl-GP..c'Liurc91 deSlgn, Inc. 4 = 05TERYILLE, MA55AGHU5ETTB repo. Ary..p4,oueroao � � Q fevreactb dn or roo-a.nlon of of �Y th.9e P�.Itl t�e��' 6 echool 0troet tel-508-420-5385 ` ,v1Uen conxnt of fvcN-Tech FIR5T FLOOR PLAN A t �B W. �"�° o,,Zuit,ma 02056 fax—008-420-5ao-4 menl of of lha!W. TAI 'h"A Y-b' Y-e Y-0' 4'.W Y-b' 3'-0' Tv - ................ ------ ..-.--.- ...... .....__. ......... D rn 's r m. 0 a I I ' _ O\ I I I T I � _ I e p 0II -- ------------ I I ------------------------ II. L Oii r L o s S Oo I a lP I z 1 /0 ---- 9T ' OPCWON'O i b 'Ir O +F I r 3 T T ♦ X WO S „ x lr W.w/ T_ {--... }- } Ir o I IL 1 I LINEN �. § T_ d n, ee o FOLOI Od1NTER. '1'-- .,. x LINEN k A _ � � � �� R iN� � � � � � � $ 33 ° � t �Hxbre •� s A U N N Al N •, ,•�1 4 YI R ' � d I .. N� N N � N N N N � ;^'a V) 9•�' § I ---------- y VIVIVZVZVZ Y � m 3 A a o a Ip N P P N � N N N i Q vp�t y i rTl k k o • • x x K k k k k k k k @ O @@ P A A P A z A r Ip W Z O N > � a a y{ y V r { @ �@ @ P P I ...__. I I � I I I I I ra Y-r' --------------- BLAZE RESIDENCE w"c-'"'r='° „ft"&aw"a_Q"to ARCH I—TE'CH .ASSOCIATES ' LOT 119.FARM VALLEY ROAD the'^Archltectvrgl orkH o WCopVlot f vt.,tlon Act-of a rc I�1 i to c t u ra I d B S i g n. i n c. 1 1 05TERVILLE. MA55ACHUSMS woo. Any°'py' raprodctlon o d@l,wion of Mex 'm a O.A I" — p 6 school 0breet tot-608-420-5835 written caneanl oP Nck4Ta0 SECOND FLOOR PLAN A660C�`eB' is""fr�e' ootult,mm 024555 fax-50.5-420-5304 meat of lfal ad. ' wxwllwllwpl�x�l�l�l/�Ylr�lll�l�lwl�wrllrlll��wrll���ll/�r!rlw��lllc.."!:11rl�lll� TOP FNDN EL. 32.8' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) rACCESS COVER (WATERTIGHT) TO ENGINEER: ARNE H. OJALA, PE 32 MINIMUM .75' OF COVER OVER PRECAST J( TWIN 6" of FIN. GRADE WITNESS: GLENN HARRINGTON, RS 2% SLOPE REQUIRED OVER SYSTEM y _ ?7 0' JUNE 5, 2001 RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE � DATE' I 9 29.$' FOR FIRST 2 _ < 2 MIN Il:CH PROPOSED 1_500 3' MAX. PERC. RATE - / *a*o GALLON SEPTIC 29 (� 29.25' TANK (H- 10 24.83 CLASS I SOILS P# �w ___) GAS \724.5' �� BAFFLE z4.67' o00o a © o o a LOCUS ._-- ( MIN � SLOPE) �6" CRUSHED STONE OR MECHANICAL 6" SUMP o 24. m m C] 0 m m [� 0 0 0 3' AT SIDES 171 ��o�o COMPACTION. (15,221 (2]) 0 2.5'1. �' ENDS ELEV. �P'�� `DEPTH OF FLOW = 4' 0 8 2' 0 0 0 ED 0 O 0 0 ED 0 22.0' „ �/ F� TEE SIZES: (� SLOPE) O 0 & A 27.0 0 30.0 INLET DEPTH 10" 3/4 TO 1 1/2 DOUBLE WASHED STONE 0 & A �� LS LS w OUTLET DEPTH = 14" 10YR 2/1 9" 10YR 2/1 O {�. LOCATION MAP NOT TO SCALE FOUNDATION- 10' SEPTIC TANK - 92' D' BOX 11 LEACHING Ms Ms o FACILITY 12" 1OYR 7/1 12.. 1OYR 7/1 ASSESSORS MAP 97 PARCEL 36 B ZONING DISTRICT: RF �� 0 5' LS S YARD SETBACKS: o, CO i Si'1 `Z FRONT = 30, 10YR 56 36" / 24.0' 36" 10YR 5/6 27.0' -�► SIDE = 15, o Cl REAR = 15' N 6.a Mcs Cl PLAN REF. - + 33. PROVIDE SWALE AS NECESSARY TO DIVERT WATER 17.0' 58„ FLOOD ZONE: C LOT 119 10YR 6/6 MCS o 4 .i AWAY FROM FOUNDATION / 2 + 45cb 1OYR 6 6 N h � 48396+/-- SQ, FT. C2 72" ix 4'� � j ! 45' � 44, -�� / & N MS C2 � + 3 .4 26,0 43- '45 41� +C29.4 MS `� "' ^� .a ?� �^ 2.5Y 7/4 4 N_ � � � 39 -_' --_/ + _ `'� 'ti`1 120" 17.0' 120„ 2.5Y 7/4 20.0' NO WATER ENCOUNTERED NOTES: + 36,3 APPROXIMATED FROM QUAD 36 PROP. DWELL. / S� SEPTIC DESIGN: (GARBAGE blsPosER Is NOT ALLOWED ) 1. DATUM IS ��" IGN FLOW: 5 110 _ 550 AVAILABLE �2 __ BEDROOMS ( -,`.GPD) = _.T�PD 2. MUNICIPAL WATER IS 2 ../. / /�--37,0 r... ,._ 55n r..rr r..,r-,h.! 1 nt l .;1:1• !' ......_ _...(.. __ .i • ..J .. A ..•! v ,:"...-GN Fes„• �_ ..._:_. l Pt t�1 4 A Pl r`)f I".I -I F Tr 0i 1 DIVERT ALL RUN-OFF N GARAGE +,2 SEPTIC TANK: 550 GPD ( 2� = 1100 4, DESIGN LOADING FOR ALL PRECAST UNITS TO Br AASHO H-_i0.4._ SLAB O El. AWAY FROM 5. PIPE JOINTS TO BE MADE WATERTIGHT. az.a• + 39,2 1500 FOUNDA ION/GARAGe N JSE A GALLON SEPTIC TANK ( 3+ 33. , / 1 9 BEACHING: 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ENVIRONMENTAL CODE TITLE V. SIDES: 2(47.5 + 10.83) 2 (74) - 172.6 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE \ w USED FOR LOT LINE STAKING. 26 ` O + 0.6 ` BOTTOM. 47.5 x 10.83 (.74) = 380.E 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. + 36.5 TOTAL: 747 S.F. 553.2 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT H2 a_\36 USE (5) 500 GAL. ACME OR EQUAL LEACHING INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 3 FROM BOARD OF HEALTH. TH1 w W CHAMBERS WITH 3' STONE AT SIDES AND 2.5' AT ENDS 3 L R�SF I�'' + �' \ ��5 * IF VEHICLE LOADING 1S PROJECTED OVER SEPTIC TANK, H-20 ,y COMPONENT REQUIRED 15;' y34.0 \ LEGEND 29 TITLE 5 SITE PLAN 1 + PROPOSED SPOT. ELEVATION OF LOT 119 FARM VALLEY ROAD + 2s.s �27.o a \ W 100x0 EXISTING SPOT ELEVATION \ IN THE TOWN OF: BENCHMARK - TOP OF \\ \ 00 PROPOSED CONTOUR OSTERVILLE BARNSTABLE CONCRETE BND. C 5.9 A ELEV. = 33.9' 100 EXISTING CONTOUR a \ \ + 32.s PREPARED FOR: JERALD BLAZE 9 .G- 40 0 40 80 120 BOARD OF HEALTH C �' 11rQ� �- a \ \ + 31.s - APPROVED DATE MA SCALE: 1 40 2001 DATE: JUNE 20, � -� SAS , 5 \ off 508-362-4541 c1iEvl I 1 fo x 0 508 362- 880 9 + 27.2 Of M \ \ w A down Cape ey engineering, inc.lnC. ` oz� ARNEs�� OF M,Ec„ b r H, 9 G - +rj 7�7 � H. �, o AF1NE 30.0 CIVIL ENGINEERS E, OJALA o wi-'► 5 s No 28348 �9 04 g 29.3 LAND SURVEYORS fc1s1ER , STry EQr`v 939 main st! armouth, ma 02675 f �,c�`� 710,710Z 01 038 FARM VALLEY ROAD Y ARNE H. OJALA,� . . .S. DA TE