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HomeMy WebLinkAbout0063 FARM VALLEY ROAD - Health I I L rm Valley Road lle 9 C OR o �_q Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 63 Farm Valley.Rd. Property Address "* James & Kathleen Mingle " Owner Owner's Name Information is _Osterville Ma. 02655 1-27-21 required for every - `-' page. Clty/Town State Zip Code Date of Inspection r�� I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. Inspector Information #- filling out forms on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. k ' 363 Whites Path. _ Company Address South Yarmouth Ma. 02664 City/Town State Zip Code i 508-477-8877 S114430 Telephone Number License Number 1 JJJl1 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 X_ZN OFIMgss .......... 2. El Conditionally Passes . `�� MICHAEL''yN 3. ❑ Needs Further Evaluation by the Local Approving Authority 'o SEARS No.SI14430 ;y 4. ❑ Fails Rrtf�`�� '04' "41, /pr6 INS 1-27-21 Inspector's Signa.Wre 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.7/2 612 0 1 8 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 1 of 18 i i i I i Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form Not for Voluntary Assessments !3' 63 Farm Valley Rd, Property Address James& Kathleen Mingle Owner owner's Name Information Is Osterville Ma. 02655 1-27-21 required for every page. CitylTown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in working order 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): I i t5lnsp.doo rev.7128l2018 Title b Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 i I i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .3� 63 Farm Valley Rd Property Address James& Kathleen Mingle Owner Owner's Name information Is required for every Osterville Ma. 02655 1-27-21 page. Cityrrown State Zip Code Dale of Inspection . C. Inspection Summary (cont.) I 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): j 1 ❑ 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): I ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): r 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health In order to determine if the system Is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning to a manner which'will protect public health, safety and the environment: 15insp,doc•rev.7/26/201 fi Title 6 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form PSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Farm Valley Rd. - Property Address James & Kathleen Mingle - Owner Owner's Name Information Is Osterville Ma. 02655 1-27-21 required for every — page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.). ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: I 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 16insp.doc-rev.7/2 612 0 1 8 Title 5 Orriclal Inspection Form:Subsurface sewage Disposal System-Page 4 of 18 I i Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Farm Valley Rd. Property Address James& Kathleen Mingie Owner Owner's Name Information is required for every Osteryille Ma. 02655 1-27-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below Invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® 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 falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t6lnsp,doc•rev,7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Farm Valley Rd Property Address James& Kathleen Mingle Owner Owner's Name Information is Osterville Ma, 02655 1-27-21 required for every page. Cityfrown 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: I 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? I ® ❑ 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 NIA) ® ❑ 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? i ® ❑ 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)] t6insp,doc rev,7/26/2Dt 8 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts j • Title 5 Official Inspection. Form j a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i .. 63 Farm Valley Rd. Property Address James&Kathleen Mingle Owner Owner's Name information is required for every Osterville Ma. 02655 1-27-21 page. CitylTown State Zip Code Dale of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design) 4 Number of bedrooms(actual): 4— I DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: 2 Number of current residents: i Does residence have a garbage grinder? ❑ Yes ® No E Does residence have a water treatment unit? ❑ Yea ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No 2019-290000gal Water meter readings, if available(last 2 years usage(gpd)): 2020-298000ga1 Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date r 15insp.doo rev.7/26/2018 Title 5 Offidel 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 v 63 Farm Valley Rd. Property Address James&Kathleen Mingle _ Owner Owner's Name information is Osterville Ma. 02655 1-27-21 required for every — page. City/Town Slate Zip Code Date of Inspection D. System Information (cost.) 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: Jul 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons Now was quantity pumped determined? Reason for pumping: t5insp.doo rev.712812DiS Title 5 orriclai Inspection Form:Subsurface Sewage Disposal System-Page 8 of 1s i I Commonwealth of Massachusetts Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form Not for Voluntary.Assessments i 63 Farm Valley Rd. Property Address James& Kathleen Mingle Owner Owner's Name information is Osterville Ma, 02655 1-27-21 required for every — page, City/Town 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 j E] Tight tank,Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 10-1-98 #98-66 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No i 5. Building Sewer(locate on site plan): 22" _ Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 15insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 y Commonwealth of Massachusetts _ Title 5 Official Inspection Form -�, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Farm Valley Rd. — Property Address James&Kathleen Mingle Owner Owner's Name Information is Ostervllle Ma. 02655 1-27-21 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other (explain) 1500 gal - - i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gal Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" _ 0 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape — Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, i liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank with in and out tees in place, both covers at 12"below grade I i i i t5insp.doc•rev.712812018 Title 6 official inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts' Title 5 Official Inspection Form — Subsurface Sewage Disposal Systen Form-Not for Voluntary Assessments i 63 Farm Valley Rd. Property Address r James& Kathleen Mingle _ Owner Owner's Name reformation is Osterville Ma. 02655 1-27-21 required for every --- - page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): , Depth below grade: , feel Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other,(explain): Dimensions: Scum thickness t 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: Hate 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): E Depth below grade: Material of construction: []concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.712612018 . . Title 5 official inspectionfo=Subsurface Sewage Disposal System•Page 11 of 18 i c Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 63 Farm Valley Rd. Property Address James& Kathleen Mingle Owner Owner's Name information is Cisterville Ma. 02655 1-27-21 required for every — State Zip Code Date of Inspection page, City/Town D. System Information (cons) 8. Tight or Holding Tank(cont,) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date a 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 16x21 with 3 outlet pipes, cover at 21" below grade t5insp.doc•rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 10 i • i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Farm Valley Rd. Property Address James& Kathleen Mingle Owner Owner's Name Information is required for every Osterville Ma. 02666 1-27-21 _... •--- _ I page. City/Town Slate Zip Code Date of Inspection D. System Information (cont.) i 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* I Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i I *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: 1805 ❑ overflow cesspool number: ❑ Innovative/alternative system Type/name of technology: t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 113 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 63 Farm Valley Rd. Property Address James& Kathleen Mingle Owner Owner's Name information is Ostetville Ma. 02665 1-27-21 _ required for every State Zip Code Date of Inspection page. City/Town 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.): I SASIs a 18'x35'field, leaching is clean and drywith no sign of failure I 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.): t6insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 63 Farm Valley_Rd. �— Property Address James&Kathleen Mingle Owner Owner's Name Information Is Osterville Ma. 02655 1-27-21 required for every page. CityfTown State Zip code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): l5insp.doo-rev.7/28/2018 Title 5 Official lnspeellon Form:Subsurface,Sewage Disposal System-Page 15 of 18 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments z 63 Farm Valley Rd. - Property Address James& Kathleen Mingie Owner Owner's Name Information is Ost Ma. 02655 .J 1-27-21 erville ,_ _ required for every -- - - State Zip Code Date of Inspection page. City/Town 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 i i Y yS'c" 0 t5lnsp.doo rev.W2812018 Tills 6 Official inspecllon Form:Subsurface Sewage Disposal System Page 9s of 18 I Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Farm Valley Rd v Property Address James &Kathleen Mingle _ Owner Owner's Name information Is Osterville Ma. 02655 1-27-21 required for every - page. Cilyfrown State Zip Code Date of Inspection D. System Information (cons.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar I ® Shallow wells Estimated depth to high round water: p g g feet Please indicate all methods used to determine the high ground water elevation: i ® Obtained from system design plans on record j If checked, date of design plan reviewed: 9-25-94 Dale ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: No ground_water per plan i Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7/26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 i I Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Farm Valley Rd. Property Address James& Kathleen Mingle Owner Owner's Name information is Osterville Ma. 02655 1-27-21 _ required for every page City[Town State Zip Code Date of Inspection E. Report Completeness Checklist complete all applicable sections of this form inclusive of: ® A, Inspector Information: Complete all fields in this section. ® B, Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Grci T6` W+�c9 hT J f 'ft l b q u ii I ,fliO 4�lYlYr?�W4-�Gr t5insp.doo•rev.7/2 612 01 8 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 'GSM 63 Farm Valley Rd. SV•yam• Property Address _ Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 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: When filling out A. General Information , forms on the I computer, use 1. Inspector: GO only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 rerum City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that:the information reported below is true, accurate and complete as of the time of the ih.tpection The inspection 1 was performed based on my training and experience in the proper function and r>aa ntenance;af on s e sewage disposal systems. I am a DEP approved system inspector pursuant t&Section 1-5F.140 6 Title 5 (310 CMR 15.000).The system: " arp f ® Passes ❑ Conditionally Passes ❑ Falls co ❑ Needs Further Evaluation by the Local Approving Authority, 6/1/2011 Inspect Ws Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board 3 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 A the same or different conditions of use. Lh, 1 R. Title 5 Official inspection Form:Subsurface Sewage Di sal System•PJ 1 of 17 t5ins•11/10 P 9 Y 9 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 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: ® 1 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for 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): 1 ❑ 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): a I i if Y ❑ 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): x t s 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•11/10 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 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11/10 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 cwM 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 every page. City/Town State Zip Code Date of Inspection F 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 f 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 a 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 1 and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply . ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments c,M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for 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 ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. El ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,^M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for every page. City/Town State Zip Code Date of Inspection D-System Information Description: Number bf current residents: NA 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 Seasonaluse? ❑ Yes ® No ,000 :168 Water meter readings, if available (last 2 years usage (gpd)): 20 2009:168,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 6/1/2011 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 every page. CitylTown 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): f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 R r. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MK 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: e0et Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 16" p g feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 5" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 ®fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 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 27" OilScum thickness Distance from top of scum to top of outlet tee or baffle 6" 0 14" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Y �yy d' Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t 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 3 Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 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•11/10 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 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 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 z evidence of leakage into or out of box, etc.): i Box is Ievel.Box has three outlet Iaterals.No evidence of solids carryover.No evidence of leakage. >i t T Pump Chamber locate on site Ian Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No s } 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments <c^M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is required for Osterville Ma. 02655 6/1/2011 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 18'x35'x1' ❑ 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.Leaching field was dry at time of inspection. 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•11/10 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 63 Farm Valley Rd. ^M Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for 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.): � II i 1 Privy(locate on site plan): i Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ti t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out p EIE E U E r fl UIn rK 611, �• a 3o yb4. 1��I', l y� . n_ • _; r t Y,,�77T +k` dW }„�y'� i�,r M'g iry` jfwk `�' 'fat F. • a ti Y * k} �6 i 5# 174 p ,/^�-�,'tea $ ^� axe i c '. . �r.,r,�.2 � A+�v�3r ts �'�•,�t� m n++r R '., •Ma :i4 6 t, �,. '�6 "'-� u1'Po'�'R46, '���. 'rn` �Myr. �., .'�;G. `�Y • 41Jv '� + r � •:., :,�{ y J x _, � kF.�.*!B a"- �? .�5, ter^., W p V M1'4�.t�. T.b% Y•JJ ➢ Y rr• I 9 20 Feet .......... _......... __.... ...... ��... Set Scale 1" = 20 I Aerial Photos .:I I MAP DISCLAIMER (:nn,,rinhf 9MS_9010 T, AIVI of Ramef�hln hA4 All rinhfe rare http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=097029&mapparback=097O... 9/20/2003 i � - Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name iriformation is Osterville Ma. 02655 6/1/2011 required for 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 field 13' 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • achusetts Commonwealth of Mass W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �^M 63 Farm Valley Rd. Property Address Linda Davidson Owner Owner's Name information is Osterville Ma. 02655 6/1/2011 required for 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 4 i I. h S i t i 5 f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste-n•Page 17 of 17 i F 4-9 TROY WILLIAMS z 9 .SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A -- CERTIFICATION RECEIVED 63 Farm Valley Road ProperIN Address: Osterville,MA FEB , 6 2005 Tim Johnson Owner's Name: 63 Farm Valley Road TOWN OF BARNSTABLE Owner's Addressi Osterville,MA 02655 HEALTH DEPT. February 15,2005 Date of Inspection: 1 1 Troy M. Williams ©� ^ Name of Inspector: Troy Williams Septic Inspections ,ICEt. 2 Company Name: 19 Hummel Drive '-- -- - Mailing Address: South Dennis,MA 02660 Telephone Number: 508)385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. "File inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 15.000).. The systenv Passes Conditionally- Passes Needs Further Evaluation b) the Local Approving Authorii) Fails Inspector's Signature: S Date: ,2 /1,5 /d S The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department'of Environmental Protection,certification Is not to be construed as a guarantee of future working condition of system,piping or components. This Inspection represents the conditions of the system on the Date of Inspection noted above. ti `1Tills report only describes conditions at the time or inspection and under the conditions of use at that time. l his inspection does not address how the system will perform in the future under the same or differept , conditions of use. di. , Title 5 Inspection Form 6/15/2000 T' P pace I of II Page 2 of OFFICIAL INSPECTION FORM= NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE AISPO$4 SYSTFM INSPECTION FORM PART A CERTIFICA'I'JON (continued) 63 Farm Valley Road Property Address: Osterville,MA Tim Johnson Owner. February 15,2005 Date or Inspection: Inspection Summary: Check A,B,C,D or lE/AL--LWAYS 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 CK1R 15.303 or in 310 CMIt 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system,components as described in the "Conditional Pass"section need to be re aced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of ealth, will pass. e Answer yes. no or not determined(Y,N,ND)in the for the following statements. If'.urt determined"please explain. The septic tank is metal and over 20 years old" or the septic tank(whetl metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is im 'rent. Svstem will pass inspection if the existing tank is replaced with a complying septic tank as approved by th oard of I lealth. •A metal septic tank will pass inspection if it is structurally sound,no eaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out o ►igh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or u veil distribution box. System will pass inspection if(with approval of Board of health): broke �jpe�i)are replaced Zedpumping ctlon is remover! ution box is leveled or replaced ND explain: The sy titan 4 times a year due to broken or obstructed pipe(s).The system will pass inspectionrd of Health): broken pipe(s)are replaced _ obstruction is removed NP explain: r , v R1 � 't§ ' Page 3 of I 1 i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 63 Farm Valley Road Osterville,MA Owner: Tim Johnson February 15,2005 Date of Inspection: C. Further Evaluation is Required by the Board of Ileallh: ' Conditions exist which require lunher evaluation by the Board of Flealth in order w determine if the system is failing to protect public health. safety or the environment. L System will pass unless Board of Health determines in accordance with 310 CMIt 15.303(l)(b at the systeut is nut functioning in a manner which Hill protect public health,safety and the envir nmenl: — Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a botdering vegetated wetland or a salt mar 2. Systen► will fail unless the Board of Health(and Public Water pplier, if any)determines that the system is fuuctiouing in a nnanner that protects the public heal! ,safety and-environment: ]'Ile system has aseptic tank and soil absorption sy rn (SAS)and the SAS is within 100 feet of a surface water supple or tributary,to a surface water s ply. The system has a septic tank and SAS at the SAS is within a Zone I of a'public water supply. 7 he system has a septic tank and ' S and the SAS is within 50 feet of a.private .rater supply well. The system has a septic tan and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ",ell•' ethod used to determine distance - ._..._.__..—........_ "This system passes • the well water analysis, perfortngd at a DEP certified laboratory, for-coliform bacteria and volal' organic compounds indicates that the well is free from pollution from that facility and the presence o moma nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crit a are triggered.A copy of the analysis must be attached to this form. 3. Other: w K a r L 1 r`. r Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 63 Farm Valley Road Property Address: Osterville,MA :. Tim Johnson Owner: February 15,2005 Date of Inspection: D. System Failure Criteria applicable to all systems: You aLu—sj 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 �L 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 ,v q Liquid depth in cesspool is less than 6"below.invert or available volume is less than%day flow Required pumping more than 4 times in the last year OT 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. ti/n Any portion of a cesspool or privy is within a Zone 1 of a public well. N 1 j Any portion of a cesspool or privy is within 50 feet of a private water supply well. l 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. lThis system passes if tine 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 At ammonia nitrogen and nitrate nitrogen is equal to or less Than S ppm,provided that no other failure criteria . are triggered. A copy of the analysis must be attached to this form-1 /V 6_(Yes/No)The systent fiLils. 1 have determined that one or more of the above failure criteria exist as de>crihed in 310 CMR 15.303. therefore the s'-stem fails. "I'he system owner should contact the Board.of Health to determine what will be necessary to correct the failure. E. f.arge Systems: To be considered a large system the system must serve a facility with a desi flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the followinng: (The following criteria apply to large systems in addition to the criteri ove) yes no the system is within 400 feet of a surface drinkin Ater supply the system is within 200 feet of a tribu o a surface drinking water supply the system is located in a nitroge nsitive area(interim Wellhead Protection Area=IWPA)or a mapped Zone 11 of a public water sup well If you have answered"yes"to a question in Section P the sys,tctrt is considered significant thr�al,of anv�tred "ye;"in Section p above the ge system has trailed.The ow pr operator of any large system pQttsi�&fell Is � sigg4(lcgpt threat under S ton F or failFd undcr Section l)sh ��y�grade the systettt in at:cordanctt with 31Q Gl' ' 15. q4.The system o 9f should contact the appropriate rcgign�l pffice of the PePartmont• 4 x j Page 5 of I l OFFICIAL. INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART II CHECKLIST 63 Farm Valley Road Property Address: Osterville,MA Tim Johnson Owner: February 15,2005 Date of Inspection: Check if the following have been done. You trust indicate"yes"or"no"as to each of the followine: Yes No le� _ I'.:;; l in; information was provided by the owner; Occupant: or Heard of I leald, Were any of the system components pumped out in the previous two weeks? ✓ — Has the system received normal flows in the PrCvious two week period'? __ ✓ Hove 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 sighs 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 infomnation 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: Yes no _ Existing information. for example,a plan at the Board of health. _ Detennined 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)] t Page 6 of 1 I OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 63 Farm Valley Road Property Address: Osterville,MA Tim Johnson Owner: February 15,2005 Datc of t1►speclion: FLOW CONDITION$ ItESII)I✓N'f1Al. Number of bedrooms(design): Z/ Number of bedrooms(actual):. �1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x rs of bedrooms): y yv Number of currcut residents: S - Does residence have a garbage grinder(yes or no): No Is laundn on a ."Cparate s"Yage system O'" or lik') vD lif)'c4 separate inspection required) Laundry SySlelll inspected(yes of 11o).fit//q Seasonal use: (yes or Ito):_NO Water meter readings, if available(last 2 years usagc(gpd)); Qy = oZ0 Do V �K f/off S D Sump pump(yes or no): wu ---r---� 3 = 184 u oo Last date of occupancy:_()I e COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _ d Basis of design (low(seats/persons/sgh,etc.): Grease trap present(yes or no):_ -- - -- ---- —Industrial waste waste holding tan*present(yes or no . Non-sanitary waste discharged to the Title 5 stem (ycs or no): Water meter readings, if available: -- Last date of occupancy/use: —_ OTHER(describe): GENERAL INI OHNIATION Pumping Records s Source of ial' rlllaliull: Was system pumped as part oftthe inspection(yes br no): If yes, volume pumped:__ gallons- Itow was glrunlity plllnpcd determined? Reason for pumping: — ----- TYPE QF SYSTEM --- --- -V—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) ltutovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DJEP approval —Other(describe):. ARprOximate age of all components. date installed(if known)and source Pf information: Wete;ewage odors detected when arriving at the site(yes or(to) �Lj 0 ,e uji ,r �M et Page 7 of I 1 OFFICIAL. INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 63 Farm Valley Road Property Address: Osterville,MA Tim Johnson Owner: February 15,2005 Date of Inspection: BUILDING SEWER(locate on site plan) Depth belu%� grade: Materials of cons truction: ._—cast iron 1/40 PVC_ other(explain):!_ _ Distance h(1W 1)1'1katc wale, supply well or suction line: Comments(on condition of joints, venting,evidence of leaLaoe,etc.): L e�_rl..e�..._!-='�'^�^_—��_L�tl:..-..__91't--�.!^_.4../2�_._�'1_•_`t�-�j-.---- SEPTIC TANK: ✓(locate on site plan) Depth below grade: 1 Material of construction:_/concrete__metal fiberglass_polyethylene _other(explain)_ _ If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no): __ (attacl►a copy of certificate) Dimensions: K f0 S fs /. SpU a 11 o ti Sludge depth — Distance fi-om top of sludge to bottom of outlet tee or ballle': Scum thickness: Distance fiont top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle: n IIoH•were dimensions determined: L` — Comments(of)pumping recoil uncndati oil s, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outica invert,evidence of leakage,etc.): c� _�a,.,-�.A ��►. w�sv(,�,;. � or...k...- . �/� ,s v.i•�.�.:.�e--- Q'c_l h...5.<....._.vr__.._ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass___poly ylene_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 o affle: Data of Ipst pumping: Comments(on pumping recommendations,inlet ,d outlet tee or baffle condition,structural integrity, liquid levels as slated to outlet Invert,evidence of leakage tc.): �y v r�# CIp Page 8 of 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued> 63 Farm Valley Road Property Address: Osterville,MA Tim Johnson Owner: February 15,2005 Date of Inspection: TIGHT or I101.1)1NG TANK: (tank must be pumped at time of spection)(locate on site plan) Depth below grade-.. —. - Material of construction: concrete metal Z. fiberg s___polyethylene other(explain): --- ------ -...-- -----._... . Dtmenstons: _ - - - Capacity: ----____gallons Design flog%. _ _ gallons/day Alarm present(yes or no) __ Alarm level:— _ Alarm in working er(yes or no): Date of last pumping: Comments(condition of alarm and at switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets e(lual, any evidence of solids can}-over, any evidence of le�aka�g'e,into or out of box,etc.): p /� if �L`..G_ J�...�__/(I.�♦✓.�i-1 CAbI✓l C- ���y� W,1 7 L .G-�I{/fi ( Z/`�• �(/��p(1 PUMP CIIAMBE R: _ (locate on site,plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition o mops and appurtenances,etc.): s � t Page 9 of I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SIJ13SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ I'AR'I' C SYSTEM INFORMATION(continued) Property Address: 63 Farm Valldy Road Osterville,MA Owner: Tim Johnson Inspection: 15,2005 Date of lnspectiu SOIL ABSORPTION SYSTEM (SAS): ,1(locale on site plea,exc4yation not required) If SAS not located explain kh) Type leaching pits, number: leaching chambers,number. leaching galleries,number leaching trenches,number, lengtl►: 7 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. CESSPOOLS: ---(cesspool must be pumped as part of inspection ocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: ' Depth of solids layer: Depth of scum laser. -'- ---------- Dimensions of cesspool: - - _ Materials of construction: . Indication of groundwater inflow(yes or _ Comments(note condition of soil,Sig of hydraulic failitre, 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 hydrauli ilure, level of ponding,condition of vegetation,etc.): • Z r' Page 10 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)_ 63 Farm Valley Road Osterville,MA Property Address: Tim Johnson February 15,2005 Owner-. Date of Inspection: 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 100 feet. locate where public water supply enters the building. A AC- _ ►o � of ys I&I/ 10 , is A S. 5.. 4 Y Page I 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOA IPNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Farm Valley Road Osterville,NlA Owner: Tim Johnson Date of Inspection: February 15,2005 SITE EXAM Slope ✓ Surface water Check cellar Shallow wells Estimated depth to ground water f ti.Y r feet Adjusted high ground water elevation feet Please indicate(check)all methods used to derenhinc the high ground %%ater elevation: — Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/obse(vation hole within 150 feet of SAS) _Checked with local Board of I lealth-explain: .-_____ Checked with local excavators, installers-(attach documentation) Accessed US(iS database-explain: to i 'j L 3•y .G� You must describe how you established the high ground water elevation: 4- i_1-.._.-G.i:.-:Ct... t,..4,.: Krh.s.��..b 1- -- -S l,v.,..,�✓�__f�..rfv..r.��( - ���..•c _ham}-- _ �of✓<<- 0.5- ' c.�� rib ��t• —' - Thig report has been prepared and the System Inspected as of the data of Inspeotlall' Thls rep, (t jg1pt a �, ►►art 1?ty or guafantt q that the mIgm rvlll(unction properly 1 tll tutyr�• There heyq beet)no warrplltlf4 or..., 4 qttaraplees, either ei ptessQd,written or Implied, relating to the slant, h�Ins an an y�. . ! pealp�rIs Lj � a TOWN OF BARNSTABLE LOCATION SEWAGE # ASSESSOR'S MAP & LOT 17 -2y-�37 INSTALLER'S NAME&PHONE NO. ` SEPTIC TANK CAPACITY 49'v y L ACHING FACILITY: (type) 'k (size) 1 X NO.OF BEDROOMS a BUILDER OR OWNER PERMIT DATE: 1113 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 o W � G 1 t �) I R ,. TOWN OF BARNSTABLE LOCATION 3-Z SEWAGE # 9 VILLAGE F. v a n-s ASSESSOR'S MAP & LOT I. 'JNSTALLER'S-NAMK&PHONE NO. 1-�i'ekey Cz n S77 27 I —Y I SEPTIC TANK CAPACITY i .SCo { - LCEACHING FACILITY: (type) r���C— 1 � %C �/-t7 (size) NO.OF BEDROOMS y BUILDER CAE�QWNER PERMITDATE: fS (t ,a q 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 Qkleaching facility) Feet Furnished by -� { r R Q �G, s :( ©j L°� 1 AhK N�. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migoar *p5tem Conztruction" 3permit Application for a Permit to Construct(� Repair( )Upgrade( )Abandon( ) %Complete System ❑Individual Components Location Address or Lot No. Lwr I' Uc:ttr iU Owner's Name,Address and Tel.No. Tt m j 6.ee,n a 3061%SM Assessor's Map/Parcel 3+5 C:r.wA p Sir , Unit 103 o Mc,p Ct7 , pe( 29— c Yar rA OZ 7 Installer's Name,Address,qpd Tel.No. Designer's Name,Address and Tel.No. 42&-91-5( ,s A f 'a .Klr, F,� �0 �rX al 2� 8/4 41afer e.t c r `/!C Zoo sr" Type of uilding: Dwelling No.of Bedrooms car- Lot Size SO,7 3% sq.ft. Garbage Grinder A) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 440 gallons per day. Calculated daily flow gallons. Plan Date V/7/ffl Number of sheets go>24 Revision Date 10-is fk' Title 15 4., 26., " Tr i 3"7 LGG 572/;—1_V. Size of Septic Tank Moo G iu tr. Type of S.A.S. 1%',K 54t tad& Description of Soil P-8 S 7A $ 0—1&1 i,A I..cGbNy Ica u=3T 13 . Sc._,Aw Lb a lm :36"—i'Zc)" M eAtum sr aA 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Sign 1 r Date %O-- Application Approved by Date Application Disapprove for the following 4`a\slyrs w Permit No. Date Issued . � pop A00501 , Fee THE COMMONWEALTH OF MASSACHUSETTS I Entered in computer: Yes PUBLIC,HEALTH DIVISION -TOWN OF BARNSTABLE., MASS�ACHUSETTS 2ppricatiot for Digpogal *r5tem Con-5 ruchon Permit - Application for a Permit to Construct(7C Repair( )Upgrade( )Abandon(µ )' ®Complete System ❑Individual Components Location Address or Lot No.q�,.o r 13 7 ��erm 'l t�s Owner's Name,Address and Tel.Nd Tim g (,C.One _-TC41nSpy Assessor's Map/Parcel% g r 3�4'5 "«n p Si- ; Uv6 it 103 r"C. C't-7 , P'1 2 4- c 4- Yr-rmn,46, , MIA 0 Zl673 Installer's Name,Address,qnd Tel.No. Designer's Name,Address and Tel.No. +42-&—91751 Ota.$ J,.-- r 9 het s.Ine'no'I& ewd �Z6S5_ Type of B(uilding: Dwelling No.of Bedrooms ure Lot Size 80 7 / sq.ft. Garbage Grinder 0/0) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 440 gallons per day. Calculated daily flow ' 444t) gallons. Plan Date !V17/fk Number of sheets orsc Revision Date /O-/o 9e Tiile .At (PI.:r. e I- r 137 LC.c. 57ZG-i-�b Size of Septic Tank 15Ga Gal a Type of S.A.S. W K 3 4' kcacwt34 Rtcldl Description of Soil, P-8574 : G�-IG,tr, nvh SaraO ! 16rt- 36r'. 13 . SrayAu L.oaw 1 Zap Nale of Repairs or Alterations(Answer when applicable) Date last inspected: µ Agreement: j The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Sign fl� 1. r1t"OD j Date /Q~-1-9'(" Application Approved by U. i Date Application Disapproved for the following reas ns ) r- : Permit No. /2 Date Issued o } .. - J THE COMMONWEALTH OF MASSACHUSETTS 'BARNSTABLE, MASSACHUSETTS QCertificate of (tompliance THIS IS TO C t e n-site Sewage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( by ,. r at as,Pe n constructed in accordance with the provisions of Title S and the for Disposal System Construction Permit No. r dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will functio\ rl^ ass designed. Date - t" - Inspector --- —.--- -- - ---- ---- No. -r — - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 3011igPo.5a1 pgtem Congtructiou Permit i r ( /> ILI Permission is hereby granted to ansIrpt Repair U de( )Abandon Xl System located at ! 7 rV and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this.permit. Date: Approved by lai z S O' fi v I TOWN OF BARNSTABLE LOCATION T Y 3 a1 tZz SEWAGE # VU,LAGE n nS ASSESSOR'S MAP & LOT ?f) INSTALLER'S-N &PHONE NO. (In n sy 7 7 I —Y/Lk SEPTIC TANK CAPACITY i ..-s-co LEACHING FACII.ITY: (type) (size) NO.OF BEDROOMS 4 BUILDER 0%OWNEE PERMITDATE: 11 1 q 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 leaching facility) Feet Furnished by . �i • I I y. . a. �Le - d Co l © T , 13 , � �f• L� •die•— � .r:+- i � , 11 �,�I;.IRi iIUIdIUI 1----•�-_--�i i o i '�, .-�-j •. �.' —ram Ll urm.i E _ —i �,�:. .,: � :,. • .,. _ - ,�,- lam i z:,,• ..:,• .:,.�•• .ram •� :�- Y N SOGT o NOTM (1) REMOVE UNSUITABLE SOILS BENEATH PROPOSED SYSTEM, BACKFILL CLUSTER SUBDIVISION WITH CLEAN GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS: NOT ZONE E JP G `s RISER MORE THAN 15% RETAINED ON No. 4 SIEVE, NOT MORE THAN 90% RETAINED SN10K �� n7 Rp ON No. 50 SIEVE, OF FRACTION PASSING No. 4, 10% OR LESS TO PASS No. PLAN DATED JANUARY 28,1988 RESIDENCE F-1 RpP�LOW .� ) 100 SIEVE AND 5% OR LESS TO PASS No. 200 SIEVE, SOIL TO BE APPROVED TOTAL ACRES 27.26 MINIMUMS 71 BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. c TOTAL NUMBER OF LOTS s 12 AREA = 43,560 S.F. (2) LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST 72 HOURS FRONTAGE = 20' ? PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE 4 ORIGINAL LOTS (116-119) WIDTH = 125' THE REQUIRED NOTIFICATION TO DIG SAFE (1-800-322-4844) AND APPROPRIATE 8 REVISED LOTS (133-140) �o WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. AVERAGE AREA PER LOT = 2.27 ACRES FRONT SETBACK = 30' SIDE SETBACKS = 15' '15= ELEVATIONS ARE BASED ON N.G.V.D. REAR SETBACK LOCUS MAP NOTES BUILDING HEIGHT = 30' 11) FOR ALL ASPECTS OF THE SEPTIC SYSTEM THE CONTRACTOR (OR 2.5 STORIES IF LESS) SCALE 1 25,000 SHALL COMPLY WITH ALL GOVERNING CODES AND REGULATIONS. ASSESSORS IN PARTICULAR 310CMR 15.000 THE STATE ENVIRONMENTAL CODE TITLE 5, THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART VIII: MAP 97 PARCELS 29-32 ON-SITE SEWAGE DISPOSAL REGULATIONS AND THE BOARD OF HEALTH 24 RECOMMENDATIONS FOR ACCEPTED PRACTICE. / •26.6 C.B. FND. r GRAPHIC SCALE 0 20 40 / r /24.0 / N DESIGN DATA A 3 SINGLE FAMILY- 4 BEDROOMS / /24.1 NO GARBAGE GRINDER y r x 27.1 DAILY FLOW = 110 X 4 =440 G.P.D. C.B. FND. SEPTIC TANK = 440 X 200% = 880 G.P.D. USE 1500 GAL. SEPTIC TANK �O 6.3 0X23.0 LEACHING FIELD DESIGN �..�rni n r- ,i-. n,;n nrnrnrn e Trn -.! x'f '♦ / �A'4A J�ALL ninr(^ -r J nr ^.,�r��.�� i ii �.� vi i�✓��� ry � vim, �i,� vi,r-, ��✓ WITH CAPPED ENDS -- �23 Q 26.2 04/ USE 3 - 4" DISTRIBUTION LINES IN A �- �� `', 18• 3 9,Q STONEL p°� '� 4 st00 ®26-4� x 27.8 18'X 34' ASS SHOWN FIELD \ go# �� s IP SYSTEM IS WITHIN 250 OF A RESOURCE AREA x 22 / �� S- ' g SF,o RSA C.B. SET THEREFORE NO SIDEWALL AREA IS ALLOWED o Tjc 05�, 22.0 440 G.P.D./.74 = 595 S.F. OF BOTTOM AREA REQUIRED V '. /� - - x 4.6 ti 6' USE 18'X 34'= 612 S.F. AREA PROVIDED Y ~ - 6 STF°y BoT �'� -- R R CLASS 1 SOIL PERCOLATION RATE 1" IN 2 MIN. OR LESS � ` pr'` t''.`B. FND. x 26.s C.6: FAD. �. x O SILT FENCEPly g Fw 23.5 D 23.0 BOO A` 26.5 TRENCH / x p�0, 23.4 x 26.2 ._ 0GSF�x 26 4. 24.5 e 22.5 5 & ~ - KEY SILT FENCE INTO -,x 24.1 � - GROUND 4" TO 6" C.B. FND. x 21.2 STAKED HAY BALE DETAIL y� \ x 20.8 'n 16.3 P 18.7 , x 21.2 HEAD:WALLX�y = - s 23.6 �17.5 �'� x .14.7-2 I N V. 15.9 2\•' 'Al Win A2 .8 12.1 vjly l w+f r r - WETLAND - - LOT l36 .. A5 LOT l3B r - j 4 x 22.5 I x 19.9 23 i i • 1.9 " Cy. A4 t j o a X)19.9 x.16.0 3 x18.9 x416.1 x13.4 1,562 sga,ft. 1,719 sr,.ft.= 3281 sq.ft. wetland j v 77450 sq.ft. upland x 15.2 r TOTAL Q� 80,73I S,F, k INV. CLAY PIPE`. X 17.4 � x 14.4 I,85 AC. �" 10.8 ,., 1 BS 'a x 18.2 ; i 10 x . . r 10.7 \ i \. x 2 8 r r r r r a x 14.1 WETLAND a; 10.4 I E �82. r i i r r . j I i r 10.2 x B6 x 14.2 ' B3 1 x 14.4 B5 10.464 x 14.8 x 21.1 x 16.6 C.B. FND. / x 17.7 4 1p6.53., N�4 0 i r WETLAND - 26 39,V BENCHMARK 14.20 `,x 61 14.2 �. C.B. FND. x 16.7 p OPEN CHARLES D. ROGERS TRUSTEE OF THE SOUTH COUNTY TRUST - -- ___ _ •6. FND. C.B. SET �e �J 11.6 SITE PLAN OF LOT 137 C.B. FND L.C.C. 5725-46 IN ALL COMPONENTS LOCATED IN POTENTIAL (OSTERVILLE & MARSTONS MILLS) COVERS LOCATED 0 WITHIN VEHICLE TRAFFIC AREAS OR BURIED 4 FEET BARNSTABLE , MASS ., OR GREATER SHALL BE H-20 LOAD CAPACITY. TEST HOLE P-8574 FOR ELEV.= 27_0 ACME PRECAST CAPE & ISLANDS ENGINEERING TIM & LECN� JOHNSON TOP OF F G = 26'f DB3 OR EQUAL SEPT. 28,1995 FOUNDATION ����\,\,�\ \,� ,\�� \/� F.G. = 26'± PIT #1 SCALE: 1"= 20' DATE: SEPT. 17,1998 INV. = 24.6 ' �,. �. ��1��.<\� ii�i./ _ ELEV. = 26.4' 4" DIAMETER \��^\ �� `'` �� ��777,..`._,,7 ' i.� REV. OCT. 1 ,1998 (ELIM. G.G.) 1500 GAL. T 0 BAXTER & NYE INC. INV. _ _ 24.4 SEPTIC TANK INV. 24.2 INV. =24.0 BOX SCHEDULE 40 PVC TOP ELEV. 24.4 = LOAMY SAND - A REGISTERED LAND SURVEYORS /° PIPE - -16" CIVIL ENGINEERS 10.00' 6" CRUSHED / INV. =23.8 SANDY LOAM - B ❑STERVILLE, MASS. BASEMENT FL. EL. 19.5 MIN• STONE BASE INV. = 23.4 a >, BOTTOM ELEV.22.4 = ZN OF 1448 OF ' -48 PERK TEST �Jti p STEPHEN y 00 Y� vR6Af81 o `3- MEDIUM - C �R vo a�aa o.30216 ci✓i�. SAND9FGISTER���`�<`� EL. 11.6 CAL. HIGH WA _ER �o I 2.8 CORRECTION -120" = ELEV. = 16.4' NO WATER OBSERVED I'RCjt, (0. i EL. 8.8 WATER OBSERVED 96 NO SCALE EL. 8.8 -108" OBSERVED WATER LOT 140 98091