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Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Farm Valley Rd. r
Property Address
Moglia
Owner Owner s Name
information is
required for every Osterville MA 02655 7/8/19 1%
page. Cityrrown 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.
A. Inspector Information r51* 1319
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Citylrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
7/8/19
Inspect i n ur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate_
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
i
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes: .
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
. Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•
47 Farm Valley Rd.
Property Address
Moglia
Owner Owner's Name
information is .
required for every Osterville MA 02655 7/8/19
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. .
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced' ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N -❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which irequire further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner Owner's Name
information is
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form. r
c. Other.
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a .47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 or 18
Commonwealth of Massachusetts
G Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
r
Moglia
inform
Owneration is Owner's Name
required for every Osterville MA 02655
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered'a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
k
® ❑ 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�~ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner Owner's Name
information is
required for every Osterville MA 02655 7/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Design flow based onperit on file at BOH
Number of current residents: 1
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
inform
Owneration is Owners Name
required for every Osterville MA 02655 7/8/19.
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day_(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑. Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information::
Pumped August 2018 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o 47 Farm Valley Rd.
Property Address
Moglia
Owner Owner's Name
information is
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval. `
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1996 per BOH record
Were sewage odors detected when arriving at the site? ElYes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 12"
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
10'
Distance from private water supply well or suction line. feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
inform
Owneration is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
6,.
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Inlet cover is not acessible due to plantings, outlet cover 6" below grade
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth: 3„
11
Distance from top of sludge to bottom of outlet tee or baffle '12
f
- 3,, z
Scum thickness
Distance from top of scum to top of outlet tee or baffle >2„
II
Distance from bottom of scum to bottom of outlet tee or baffle >211
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev"7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
i? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow-
gallons per day
t5insp.doc-rev.7/26/M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
,if Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
i
Moglia
inform
Owneration is Owner's Name
'
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes.- ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
D-box is 6" below grade and in very good condition
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd. ,
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
40x15
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach field is served'by 3 laterals, it was video inspected and is damp at this time, no indication of
past hydraulic failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert .
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v 47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc r rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
. `7&-`� c,Z") )TOWN OF%BARNSTABLE
J LOCATION , A Ih 4;l ,./ SEWAGE e�/o•t/7,,=
VILLA ASSESSOR'S MAP& 6•6O
L -5, NAME&PHONE NO&7Y&d�4 �k S I�7e-.77J•91V,,q
SEPTIC TANK CAPACITY .�,.``e�
' LEACHING FACILTfY:(type) VJ ' . '7 r 47w (size) ov X/S'
NO.OFBEDROOMS 3
BUILDER C tI�OW�R /f/l e'4"'f A mt.d�
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished bdq
•
g
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�e
• 47 Farm Valley Rd.
Property Address
Moglia
inform
Owneration is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10,
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:
GW adjustment at 10' per permitting on file, 5+ft seperation per complince on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping
You must describe how you established the high ground water elevation:
Site is at 22' and nearby surface water is at 12'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Farm Valley Rd.
Property Address
Moglia
Owner information is Owner's Name
required for every Osterville MA 02655 7/8/19
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:,
1, 2, 3, or 5 completed as appropriate a
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIFONMENTAL AFFAIRS .I ,
DEPARTMENT OF ENVIRONMENTA
L
TIO61
Z005
NSTA'kkEEPT,
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 6
' i/ ._ �/ L....,.�,.q.Air,-.+-=t-+-R•'
Property Address: ' C ' 1—
9
Owner's.Name � v.
Owner's Address: V ,6
Date of Inspection:
Name of Inspect please print) —
Company Name
Mailing Address: A �U�&
Telephone Number:
CERTIFICATION STATEMENT/
1 certify that I have personally inspected the sewage disposal system at tis 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
i training and experience in the proper function and'maintenance of on sit--sewage disposal systems. 1 am a DEP
approved system inspector pursuant to
Section 15.340 of Title 5(310 CMR 15.000). The system:
M/ Passes
Conditionally Passes .
Needs Further Evaluation by the Local Approving Authority
F
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 repo-tto the appropriate regional office ofthe
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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°n the future under the same or different
conditions of use.
i I '
j. Title 5 Inspection Form 6/15/2000 page I
l �
Page ofII f
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: tj
r
Date of Inspection:
EAU
(57
Inspection.Summ ar ChecA,B,C� or E/ALWAYS complete all of Section D
A. yytem Passes:
J-have not found any informatioa which indicates that any of th'e`.failure'criteria described in 310 CMR
15:303 or in 310_CMR 15.304 exist.Ar_v.failure criteria not evaluated are indicated below.
Comments:.
B. System Conditionally Passes:.
One or more system component3 as described in the"Conditional Pass"section need to be replaced.or
repaired. The system,upon completion cf the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the followingstaiements.If"not determined"please
explain.
i
The septic tank is metal and ove€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 ymrs old is available. I
I
NI)explain:
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
obs--ruction is removed
distribution box is.leveled or replaced
ND explain:
_ The system required.pumping more than 4 times a year due to broken or obstructed t e s ..The system will.
_ Y 9 P P b Y PP ( ) Y
pass inspection if(with approval of the Board of Health):.
'r
broken pipe(s)are replaced
obstruction is:removed
ND explain:
I
i
2
Page 3 of 1'1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- ; PART A '
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection
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.un less Board.of.Health.d.etermines in accorda7nce;with310 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
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 l 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to cr 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:
' t
I
3
i
Page 4 of I I
OFFICIAL.INSPECTION FORM—NOT FOR VO
LUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM'
PART A
CERTIFICATION(continued)
Property.Address:
Owner:
Date of Inspection
i
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 factlty or system component due to overloaded or clogged SAS or cesspool
_ Discharge or ponding of eff_uent 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 mess than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water.supply.
Any portion of a cesspool os privy is within a Zone 1 of a public well.
f Any portion of a cesspool cr privy is within 50.feet of a private water supply well.
Any portion of a cesspool os.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 coliform bacteria and volatile organic.compounds
indicates that the well is,free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria.
are triggered.A copy of the analysis must be attached to this form.]
/00(Yes/No).The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.333,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 largesystem.the system.must serve a facility with a-design,ilow of 10,00.0:'gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
i
yes no
the-system is within 400.feet-7f a surface drinking water supply
the system is within 200 feet--f 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
_ I '
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 systz-n 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.
'4
Page 5 of I 1
! OFFICIAL I`NSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL_SYSTENT INSPECTION,FORM,
PART B . .
i
CHECKLIST i
Property Address: 7 4z= ' ,e
Owner: .
Date of Inspectiord' A 44 4r 05
Check if the following have been done. You must indicate"yes"or"no"a_to each of the following: _
Yes No
Pumping.information was provided by the owner,occupant,or Board of Health '• �'
ere.any of the system components pumped out in the previous two weeks?
i Has the system received normal flows in the previous two week period ?
V 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 rhey 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.? • _ _ ,
V _ 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.he site has been determined based on:
Yes no
Existing information. For example,a plan.at the Board of HealAh,
_ — 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(3)(b)]
Page 6 of I 1
OFFICIAL-INSPECTJON-FORM"NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C a
y SYSTEM INFORMATION ,
Property A dress:
' 1 '
Owner
Date of Inspection .rf<P �(X,FI.�,ild CJj� j S
— 49 W CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ..3. Number of bedrooms(actual): .
DESIGN flow based on 310(design):.-
15.203 (for example- 11:0 a x#of bedrooms):
Number of current residents: � �/
Does residence,have.a garbage grinder(yes or no): ' ID
Is laundry on a separate sewage system (y s or no) .[if yes separate.inspection required]
Laundry system inspected(ye or no; 7
Seasonal use: (yes or no):6100 ...
Water meter readings, if av 'lable(last 2 years usage(gpd)):Q V!�DO
Sump pump(yes or no) C
Last date of occupancy:Mlh .4jjz C-o(
COMMERCIAL/INDUSTRIA00
Type of establishment:
Design flow.(based on 310 CMR.15.203): gpd
Basis of design flow(Seats/persons/sdit,etc,):
Crease trap present(yes or no):_
Industrial waste holding tank present(wes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION j
Pumping Records
Source.of information: ° J&V
Was system pumped as part of the in. vction(yes or no)�
If yes, volume pumped: gallons --How was quantity pumped determined?
Reason Tor.pumping-,
TYP OF SYSTEM
ptic 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)
_Tight tank _Attach a copy of the DEP,approval
--Other(describe):
A r xu.ate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arrving.at the site(yes or no):�i(�
r
Page 7 of 11
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(caAinued)
Property Address: �,'--Z�� C9 (
Owner , �
Date of Inspecti :
BUILDING SEWER(locate on site plan0z-6
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):-
Distance from private;water supply well.or suction line: r
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: vconcrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:/O-
Sludge depth:/r30 !/
Distance from top of sludge to bottom of outlet tee or baffle: 7
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: ✓ '
Distance from bottomof scum to bottom�of"outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, ' tlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc. • _
41
— ga +� qJ
GREASE TRA : (locate on site plan)
/�� p )
.Depth below grade:—
Material of construction: _concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
li 7
Page 8 of 11
OFFICIAL-INSPECTIONTORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: Ad,-�'
���
Owner: r �d
Date of Ibspectio :�L2 cy;' )C)S
TIGHT or HOLDING TAN19�W(-ank must be,pumped at time of inspection)(locate on site plan)
Depth below grader
Material of construction: - concrete metal fiberglass_polyethylene. other(explain):
Dimensions- .
Capacity: gallor_s
De
sign Flow: gallons/day .
Alarm present(yes or no):
Alarm level: Alarm in workin,order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
".DISTRIBUTION BOX:Zif presert must be opened)(locate on site plan) _
Depth of liquid level.above outlet invert:
Comments (note if box is level and distribution.to.outlets equal, any evidence of solids carryover,any evidence of
jeakage into.or out of box;etc. : `
c�
PUMP CHAMB (locate on sae plan)
O
Pumps in workin
g nb order(yes or no):
Alarms in working order(yes-or no):'-
Comments(note.condition of pump chamber, condition of pumps and appurtenances,etc.):
t:
1
8
i
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
^' PART C
SYSTEM INFORMATION (continued)
Property Address:.�_7� , 5 6�• ,
Owner: (_G( f
-Date of Inspectio
SOIL ABSORPTION SYSTEM (SAS):c./ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Teaching pits,.number:_
leaching chambers,number:
leaching galleries,number:
leaffing trenches, number, length:
eaching fields,number, dimensions: VO 6-
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
Z S
xbo
CESSPOOLS:460(cesspool must be pumped as part of inspect ion)(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 or no):
Comments(note condition of soil,signs ofhydraulic failure,ievel of ponding,,condition-of vegetation,•etc:):..,
i
PRIVYU./U(locate on site plan)
Materials of construction:
t Dimensions: ,
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of pcnding,condition of vegetation, etc.):
a
a
9
�L i'
Page 10 of l l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM.
PART C , , ,
SYSTEM INFORMATION(continued)
Y Address:Prop
erty 7 C � N
Q
Owner:
� Date of Ins c e ton
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within I00 feet.Locate where public water supply enters the.building.
'nay
CP
5)(5ne-
10
{ Page 1 1 of l]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C 'f•
SYSTEM INFORMATION (continued)
-i
{ Property Address:
Owner- 0.
Date of Inspectio : C06"
SITE EXAM
Slope
j Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet arSAS)
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 Wvatic-n: 3
R
permi-Number: Date:
Competed by:
HIGH GRDUND-WATER LEVEL COMPUTPTION
i
+ Site Location: � � v��G / wG�d Lot No.
i- Owner:_ C_ / �L/�JQl7�` Address:
c•
Contractor: �/) �Gp / CD�f Address: 71l �y�✓'V/"�'
Notes
STEP 1 Measure depth to wager tale
,cry
to nearest 1/10 ........... .Date _ Z!f/Y
month/day/year
STEP 2 Using Water-Level Range ?one
and Index Well Map locate
site and determine:
A) Appropriate index we-I.................. < 7 I
Water level ranoe zone .............
i
STEP 3 Using monthly report "Current
Water Resources Conditicns"
determine current depth to 1�
water level for index well ..........................�Z��
month,/year
STEP 4 Using Table of Water-I.evez Adjustments
for index well (STEP 2A)_current depth
to water level.for index v.ell (STEP 3),
and water-level zone (STEP 2B) i
determine water-level adjustment ........ ..........................
j
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4;
Trom measured depth to water �9
level at site (STEP 1) ...... ..................................................... (/r�
I
i
Figure 13.—Reproducible computation form.
i 15
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a 1068 3058 1068
Existing
ac � ndin , 4I F 1 Afi ,.I 11 `1 !I ! '�tt i Lf1 Is 1 41' V J
ko ononreteslab
CD
Existing Front wall
N
N [�1
11
Shaded area will be 5" concrete
slab wI 10" 10" thickened edge. 1068 3068 1068 (2) 12" 0 by 48" deep concrete
Imbed (2) #5 rebars in this piers
perimeter and extend into concrete T-4"
piers. Layer 8" of crushed rock Floor Plan
under this area for drainage - -
New Front Entry
Moglia Residence
by Bay Builders 6/28188 .
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ASSESSORS MAP NO: I
�� ,� _
No. FARCq,N�, 0 � / Fee Ov
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYication for Zioonl *pgtem Construction Permit
Application is hereby made for a Permit to Construct(V)or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. ' t�A24A A Owner's Name,Address and Tel.No.
Assessor's Map/Parcel lY`R
` t o- ---f >(L- .
Installer's Name,Add and Tlel.No Designer's Name,Addressand/Tel.Nlo! ° Ste$,.9-40-Z1 S Al
/1/� «11. -W.&_ LAW i..AI-k - o'Za 3l.®.
8 _ ur)
Type of Building: ;72_nloq17
Dwelling No.of Bedrooms S Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow S3 0 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets 7- c�rS Revision Date
Title SjiCg-_ ?Lra*-A ar` LA�sa A? t�A nrs att OF- Leis r UAL ��rt1d► gar t t'V �4�
Description of Soil :5;S c� '5 *-M
Y
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 a Environmental Code apd not to t„p ace th systejn operation until a Certifi-
cate of Compliance has been iss a by th oar Health. LZ�v�
Signed - - - Date
_ Application Approved by ' Date -� s
Application Disapproved forte following reasons
Permit No. � Date Issued l�' � �
" __-o t
No. � �7 Fee
�. THE COMMONWEALTH,OF MASSACHUSETTS "
`PUBLIC HEALTH DIVISION -TOWN OF°BARNSTABLEa MASSACHUSETTS
ZfppIicatiattfor Mtsspaal *pgtem Conotruction Permit
s Application is hereby made for a Permit to Construct(V)or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. 97 -F A ��V �A� Owner's Name,Address and Tel.No. ,
t >AV tom; FLAX-XQ
r � s
Assessor's Map/Parcel -Z•7 't M%6-Tc�..�ta
y Installer's Name,Add and Tel No ( Designer's Name,Address�and Tel.No. t �"� S'�0-Zls�3
MASX
Type of Building: 8CO - l!1 1. 5 0
Dwelling No.of Bedrooms 3 Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons peday. Calculated daily flow gallons:
Plan Date l Number of sheets Z Sk+ffc�S Revision Date
Title StT'ts PLA" e1�- ty,.1 ���� OF Lrn- VSL:F t Li_rw
Description of Soil rpL^u 54kme ' rr. ac Z
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 a Environmental Gode and not to place th systepi operation until a Certifi-
cate of Compliance has been iss a by oar �Health. Q
Signed Date t
Application-Approved-by-
Application Disapproved for following reasons
y ,
Permit No. / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate icate of Compliance
byVYI S TO CERTIFY,that the On-site Sewage Disposal System•tistalled-(F )or repaired/replaced( )on
Installer
at 47 , #7 Awl, - has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. " dated 5? ,'c70 -
Date l �s I1 - Inspector `�. � ,,,.....:._
(
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
- No. ��-----=------------��-----------Fee
THE COMMONWEALTH OF MASSACHUSETTS
r
PUBLIC HEALTH DIVISION - BARNSTABLE3 MASSACHUSETTS
Miopo5a[ *pgtem Construction ermit ,
Permission is ereby granted to
to cons t( )repair( )an On-site Sewa a System located at No.# f v
Street'
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
.l '
A,11"!construction must be completed within three years of the date below.
Date: Approved by
Board of Health
7=SEPnC
TOWN OF BARNSTABLEf'�lc /yx, I- SEWAGE #
�,t ASSESSO 'S MAP & LO,NAME&PHONE7K CAPACITY LEM �' ;r'
LEACHING FACILITY: (type) (, a ✓r 4 44�2 -(size) 00
,��NO. OF BEDROOMS 3
BUILDER OR O R LAMt 4L�l�Po
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
G
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h 7
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13r TOWN OF BARNST _LE N ,
LOCATIO ✓� `P SEWAGE #
�._LAGE C �2 poi � ASSESSOR'S MAP & LOT �D /
INSTALLER'S NAME&PHONE NO. l aild 4Q,4 # !,, 6 7)
SEPTIC TANK CAPACITY D Q c
LEACHING FACILITY: _A�e&I (size) Ar f
pJO. OF BEDROOMS
BUILbER OR OWNER �t4� , �il �7 w
PEWITDATE: G'"F�e�=y'C� COMPLIANCE DATE:
,Separation Distance Between the: ,r ,
r� 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 ;
withinf300 feet of leaching facility) . Feet
Furnished by_
,kt f:r
f_. -: r _. �.. __.
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10 i �3f TOWN OF BARNS T LET
s LOCATIO .t�tn 'P �" SEWAGE #
VILLAGE �°d��-f'✓�i-i �l ASSESSOR'S MAP & LOT —0
INSTALLER'S NAME&PHONE NO. l /l��Z'. get"
SEPTIC TANK CAPACITYL�
/ 1
LEACHING FACILl TY: (type) cCG � (size) VL" X l f-
1
NO.OF EEDROOMS
BUILDER OR OWNER J S f
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
14tll - - -
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_ SOIL EVALUATOR&PERCOLATION TEST FORMS
' �1HE tp Page 1 of 4
.Town of Barnstable
BA NSTABLZ ' Department of Health, Safety, and Environmental Services
i639.� A Public Health Division ArED N1A�
367 Main Street,Hyannis MA 02601
Office: 508-790-6265
FAX: 508-775-3344
Soil Suitability Assessment for Se wage Disposal
ASSESSORS MAP N 5:1
PARcallo-� �-�t
-�
NO. Date: Z �o
Performed By: Dater Z
Witnessed By: t, i< AgZYye.I
Location Address Owner's Name
Lot#: Address,and _
Assessor's Map/Parcel: Cvl Z� Telephone#
NEW CONSTRUCTION REPAIR rAD
Office Review
Published Soil Survey Available: No Yes
Year Published Publication Scale Soil map unit
Drainage Class Soil Limitations
Surficial Geological Report Available: No Yes
Year Published ick2s6 Publication Scale _A',�co
Geologic Material(Map Unit) l , n
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Wetland Area:
National Wetland Inventory Map(map unit)
Wetlands Conservancy Program Map(map unit)
Current Water Resource Conditions(USGS : Month ,�u
Range: Above Normal Normal Below Normal
Other References Reviewed: _CLAq;- �►� +vwtw�SSlDps� 1st A.► MT'D�D. L L/ P
DEP APPROVED FORM-12/07/95
RM
J FORM 11 - SOIL EVALUATO RtF of 4
Page
Location Address or Lot No.
On-site Review
Deep Hole Number .t f-'Z. Date:. .s-z
Time: 'l\`, Zf) Weather G.�C�PV—,
Location (identify on site plan) Slope (%) Surface Stones `moo
Land Use .VAc.-04--k'
Vegetation 1., u�t . �Coup�=� LAA
�
Landform
Position on landscape (sketch on the back)
Distances from: Drainage way ?. feet
Open Water Body feet
t feet Property Line spa
Drinking Water Well feet
Possible Wet Area zoo � Other
��. feet
�
DEEP OBS
ERV 11 AT10N HOLE LOG
Soil Other
0/4
Depth from Soil Horizon Sojl Texture
ext f e Soil Munselo Mottling (Structure,stones, Boulders, consistency,
Surface(Inches)
3�'l _
•40, _���' ..6 L.� �o��z Sl L Z�' ��s�t3 t�
541' _VZp`t
47?,if—1Zoft Ago,sqo to Yit qjt sti
DepthtoBedrock: e�
Parent Material(geologic) �\ Weeping from Pit Face: b --
Depth to Groundwater: Standing Water in the Hole:
I
E$timated Seasonal High Ground Water:Vi 10 —
DEp APPROVED FORM-12/0719S
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FORM 11 - SOIL EVALUATOR FORM
Page 3 of 4
Location Address or Lot No. Uo-C- 1-SU.
Determinah'o�i for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole ...... inches
❑ Depth weeping from side of observation hole l,)I/Ac inches
❑ Depth to soil mottles . '11/P� inches
round water adjustment feet
_. feet
Index Well Number ................. Reading Date .................. Index well level ....
Adjustment factor ..... .......,.\ Adjusted ground water level ...... ... ..... .... .. ... . . ..
A Nam >
Depth of Naturally Occurring Pervious 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? —4E5-- -
It not, what is the depth of naturally occurring pervious material?
Certification
I certify that on g� (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 training, expertise and experience
described in 310 CMR 15.017.
Signature , Date
DEP APPROVED FORM•12/07/95
. FORM 12 - PERCOLATION TEST
Page 4 of 4
1
Location Address or Lot No. L&5- 13(. 'V�4�L
COMMONWEALTH OF MASSACHUSETTS
Massachusetts
Percolation Test*
Date: ...... F_z - Time:, I i`t577-
Observation Holla
Depth of Perc It t
S�
Start Pre-soak z-3
End Pre-soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate Min./Inch ````= -t' SA'V`m_
Nut
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed Site Failed ❑
....................................................................................................................................
Performed By:
Witnessed By: R, I w
Comments: . .:::.:::.:._.:...:...:...:...._:;.�..v.....::.M..::::....:..:.::...,.._n...,�.�._..�.�.:__:.:.:._..__�.:..:....
DEP APPROVED FORM-12/07/9S
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FROM FAX NO. : Aug. 16 2005 03:26PM P1
09-33-1996 07:310M FPO,'-1 212 ?97 2503 TO iSO97710399 P.01
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E1,M0 CONCRE't FOUNDATION
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52.718 sq.ft.
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{n
I CERTIFY THAT THE STRUCTURES. ARE SHOWN ON THE PLAN AS THEY EXIST CON THE GROUND
�•ze-a� co1
DATE. PROFESSIONAL LAD SURVEYOR
PLOT PLAN ,a cw
PEPARED FOR; OAVID DUMONT
LOCATON: LOT 136 FARM VALLEY ROAD, .OSTERvILLF. J.
DATE: 9--28-96 WYLE
SCALE: 1" = -80' .3
FLOOD PLAIN DATA: LOCUS IS NOT LOCATED IN A FLOOD HAZARD ZONE
PREPARED BY; STEPHEN j. DOYLE AND ASSOCIATES �
42 CAN7MBURY LANE, EAST FALMOUTH, MA.
TELEPHONE: 508/540-2534
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