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0029 FARM VALLEY ROAD - Health
29 Farm Valley Road, Ostei: ille A'= 120 - 148 d 1 e y 'i i S 1 {, i 4 S 1, i E i< f Commonwealth of Massachusetts Title 5 Of#icla o.,pe on Form. Suftw 'SevmW WsposalF W for Velur y �.. . 29 Farmvafty Road Property Addrm Abigail O'Brien Owner Owner's Name information is required.for every Osterville MA 02655 3-11-14 pa ge- Cityrrown State gip Code , Date of Inspection Inspectton resuhs must be submi�sd an ibis foirn. 1 may not be aftired in.any way.Please see completeness check0st at the end of the form. Important:When A. General Information filling out forms , on the computer, use only the tab 1. Inspector: key to move your S cursor-.do not VV Paul Martin use the return Name of Inspector key. Neighborhood Waste Water Ir_�► Company Name 350 Route 28 Company Address I I W.Yarmouth MA 026?3 Cityrrown Stab Tip Code 508-775-2820 S15106 Telephone Number Lice Nurrim ^p B. Cerdficatiolt I.certify that I have personally.ink the aewcaige dispose system a€:this of y `� Arad tt the information reported bebw is true,accurate and �as of ttte the performed based on my.training and eer in,the proper funrdton;arid s�f onte swage.disposal systems t.aM a DgP sett f T T'itle.S{310 CUR 1 000d .,The system: Passes 0 Conditionally Passes Q Fails. ❑ Needs Further Evaluation by the Local Approving Authority ! 4-13-14 Ivor s signature Date K . The system inspector shah submit a copy of this inspection report to Approving AWtwft( o. • of Health or DEP)within 30 days of cmipleting the irtsmetion. It the system is a' or has a design flow of 10,000 gpd or greater,the inspector and the systt outer stall�the . report to the appropriate:region.01 office of ft,E)EP.The .� stt l owner and copies sent to the buyer,if applicable,'and:the apProrg•arttty w s �k This, old condom at UM of t use at Via.• ,Ts. does not trQur :> . ttl►e scene or dint coed of use. t5ins•3/13 TAB 6 Sul raoe.Sewaa.Di 084systm•Page 1 d 17 Commonwealth of Massachusetts Tit S Of fici 1-10's 8000040 Sew Pos�: Fein N t;f�Very Assessment 29.Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name requiragon required for everyOsWvft MA 02655 page. Crtyrrown Z4)Code -fInsPection: B. Certification. (cone.) Inspection Summary: Check A,B,C,D or E/always complete.all of Section.D A) System.Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CNIR 15.304 exist.Any failure criteria Prot evaluated are indicated below. Comments: System was in proper working condition and showed no signs of failure. S) System Conditionally Passes: ❑ One or more system components as described in the'Conditional Pa"seen:need.to be replaced or repaired.The system, upon-completion.of the-.reply #ar re ,as appraoved by the Board of Health,will.pass. Check the box for"yes", "no"or"not determined",(Y,N,ND):for the folioring setts,if*not determined,"please explain. The septic tank is metal and over 20.years old*or the septic tarn(whettaer.metal or not)is structurally unsound, exhibits substantial infiltration-or exfiltration or tank failure is h.two e t.System wry pass inspection if the existing tank is replaced with a comptying.septic.tank a a aWoved by the,Board of. Health. *A metal septic tank will pass inspection jf it is structurally sound,not lep ki%and,if a Certificate of Compliance indicating that the tank is less than 20-years old is.avaiiable.. ❑ Y ❑ N ❑ ND lExplaln below): t5ins•3113 Title 5.of.idw kapeCbW Fon'.&*WfaW Seaage.D0P08d%MWM Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Sulmrface Sewage Di sal System Form Not for Voluntary Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owners.Name information is Osterville MA 02655 3-11-14 required for every page- CWown State Zip Code Date of Inspec iJon B. Cer ification (cunt.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) system Conditionally Passes(coat.): ❑ 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): s ❑ The system required pumping more than 4 times a year due to broke or obi pipe(s).The. system will pass inspection if(with approval of the Board of HeaM): ❑ 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 Heakh in,order to determine if the system is failing to protect public heakh, safety or the environment 1. System win pass urdess Board.of Health- rdoes.in accor+lance wftk 310 CNIR 15.383(1bj that the system is not 1doning:,in a manner Wit;putifi4c health, safety and the envhwwent: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or pnW,*within 50 feet of a bordering vet wetland ar a salt marsh t5ins•3M 3 'roe s oftd kmPetdon Form:Subp:j*a Sewage DWPoW syatem-Page 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Sulnurfaae Serovage Disposal System Form-Not for Voluntary Assessments 29 Farmvafley Road Property Ad*m Abigail.O'Brien Owner Owners(dame information is required for every Osterville MA 02655 3-11-14 page. Cityfrown State Zip Code Date of ft*pec ion B. Certification (cont.) 2. System will fail unless.the Board of Heals( -Public,WaW Supplier:if any) . determine that the system is functioning in a manner that pry the ptdit 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 welE**. Method used to determine distance: "This system passes 0 the well amber,ariatysk :at a DEP.certifind ,for dal . coftM bacteria indicate,absent o0d ffiii presence:ofam moniani ge ni4 equal to or:16Ss than 5 ppm, Provid i tW na 01W.failure.crit8ft.WS, A y cf the analysis must be attached:to this form. 3. O#W. a) System Failure CrReda APB to AN>5�=. You must hxNeate."lies"or"io"tw q;: .: tom:' Ye . No Baplcup of , Oftw id Discharge sly quid �vel ► tatet ttiF.ar►w . Joss' 0 -®. �of> tiar tx . tki�t.�=d�i 1r t�:•3ns r�sas :aa,�` Commonwealth of Mlassachusetts Title 5 Official ,Inspection Form . Sulnurfiace Sewage Disposal System Form-Not for Voluntary Assessmertts 29 FarmvaUey Road Property Address Abigail O'Brien Owner Owner's Name information is Osteryille MA 02655 3-11-14. required for every State Zip Code [date of hspechon page. Ciyfrown 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 wafer quality analysis. [This. system passes if the well water and;;pedo at..a DEP cad laboratory,for fecal coliiform bra absent and the Wesence of ammonia nit s ate#;u ate WbWn is a0dor s was S ppm, provide that no comer f&WjreVdWW are A t of the..axis and chain of custody rrnst be altachedt- o- The system is a cesspool serving a felity.with a n ftwof 2000gpd- ❑ 10, pd• ❑ ® The system 'I have.determined that oAe or,9wo of the above fagure criteria exist as d in 310 CMR 15.303;dwralbte thesysterrt .The . system owner should contact the Board of Health to-de n whd vill W necessary to correct the failure. E) Large Systems: To be cow a,lar":systemthe sys muss a: :a design flow of 10,000 gpd to 45,58t1 9Pd. For large systems,you must indicate either°.yes"or"no"to each of the aw+r ,:ina dditionlo.the, questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drin#cfng water sly ❑ ® the system is within 200 feet of a tributary to-a surface drb*,ing;water.supply ❑ the system is located in a nitrogen sensitive area(lnlprim Wellhead P0ection Area—IWPA)or a.mapped.Zone if of a putiiic w r..supply well If you have answered"yes"to.any question in.Section E the system tdereci ss iws a signiftcant.threat, or answered"yes"in Section D.above tt�large system has,failed The owner or operator of any,_large system considered a:scent threat under.Section E_or faNed under Sectioi D.mil u ride e system in aocordance.with 310 CAR 9'5.304.,.The system own* 'ihe appropriate regioml office of the Department. t5ins 3/13 TW 5 OMCM •Pop5af 17 Commonwealth of Massachusetts lvTithe 5 Official Inspection Form Subsurface Sewage Disposal system Form.Not for voluntary Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name information is required for every Osterville AAA 02655 3-11-14 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? ® El available 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 ubstge, -d*mai systems? The size and n of Me Soil Awn System{s 8 on: e sitehas 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 rplatad to Part C is at issue ❑ ® approximation of distance is.unacXXDptat>te)[310-CAR 15.3012(5)j D. System Information Resklential.Flow Conditions: Number of bedrooms(design): 4 Number.of bedrooms(actual): 4 DESIGN floor based on 310 CHAR 15.203.(for example..110.god x of:bedrooms): 44o,gpd ftis-3113 TWe 5 Oftd Unpacbm From:Subaaf—Severe Omp-d&OWM'Page 6 of 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form subsurWe see Disposal systm fom-Not#or Voluntary Assessments 29 FarmvaHey Road Property Address Abigail O`Brien Owner Owner's Name information is MA 02655 require for every Osterville page- CWTOwn State ? .Code.. Ede of Inspection D. System Information Description: 0 Number of current residents: Dos.residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection 0, Yes 0 No information in this report) Laundry system inspected? 0 Yes M No Seasonal use? Yes ❑ No . . Water meter readings,if;avaihable(last2 rs u ) 1 it Det✓ad: l` S � ump pump? Last date of occupancy: _ F10W- it Type of Establishment Design.flow(based on_310 CMR 1520) s , Bases.of design few(seatsJPersortsll,f#-, c} Grease trap present? Industriahwasts ltoldmg;.tar :pressnYl Yes 1+ -canary waste disr.#arged to ibe:Titie 5 Yes No War.meter 4111113 t5iiis-3l43 Toe S r+-F—stosolow .: avw l oil .. Commonwealth of Massachusetts Title 5 Official inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name information is Osterville MA 02655 3-11-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Odw(describe below): General Information Pumping Records: Source of information: 04,10 and 12 1500 gallons per boh 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,soft absorption.system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ InnovativelAttemative technology.Attach a copy of the current operation,and maintenance contract(to be obtained from system owner):and a copy of last inspection of the.I/A system by system operator under aont.ract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Oftw(describe): teats•3N 3 Tipe 5 Fam:,Snbsxdace 8wmW DWposd&M m•Page s a 17 Commonwealth of Massachusetts Title 5 Official inspection Fonn Subsurface Sewage Disposal System:Ern-Not for Voluntary Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owners Name information is required for every Osterville MA 02655 3-11-14 page. Citylrown state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: 17 years per permit dated 7-18-97 Were sewage odors detected when arriving at the site? Yes No Building Sewer(locate on site plan): 26" Depth below grade: feet Material of construction: 0 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.): The main line was in proper working condition and showed no signs of leakage or structural damage. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ®concrete metal 0 fiberglass 0 polyethylene 0 other.(explain) If tank is metal, list age: yews Is age confirmed by a Certificate of Compliance?(ate a copy of certificate) 0 Yes No Dimensions: 1500 Balk ns Sludge depth: 0" t5ins•3113 Tifa 5 0fidaf,k m Farm:Stbw1bcs Sewage OW"System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Sultiewf ce sewage.D*XN 1 System Fom.W flor Voluntary Assessrraft 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name information is Osterville NIA 02655 required for every �-11-14 page. CWTown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) 34" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4° Distance from top of scum to top of outlet tee or baffle. 4" Distance from bottom of scum to bottom of outlet tee or baffle 2" How were dimensions determined? estimated with tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle ConditionR i gritjr,. HOW levels as retated to outlet invert,evidence of leakage,etc.): The tank was in proper working .and sheared rio signs of; or sues. Gnome.TTW(bcate on site plan) Depth below.gr : feet tidal.of;construction: D concrete [I metal Cl tibes E�pcle. 0 otl { Dims: Scum thickness Distance fC=top of scum to t0po:of outer r;i aft Distartcs of �:aac ;of cicit t�.�1 ;: Dale;of , Dixie :; T�eSS3 - Commonwealth of Massachusetts Title 5 .Official .Insertion Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 29 Farmvalley Road Pmperty Address Abigail O'Brien Owner Owner's Name information is Osterville MA 02655 3-11-14 required for every page. CityrTawn State Zip Code Date of inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and..outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leak, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions.- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No: Alarm level: Alarm in wort q order: 0 Yes ❑ No Date of last pumping: date. Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attar:? ❑ Yes ' ❑ No t5ins•3113 ROe 5. .Form:Sew :Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Faun was Im Subsurface Sewage Dispoeal System Form-Not for voluntary.Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Nam information is Osterville MA 02655 3=11-14 page.required for every �yrr� State Zip P Co Date of b"ection D. System information (cunt.) 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,): The d-box was in proper working condition and showed no signs of.leaking.or solids carryover. (Pump.Chamber(locate on site plan): Pumps in working order: E] Yes: NW. Alarms in working order. 0-;Yes .a No* Comments(note condition of pump chamber,condition of pumps and appuFiaenan etc:): *If um or alarms are not in world order,.system is a conditional:pass. pumps n9 Soil Absorption System(SAS)(locate on site Plan,excavation not re If SAS not located;explain why: t5ais•3/13 Ti»e S.E».tr :farts Su�''PWp Pew 12 01.47 Commonwealth of Massachusetts Title 5 Official Inspection Fort Sutface Swage Disposal SyAm Form_Not.for Voluntary Assessments 29 Fanmvalley Road Property Address Abigail O'Brien Owner Owners Name information is Ostenrille MA 02656 3-11-14 required for every page- city/rown State Zip Code Date of Inspection . D.:System Wforma#ion �conq Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number.. ❑ leaching trenches number, length: ® leaching fields number,dimensions: 18'x60'x1'deep ❑ overflown cesspool number: ❑ innovative<afterrnative system. Typefnarne of technology: Cornments.(nots condition of sol,:.signs l ;fat e, daP sot, a of n Dn,e�Y The Teadait►g fief was-dryr oW sho+ ce speiak(cesspool must be pumped as part of ir.mpecti, Number arid.configuration Depth-top:of liq to inlet invert Dept#n of.solids layer Depth of scum layer Q St9 wof cesspool tad. t irc 1�es Q t5ens•Wr T e S oiRt6aF O n'60t/rc: F 2!$Y P 13a1.1T Commonwealth of Nlassachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name information is required for every Osterville MA 02655 3-11-14 page, CkyJTown State Zip.Code Date of Iran D. System.Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of pondi%.condition of vim, etc.): t5ins•3M 3 Tie 5 OftW kwpaWm Fawn&6%dm.SvwW Wposd SysWw-Pegg 14 of 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Fwm-Not for Voluntary Assessments 29 Farmvalley Road AddressProperty Abigail O'Brien Owner Owner's Nam information is Osterville MA 02655 3 page. -11-14 for every City/Town State Zip Code Date of Inspection. D. System Information (font.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or.benchmarks. Locate all wells.within 100 feet. Locate where public water supply enters the building. Check one of the loxes below: ❑ hand-sketch in the area below drawing attached separately t5irs,W13 Title 5 Oriel Fem She Smage 04=dSystem•Page iS of W 1 -Asp. As=Buih Cards Page 1 of 2 Locate_ aBtFa ? ".36'1 UWrMAXn RAW G Plum B0. A 1. BB 'fa C1iPt33Y/S•aoa ' i ��� r�nr•r or Ba a _�snrs�$VJILL.OR:mac trams_ Zuni= 6rewitit �a4ar�a�r 7-/Y 97 na�a /Z"�i•17 VAMAUMtit ire* IND i . i �1 Commonwealth of(Massachusetts Title 5 Official Inspection Form Swbsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name information is required for every Osterville AAA 02655 3-11-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: Check Slope ❑ Surface water ® Check cellar 0 Shallow wells Estimated depth to high ground water. 22'below.bottom of leaching field per plan dated 7-9-97 Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 7-9-97 If checked,date of design plan reviewed. Date Date ® Observed site(abutting property/observation hole within 154.feet of.SAS) ❑ Checked with local Board of Health-explain. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: M 1 W-29 Zone C-3-4'LeveI4.25 Adlusti at--3.5' You must describe how you established the high groundC*ater elevation: Referenced original plan dated 7-9-97 that shows groundwater at elevation 11.6 w#tich is 22.0'below the bottom of the leaching field. Betomfift#ft hmpec*m Report,please see Report ori7,WteResS-Checkbst as next page. L44ro-3113 Title 6 Offad Mqmxfm Form:St f i!fim Sewage DbpoW SysWm•Pap 16 of 17 Commonwealdi of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 'f 29 Farmvalley Road Property Address Abigail O'Brien Owner Owner's Name information is Osterville MA 02655 3-11-14 required for every Cityrr page. State Zip Code Dam 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 4-E r e61e,6 t5ina•3113 Title 5 Of el.. .Sewage Disposal Sy Pop 17 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is Osterville Ma. 02655 9/7/2010 required for 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 forms on the computer,use 1. Inspector: only the tab key to move your Robert paolini cursor-do not Name of Inspector use the return key. Capewide enterprises,LLC. L Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification 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 El Needs Further valuation by the Local Approving Authority ;r �FM� SEP 1 e RECD 9/7/10 t 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 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: The septic system is in proper working order at the present time. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f \ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town. State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 . every 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 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes. No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any 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- 1 0,000g pd. ❑ ® 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•09/08 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 °M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M a 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2008:60,000 g ( y g (gp ))' 2009:52,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9/7/10 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•09/08 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 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town 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: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: Were.sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"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.): Joints appear tight.No evidence of Ieakage.System vented through the House vents. Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: tr I ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) i metal, list age: If tank s m e g years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 2 compartment Sludge depth: 611 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is Cistervilie Ma. 02655 9/7/2010 required for every page. City/Town 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 26" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10" 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.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town 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 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•09/08 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 °M 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 • 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 No 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.): Used camera to observe box under driveway.Box has three outlet Iaterals.No evidence of solids carryover.no evidence of leakage. Pump Chamber(locate on site plan): Pumps i��working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every 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: 18'x50' ® 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.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil. 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•09/08 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 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ..Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 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 , a T�Nip 4. y • t5ins•09/08 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 wM 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 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: Bottom of SAS 20' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Farm Valley Rd. Property Address Pamela Beers Owner Owner's Name information is required for Osterville Ma. 02655 9/7/2010 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE � LOCATION. /t1 "f WXE4 I SEWAGE # 7 363 ASSESSOR'S MAP & LOT INSTALLER'S NAME 6z PHONE NO. A & B QZ= 775-6264 SEPTIC TANK CAPACITY ��� 6 p1 ea xy m .—;i 7 j�k LEACHING FACILITY:(type). 'y �'sr'���►v��ryLe� (size) OFBEDROOMSPRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER r(2.AJ/iP�. DATE PERMIT ISSUED: 7 7 DATE; COMPLIANCE ISSUED: VARIANCE GRANTED: Yes - No r. i r` O � v ' .I r I L a 1 P-°_ No. Fee THE COMMONWEALTH OF MASSACHQ, ETTS L PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21pp iration for ai.5p0$ar *p6tem Cow5trkrtton Permit Application is hereby made for a Permit to Construct(�)or Repair( )an On-site Sewage Disposal System at: Location Address Lot N I�iF Owner's Name,Address and Tel.No. / �� o�Q �AZM, VAA—t_ AAAZC 4 05AAJ [s' 6 STWAW t i,4.-S Installer's Name,Address d Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms - Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 44� gallons per day. Calculated daily flow 44c gallons. Plan Date�Q Number of sheets 1 Revision Date Title SI` — hAi4 et= L t4o, ICJ 1$A*--W7'13BL4 •Co-iT57LV►L4XS MAC F_Az MA" 4fSVSr1/d �►2�N1�� Description of Soil b I I" SA WPM LOAUA I i Htd I wro v dU t� _' yA/J,0 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment ode and:not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o He Signed Date 102—,9-22 Application Approved by e Application Disapproved for the following reasons Permit No. 9 ;?—--_ Date Issued 2/z ",,92 Y't rr. « •-+w.........,�:" `.. v+� -;s. ...-. .;; r3ta.,•+F;`�: '.f i s ' P-o No. _ ®# Fee COMMONWEALTH OF MASSACHU ', ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE S MASSACHUSETTS 2ppricattion for Miq aar *pgtem Congtruction Permit ,Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address<Lot No' Owner's Name,Address and Tel.No. �2rJ1 • M VA2M. V A, "Vi i?.� n�AZG & 4vSA U Installers Name,Addre%,AAd Tel.No. Designer's Name,Address"and Tel.No. 14 f /3 c© PI'lq 1VC.o t k Type of Building: Dwelling No.of Bedrooms 4- Garbage Grinder(,K) ' ',,,Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 'IfAo gallons per day. Calculated daily flow gallons. f Plan. Date�3 - 51 1 Clem Number of sheets ( Revision Date Title Sty Aii or- L-4Wb , iN 13 45-rA734G LVeM-- VI(011s' A11A (-az Ao12C ,4.1U4A/J XW2G►Jti:, Description of Soil L7 i I" S kV�,,4 C&tM 1 i 3'3 Wo w,w 7;ANa 53"-17o" C' kAiM !'Also 1 ;Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment ode and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o HI ' Signed bate ,.. Application Approved by Applicat n Disapproved for the following reasons i a Permit No. T �� . Date Issued k' r 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of QCompliance > - - THIS IS TO CERTIFY,that a On-site Sewage Disposal System installed( )or repaired/replaced( )on by ' C AX/C O for a a has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constru ion Permit No. - ra 3 dated 7-/. 4'2. Use of this system is conditioned on compliance with the provisions set forth'below: a No. 7 i y(. Fee /y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS *pgtem Congtruction Permit Permission is hereby granted to c" �t1c a to construct Oo repair,( )an On-site Sewage System located at L6 A -S ' 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. All construction must be completed within two years of the date below. y Date: Approved by a? TOWN OF BARNSTABLE Wv I3T " 36 LOCATION 3 VILLAGE b 5760tV //Q, ..`. ASSESSOR'S MAP LOT [2.0`�yS T1:STALLER'3 NAME & PHONE NO. A & B CANCO 775-6264 ?. :`. $ P 'IC TA iK CAPACITY SUD 6A/p4 Ca.H�►�¢T� ,•f�s �Sv ion! ( ' • • I>BAClING FACILITY:(type)3'y size) /�: X��% h�lc✓ NO OF BEDROOMS . PRIVATE WELL OR PUBLIC WATER BUfLDBR OR OWNER, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• VARIANCE GRANTED: Yes No " - 1. V3 J ..l Town of Barnstable 1'# Dig Department of Health,Safety,and Environmental Services Public Health Division Date 4-14e• S, /997 367 Main Street,I lyannis MA 02601 "'"W Time Fee Pd. �� TEDNII�I��� Date Scheduled - 15 7 7 �a� Soil Suitability Assessment for Sewage Disposal Performed By: V u &q X-2 �x•r-�-r!- Witnessed By: �1 -✓w1 V� "�1� LOCATION &GENERAL INFORMATION=' - Location Address �-l)1- i3� Owner's Name MAgy—+SvSAN �,•aEJJ IG Olo "ti 14t; 6o L�F M � i 1--Ap—AA VAL-L-E:� Address 1010 V-i E 13'2, Assessor's Map/Parcel: AA ap (ZD �GL l�i3 Engineer's Name -7j}-C7� NEW CONSTRUCTION REPAIR Telephone# Land Use '5u-0Dl0S1QA Slopes(%) 3 r 8 Surface Stones a Distances from: Open Water Body ft Possible Wet Area 0- ft Drinking Water Well ft Drainage Way (D'Z r> ft Property Line /Z) ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I FAzA,1 V ALL�`�Al IC DAD. zi•LS I p tr N t 133 N I 2303 0 Q � - N v /0ION 9 4o 1.02 A- I Co v w / Parent material(geologic) CV7-WASP �c�SiN t' ryl� Depth to Bedrock anding Water in Hole: Weeping from Pit Face Depth to Groundwater: St Estimated Seasonal High Groundwater ' ab Y3l�TI+.ItNJII°�tA T INN Or SEASONAL Hives A'II'EP.T A IIIJr' Method Used:p weeping from side of obs.hole: in. Groundwater Adjustment stment ft. De th Observed standingin obs.hole: Ald G(/ � Depth Depth to p g Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date.3 �S Time Observation I 2 Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time c+ Time(9"-6") I i End Pre-soak Rate Min./Inch (9l�lt/3t�e o S.&rogxmAvmF Cj4 2anw luesv Site Suitability Assessment: Site Passed V11", Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-j Copy: Applicant t DEEP OBSERVATION HOLE LOG Hole# t Depth from Soil Horizon soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. n •stency.° I1 Sdkoq kAfv /o m 41 o 0 DEEP OBSERVATION HOLE LOG Hole# 'Z 1 Depth from Soil Ilorizon Soil Texture ! Soil Color Soil t Other Surface(in.) (USDA) I (Munscll) Mottling (Structure,Stones,Boulderes. % /'Z��35 s8 ✓ 4c"V /0 02 514 v m DEEP:'OBSERVA' `YON`HOLE`'LOG' Hole# Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° I I ' i DEEP;OBSERVATION'HOLE LOG`` Hole# Depth from Soi l Horizon Soil Texture Soil Color Soil Other Moulin Surface(in.) (USDA) (Munsell) g (Structure,Stones,Boulderes. % I i I I I � I ,Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No^' Yes Depth of Naturally Occurring Pgrvious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? I Certification , I certify that on / 95r(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin ,expertise and experience described in 310 CMR 15.017. Signature 66 , .. Date 3--18,91 r j ALL COMPONENTS LOCATED IN POTENTIAL COVERS LOCATED TO WITHIN VEHICLE TRAFFIC AREAS OR BURIED 4 FEET N soGT'y n -12" OF F.G. OR _GREATER SHALL BE H-20 LOAD CAPACITY. - O e�MAs ELEV.= 39.0 ACME PRECAST TEST H LE MARCH 18,1997 TOP of F G= 38'f DB3 OR EQUAL BAXTER & NYE INC. SMOKE 2� Ro. FOUNDATION � � � •�� T\�\ �\� ROpp .LOCUS / F.G. =37't P-8900 j�INV. = 36.0 \. F.G.= 37.5f ,�.\ _ �liTi,�.� a�����, �,. ELEV. = 39.0 z INV. = 1500 GAL. 4„ DIAMETER T 35.8 INV. = 35.6 DIST sc;HEDUIE 4 A SEPTIC)TANK INV. =35.4 BOX \ o P. C. PtpE TOP ELEV. 35.6 SANDY LOAM o 6" CRUSHED INV. =35.2 II' 11 10.00'0� INV. = 34.6 vvvvvvvvvvvvvvvvv MIN. STONE BASE II LOAMY SAND v v O v v v v v v v v v v v v v —33" vv � vvvvvovovvvvvv � I -40 PERC TEST LOCUS MAP BOTTOM ELEV. 33.6 C SCALE 1 25,000 CLEAN ASSESSORS MEDIUM MAP 120 PARCEL 148 SAND PROFILE - GRAPHIC SCALE N ` NO SCALE 0 20 40 WATER LEVEL = 11.6 —120" NO WATEREL. = 29.0' RESIDENCE F-1 PRECOLATION RATE = 1" W 2 MIN. OR LESS MINIMUMS WATER LEVEL ESTABLISHED AREA 43,560 S.F. P-8739 ON LOT 140 FRONTAGE = 20' WIDTH = 125' FRONT SETBACK = 30' SIDE SETBACKS = 15' REAR SETBACK = 15' 4j�Ib BUILDING HEIGHT = 30' NOTES: (1) REMOVE UNSUITABLE;,SOILS BENEATH PROPOSED SYSTEM, BACKFILL i WITH CLEAN GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS: NOT I MORE THAN 15% RETAINED ON No. 4 SIEVE, NOT MORE THAN 90% RETAINED ON No. 50 SIEVE, OF FRACTION PASSING No. 4, 10% OR LESS TO PASS No. (I 100 SIEVE AND 5% OR LESS TO PASS No. 200 SIEVE SOIL TO BE APPROVED f BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. (2) LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST 72 HOURS PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE THE REQUIRED NOTIFICATION TO DIG SAFE (1-800-322-4844) AND APPROPRIATE IFG28I WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. Notes I FOR ALL ASPECTS OF THE SEPTIC SYSTEM THE CONTRACTOR SHALL COMPLY WITH ALL GOVERNING CODES AND REGULATIONS. .- IN PARTICULAR 310CMR 15.000 THE STATE ENVIRONMENTAL CODE TITLE 5, THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART VIII: I w ON-SITE SEWAGE DISPOSAL REGULATIONS AND THE BOARD OF HEALTH d h I RECOMMENDATIONS FOR ACCEPTED PRACTICE. 00 ^�h I N � O2 TWO COMPARTMENT SEPTIC TANK REQUIRES 2 WEEKS OF LEAD TIME I N N TO ORDER FROM SUPPLIER. U` I d THE SEPTIC TANK'S FIRST COMPARTMENT SHALL BE SIZED FOR 880 GALLONS MAN, V' THE SECOND COMPARTMENT SHALL BE SIZED FOR 440 GALLONS MIN. v I ALL IN ACCORDANCE WITH 310CMR 15.224 MULTIPLE COMPARTMENT TANKS. TWO TANKS IN SERIES MAY BE SUBSTITUTED SUCH THAT THE FIRST TANK I IS 1500 GALLONS & THE SECOND TANK IS 1000 GALLONS AS PER 15:225. I N I I ' 4' S> 5, 4, CV (p ( � Icy �'< z / , f // // // // / CN_ fF � w it Y ` ,-tom•• •• a/ ' F { M j 3/4" TO 1 •1/2" i WASHED STONE TOPPED WITH 2" OF PEASTONE I I GROSS SECTION r - z0T .1 I I NO SCALE I LI benchmork = 30.70' n.g.v.d. C.B. SET N56'11'06"E 20.00' 39,860 sq.ft. � 230i53S# = 15.94C.B. SET0vi o f pROPOSED 18, ; EXP A S ' �4N FG=34 50.00' AREA 1 f C.B. FNp f —FG=36- , r` BOX OFF <, Ra'p DIST. 1 W,go C.B. FND. #1 74.00,, ` � 1 lei/l JAW 14.0(9, S �QS po t- o 8. 0 0 O t . o ^11 5p,� OF F0U N 20.0 tt NDA Ti N 0 S� fr co O - r `f �624,00, Ap' oo N 1 00 4.0p,'7.60, #2 J �j r F o RAG _ 3.0 Gq , TP ` 1 2 0 to _ f T 41474 � 2 411 _ 5.4p, o _- f . 00, 44,343 sq.1t. 1.02 acres FG=38Ji w` f FG=42 �f / l FG=44 vs FG=46 42.21� � FG=48 C,r 1-I F-1 -r[4 A-r PrzcFm� 'ncv�w N .B. SET CoAA1=I`IE5 Wlr64 'i-1'FE sIt>euNEt�rtu�- N63°03'41'E `_.. (Zt�utt E�vtr=�aTS �T= 7-4E. -Mv�.W OF BAQIATr;-13C.� Alm +far' lo�=a " ( 4 114 A FLoo MT 1,20 OPEN ,15P.IC�' QA`zj,vz� Z oIJ - �- 248,78' ��-^- N63°03'41"E DESIGN DATA ELEVATIONS ARE BASED ON N.G.V.D. SITE P L�f�'�N OF LAND SINGLE FAMILY— 4 BEDROOMS IN WITH GARBAGE GRINDER (OSTERVILLE) DAILY FLOW = 110 X 4 = 440 G.P.D. SEPTIC TANK = 440 X 200% = 880 G.P.D. BARNSTABLE USE1500 GAL. TWO COMPARTMENT SEPTIC TANK MASS . COMPARTMENT ONE 440 X 2 = 880 G.P.D. MIN. COMPARTMENT TWO 440 X 1 = 440 G.P.D. MIN. FOR MARK & SUSAN GRENIER ZONE W.P. - UEACHING FIELD DESIGN _ CLUSTER SUBDIVISION NOTE: SCALE: 1 "= 20' DATE: JULY 9,1997 ALL .PlIcES TO BESCHEDULE •40-PVC PERFORATED USE 3 - 4" DISTRIBUTION LINES IN AN PLAN DATED JANUARY 28,1988 LOT COVERAGE- TOTAL ACRES 27.26 NO MORE THAN FIFTY PERCENT 50� OF THE TOTAL UPLAND AREA BAXTER & NYE INC. 18'X 50' WASHED STONE . FIELD - ( �) � � AS SHOWN OF ANY LOT SHALL BE MADE IMPERVIOUS BY THE INSTALLATION OF tHo�: TOTAL NUt�BEB aF LOTS = 12 �- REGISTERED LAND SURVEYORS FAR 440 G.P.D.,/.'i4 + 50% 892 S.F. OF BOTTOM AREA REQUIRED 4 ORIGINAL LOTS (116-119) BUILDINGS, STRICTURES AND PAVED SURFACES. xm SULL,�'��,� ( ) t e�,� CIVIL ENGINEERS r�o.2r 722 , SE 18'X 50'= 900 S.F. AREA PROVIDED 8 REVISED LOTS 133-140 SITE CLEARING: A. C2,�. AVERAGE AREA PER LOT = 2.27 ACRI.S q�.� ,CLASS 1 SOIL PERCOLATION RATE 1" IN 2 MIN. OR LESS A MINIMUM OF THIRTY PERCENT (30%) OF THE TOTAL UPLAND AREA ❑STERVILLE MASS, Y a� ° . ELEVATIONS ARE BASED ON N G.V.;::. OF ANY LOT SHALL BE RETAINED IN ITS NATURAL STATE, WITH ONLY LIMITED F j'S�_L�CTIVE CUTTING OF TREES AND CLEARING OF �. �� UND.-RSTORY SH;!'?UBS AND GROUNDCOVER ALLOWED. #96152